Care Plan Assignment ATI 3 Heart failure PDF

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Care Plan Assignment Name:

Date: Assignment: ATI 3 RL Heart Failure Clinical Instructor

This assignment will be graded. Grading points:  Nursing Diagnosis are specific and appropriate to this patient. (MUST BE NANDA APPROVED) Use your Nurse Pocket Guide or the website I have posted on the reference page of this example, or your Med-Surg Book, or other resources to find the appropriate diagnoses-cite references on last page of this assignment) -40  Nursing Diagnoses are prioritized (#1 most important, etc) : 15  Goals are specific and measurable: 10  AEB only with Actual: 5  Three most important nursing interventions (with rationale) for each diagnosis: 30 – Be sure to hit more than just one phase of the nursing process (so all three shouldn’t be assessment interventions) *note this example does not provide rationales, but you should state why you are choosing the interventions you did…this will help with critical thinking) You may want to pop your rationale in a different text color.

Patients Medical Diagnosis: (Choose most significant) Heart Failure

Current problems: (List any significant problems or concerns) 1. Shortness of Breath 2. Fatigue 3. Weight gain 4.

Nursing diagnosis #1 #1: Impaired gas exchange R/T: AEB: Dyspnea Goal: Demonstrate adequate ventilation and oxygenation by O2 monitor within normal ranges for the patient and be free of respiratory distress by the end of the day he arrived on unit 3/24/21. ____________________________________________________________________________

Nursing Interventions:#1 1. Auscultate breath sounds, noting wheezing and crackles. 2. Teach patient to cough and deep breath as well as apply oxygen to patient 3. Position patient in high fowlers position.

Nursing diagnosis #2 #2: Excess fluid volume R/T: Excessive fluid intake and excessive sodium intake. AEB: Weight gain Goal: Have a balanced I&O, stable VS, stable weight and absence of edema by discharge.

Nursing Interventions: #2 1. Monitor I&O and have a set limit of intake. 2. Take daily weight and VS q4h. 3. Auscultate breath sounds for crackles or wheezing.

Nursing diagnosis #3 #3: Fatigue R/T: Physical exertion, inadequate sleep, restlessness. AEB: Patient reported he was fatigued. He stated walking up stairs he is our of breath. Goal: Report improved sense of energy by discharge. ____________________________________________________________________________ __

Nursing Interventions: #3 1. Assess vital signs. 2. Review medication regimen. 3. Determine presence or degree of sleep disturbances.

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