Care Plan for congestive heart failure

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    i need help, nurses! i have a care plan to do for a pt with congestive heart failure. Any help with diagnosis and interventions??? i really would appreciate it. Thank??
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    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
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    Thread moved to General Nursing Student Assistance forum to encourage more responses.
  6. 0
    Nsg Dx 1. Impaired gas exchange r/t alveolar-capillary changes

    goal:Within 30 min of intervention client will demonstrate improved ventilation and adeqte oxegenation by ABG’s within client normal limits and absence of symptoms of resritory distresse.
    intervention
    1. assist client to fowlers position whit head of bed at 90 degrees.
    2. Teach paient to take slow deep breaths
    3. Asses lungs field for breath sounds
    rational
    1. of It decreses the work breathing, reduces cardiac work load, and promotes gas exchange.
    2. Taking deep breath increases oxegnation to the myocardium and improves prognosis.
    3. The precence of crakles may signal alveolar fluid congestion and left-sided HF.

    This most likely can't help you now but this is the care plan I working on so I thought it would help so others can get some ideas.
    Last edit by bambam1288 on Dec 7, '09 : Reason: clarity
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    Quote from bambam1288
    Nsg Dx 1. Impaired gas exchange r/t alveolar-capillary changes

    goal:Within 30 min of intervention client will demonstrate improved ventilation and adeqte oxegenation by ABG’s within client normal limits and absence of symptoms of resritory distresse.
    intervention
    1. assist client to fowlers position whit head of bed at 90 degrees.
    2. Teach paient to take slow deep breaths
    3. Asses lungs field for breath sounds
    rational
    1. of It decreses the work breathing, reduces cardiac work load, and promotes gas exchange.
    2. Taking deep breath increases oxegnation to the myocardium and improves prognosis.
    3. The precence of crakles may signal alveolar fluid congestion and left-sided HF.

    This most likely can't help you now but this is the care plan I working on so I thought it would help so others can get some ideas.
    Isn't your third intervention actually an evaluation?

    I mean no offense -- I am just so new at this that I read these post all the time so I can understand this stuff.
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    I am too I am just going with what the book says. I look and a lot of my suggested msg intervention suggest assess pt status because you are are going back and assessing the pt a lot to insure you don;t have complications.This is my thought process i could be wrong.
    Last edit by bambam1288 on Dec 8, '09 : Reason: clarity
  9. 0
    Oh gosh it is going to be years before I can do this properly!


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