Nursing Care Plan Congestive Hearth Failure
Hearth Failure
Hearth Failure
NEW PROFESSIONS TECHNICAL INSTITUTE
4000 West Flagler Street Miami, Florida 33134
(305) 461-2223 / Fax: (305) 461-3029
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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