PATIENT_____________________________________

DATE

PROBLEM

GOAL

TO DATE

INTERVENTIONS

RESP

DISC

Heart Failure

related to

Coronary Artery Disease

Cardiomyopathy

Congenital Heart Disease

Heart Valve disease

Arrythmia

Patient has exhibited symptoms indicative of heart failure since the previous assessment.

Actions taken to respond:

Patient’s physician contacted the same day

Patient advised to get emergency treatment

Implement physician-ordered patient-specific established parameters for treatment

Patient education or other clinical interventions

Obtained change in care plan orders (increased monitoring by agency, change in visit frequency, telehealth, etc.)

Patient safety will be maintained, and patient will be free of discomfort

Patient / caregivers will verbalize understanding of diagnosis and treatment

Patient / caregivers will demonstrate correct administration of medications

Monitor blood pressure

Monitor for shortness of breath, weakness, dizziness, chest pain, jugular vein distention, decreased peripheral pulses, arrhythmias, fatigue, rales, dyspnea, changes in mental status, cool clammy skin, edema, cough, weight gain, fatigue, loss of appetite

Monitor respiratory rate and depth, lung sounds

Labs as ordered

Instruct patient / caregivers to:

Monitor intake and output

Monitor weekly weight

Monitor urine color

Administer oxygen as ordered

Alternate activities with periods of rest

Administer medications and treatments as ordered

Avoid straining at stool

Limit salt intake