care plans

Hello, if anyone has any suggestions on doing care plans, your input would be greatly appreciated!!! I have a CHF patient in my clinicals, she didn't complain of pain, the only thing she complained about was the pain from her hep lock while she was receiving Potassium. Other then that, she was fine, alert, walking, and ready to go home. I don't know what to write on the care plan for a nursing diagnosis, what kind of intervention??? nursing diagnosis??

rationale?? expected goal for short and long term???? Thanks to anyone who replies in advance!!!!! :)

How old is your pt? Any other significant health hx? What is her EF-- Need to know this in regards to short/long term goals.

What will be her D/C meds?

I will help you get started...

Nursing diagnoses: Fluid volume overload, Decreased cardiac output,knowledge deficit, Activity intolerance, Inability to cope

Nursing interventions: Weigh pt daily, strict I/Os, limit salt intake, med/disease process instruction....

Teach pt to monitor own weight at home--when to notify doctor, ie gaining 3-5 lbs in 1day.

***Answer my first questions...it will help you out :) ***

Good luck!

Thank you so much for helping me!! Primary Diagnosis is the CHF, other problems are BIL Ankle Edema, Arthrits, Cancer (Uterine), Heart Disease, Kidney Disease, Asthma, High BP, She's on a cardiac diet which she still drinks coffee (regular) and still eats her salt, she's really not overweight, 162 pounds, and was a risk factor for falls while in the hospital R/T SOB.

She was receiving Potassium via Heplock, her lungs and bowel sounds were good. The only edema noted was on her feet and ankles. She's 85, and went home on Tuesday! Don't know what meds she was sent home with except for the Lasix, have no idea what they told her to do when they discharged her.

I was not sure about the fluid volume overload because the swelling in her feet and ankles wasn't that bad, but not sure if that matters, this is all new to me, clinical nurse just kinda threw us in there!! thanks again, i really do appreciate it!!!!!!!!!!!!!!!!!!!!! :)

How old is your pt? Any other significant health hx? What is her EF-- Need to know this in regards to short/long term goals.

What will be her D/C meds?

I will help you get started...

Nursing diagnoses: Fluid volume overload, Decreased cardiac output,knowledge deficit, Activity intolerance, Inability to cope

Nursing interventions: Weigh pt daily, strict I/Os, limit salt intake, med/disease process instruction....

Teach pt to monitor own weight at home--when to notify doctor, ie gaining 3-5 lbs in 1day.

***Answer my first questions...it will help you out :) ***

Good luck!