Goals:
(1) clinical status
(2) clinical stability
(3) maintenance plan
Clinical status goals:
(1) has achieved dry weight (following diuresis)
(2) walking without dyspnea or dizziness
(3) optimal blood pressure range identified (with control of serious hypertension)
Stability goals:
(1) renal function stable or improving
(2) in fluid balance, even when on oral diuretics
(3) if intravenous inotropic agents used during admission, discontinued at least 48 hours before discharge
(4) oral heart failure regimen stable for at least 24 hours
Maintenance plan:
(1) patient education
(2) family or caregiver education
(3) flexible diuretic plan
(4) call to patient within 3 days scheduled
(5) instructions for when to call health care provider and how to handle an emergency
(6) followup visit with health care provider scheduled for 5-10 days after discharge
Elements of education:
(1) sodium restriction
(2) fluid limitation
(3) medication schedule
(4) exercise prescription
