Nursing congestive heart failure Care Plan

CarePlan.docx

( 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

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