Hearth Failure

Nursing Care Plan Congestive Hearth Failure

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STUDENT NAME: DATE:

CLIENT’S INITIALS: CLIENT’S AGE: GENDER: M / F ALLERGIES: Advance Directives: Restrains: Y / N DIET (including tube feeding with rate)
Admitting Medical Diagnosis:
Chief Complaint:
History of Present illness:
Past Medical History:
Cultural and Spiritual Assessment:
Medications taken at home or before transfer: (include dose and frequency)
Summarize Pathophysiology (in our own words, include definition, etiology and physiology)
Definition of Concurrent Diagnoses (all of them) Correlational of all diagnoses with current condition
Signs and Symptoms: (Indicate which ones your client has) Diagnostic test for this condition: (Indicate which ones utilized for client)
Treatment (med/surg/pharmacological) Nursing Interventions and rationale:

Medications administered during client assignment including IVF’s, Rate, and reason for Fluids.

Generic/Trade Name Classification Major Action

Reason Prescribed to Client

Dose Given/Normal Range Adverse Effects

Precautions/Contraindications

Nursing Implication
.
Generic/Trade Name Classification Major Action

Reason Prescribed to Client

Dose Given/

Normal Range

Adverse Effects

Precautions/Contraindications

Nursing Implication
Generic/Trade Name Classification Major Action

Reason Prescribed to Client

Dose Given/

Normal Range

Adverse Effects

Precautions/Contraindications

Nursing Implication

LABORATORY AND DIAGNOSTIC TESTS

Other Pertinent labs

DATE DIAGNOSTIC STUDY RESULTS SIGNIFICANCE TO PATIENT

NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS SCIENTIFIC PRINCIPLE/ RATIONALE EVALUATION MODIFICATION

NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS SCIENTIFIC PRINCIPLE/

RATIONALE

EVALUATION MODIFICATION

DISCHARGE PLANNING

CLIENT’S NEED FOR DISCHARGE INTERVENTIONS RATIONALE

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