Care Plan for congestive heart failure

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    i need desperate help!! i have to do a care plan for a pt with congestive heart failure!! any help with nursing diagnosis???
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  4. 1
    writing a care plan requires that you follow the steps of the nursing process in the sequence that they occur. the nursing diagnosis is done at step 2 and the interventions at step 3. if you don't complete step 1 first you might as well forget about steps 2 and 3 being any good at all.
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    don't shortchange the assessment part of the care plan activity. the assessment is the foundation of everything that follows. even if this was a hypothetical patient, you can still do the 4th bullet of data collection listed below. assessment includes:
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    after all that activity you move on the second step which is to make a list of all the abnormal data. in effect, you are going to make a list of the signs and symptoms of congestive heart failure along with any of your patient's abnormal responses (difficulty with adls) to them. they are the evidence (as in the aebs in your nursing diagnostic statements) that are the proof of the nursing problems (nursing diagnoses) you end up choosing. it would be a good idea to have a nursing diagnosis reference to help you out with this because every nursing diagnosis has a list of symptoms called defining characteristics. to choose a nursing diagnosis, your patient must have at least one, if not more, of these defining characteristics--another reason why you need to have assessed the patient! you never choose a nursing diagnosis without evidence to back it up--ever. your interventions are always aimed at treating the abnormal data on that list. this is why your assessment is so important.

    see
    sbyramRN likes this.
  5. 0
    need a list of nursing diagnosis for congested heart failure done in laymens term please.
  6. 1
    Quote from dlbm
    need a list of nursing diagnosis for congested heart failure done in laymens term please.
    Are you serious?????? Get a nursing care plan book....google NANDA approved nursing diagnosis. Is it that hard???? I am amazed by how many people come on here asking for someone to do their work for them. How are you going to learn if you have others do it for you????

    BTW, it isn't congested heart failure. Maybe if you knew what the real diagnosis was, you would have an easier time figuring out some nursing diagnosis.
    Valerie Salva likes this.
  7. 0
    this is one of the most commonly requested helps for a care plan. if you do not know how to diagnose, getting a care plan book is not the answer. diagnosing is an activity that requires you to assess first. whether this is a real patient that you took care of or a case scenario, assessment consists of:
    • a health history (review of systems)
    • performing a physical exam
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
    • reviewing the signs, symptoms and side effects of the medications they are taking
    then, you make a list of everything that is abnormal about the person. note: in your reading of heart failure you will find there are several kinds of heart failure so make sure you get the symptoms of congestive heart failure correct. you match the defining characteristics of possible nursing diagnoses against this list you have compiled. if you have a copy of taber's cyclopedic medical dictionary you will find the nanda taxonomy of nursing diagnoses that includes all the nursing diagnoses along with a cross reference of medical diseases with likely nursing diagnoses in the appendix. a doctor decides on a diagnoses by questioning the patient, doing an examination and performing tests. he then looks at the abnormal signs and symptoms he is faced with. he diagnoses based on what the signs and symptoms are. we do the same. every nursing diagnosis has a set of defining characteristics (signs and symptoms). these are listed in the nanda taxonomy.

    for help in constructing care plans see http://allnurses.com/general-nursing...ns-286986.html - help with care plans

    other threads that addressed care plans about chf were
  8. 0
    Quote from dlbm
    need a list of nursing diagnosis for congested heart failure done in laymens term please.
    nursing diagnosis are rarely written in laymens terms. patient problem lists and teaching material is in laymen's terms. performing an internet search using "care plan for congestive heart failure + laymans terms" will bring up many links for you to review and choice those most helpful for your assignment. searching websites of professional oganizations like american heart association will usually provide bounty of patient teaching materials.

    examples:
    congestive heart failure

    congestive heart failure care guide information

    living with advanced congestive heart failure: a guide for family ...

    singapore: all about heart failure

    aha: heart failure
  9. 3
    Quote from sbyramRN
    Are you serious?????? Get a nursing care plan book....google NANDA approved nursing diagnosis. Is it that hard???? I am amazed by how many people come on here asking for someone to do their work for them. How are you going to learn if you have others do it for you????

    BTW, it isn't congested heart failure. Maybe if you knew what the real diagnosis was, you would have an easier time figuring out some nursing diagnosis.
    Please be mindful that this is the GENERAL NURSING STUDENT DISCUSSION section.
    Members post here from around the world asking for assistance. English may not be their primary language. They may be high school students working on a project or prenursing students. We don't know the background of member with each request. Teaching one HOW to get the info they desire is much more successful than criticism.
    jorla9903, VickyRN, and donsterRN like this.
  10. 0
    dear sbyram,excuse me but i never asked you to do my work for me.do you or do you not remember your first care plan ?why are alot of you nurses so hard on us that are just beginning?so i said congested instead of congestive have you not thought that thats how i talk are you that sterotype .
  11. 0
    Type in NANDA nursing Dx on yahoo or google. Go through them one by one, and just pick the ones that apply to you and then state why for the related to part. This is what I did, and I never had to spend the money on a careplan book - I winged it all through NS... just put some thought into it. Ineffective airway clearance r/t excessive secretions as evidenced by a wet cough/decreased o2 sats. that's one. anxiety related to hospitalization as evidenced by patient states he is worried about his diagnoses is always another one.

    What I learned in nursing school is not to spend too much time on the careplans. Just do what you need to do to get the passing grade. Carepalns are apart of clinical (at least they were for me), and clinical was either a pass or fail. No need to go all out and spend hours and hours doing a careplan. Spend that time on focused on your lecture exams, which are the grades that will show up on yoru transcript for life.

    I do remember my first careplan, and definitely can relate to your assignment. You're going to do great!
    Last edit by inland18mempire on Feb 7, '09
  12. 0
    thank you


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