Cardiac History

Care Plan for Cardiac History

Category / Primary Body System:

Cardiovascular

Problem:

I have a cardiac history, including the risk of chest pain and side effects from cardiac medications.

Goal:

I will not have side effects from cardiac medications or experience chest pain for 90 days.

Plan/Approach:

1. Monitor Cardiovascular Status:

   • Step-by-Step Approach: Monitor blood pressure, apical pulse, heart sounds, lung sounds, oxygen saturation, edema, skin color, peripheral pulses, temperature, and presence of pain.
   • Technological Aids: Utilize blood pressure cuffs, pulse oximeters, and stethoscopes.

2. Chest Pain Monitoring:

   • Step-by-Step Approach: Monitor for onset of signs and symptoms of chest pain. Notify MD/RNP if symptoms are present.
   • Educational Efforts: Educate the patient on recognizing early signs of chest pain.

3. Baseline Changes:

   • Step-by-Step Approach: Report any changes to baseline cardiovascular status to the attending physician.
   • Monitoring Strategies: Regular assessments and documentation.

4. Diet Compliance:

   • Step-by-Step Approach: Provide diet as ordered and encourage compliance.
   • Educational Efforts: Offer nutritional counseling and dietary education.

5. Lab Monitoring:

   • Step-by-Step Approach: Draw labs as ordered, monitor results, and encourage diet compliance.
   • Technological Aids: Use laboratory tests to track health metrics.

6. Care Assistance:

   • Step-by-Step Approach: Provide assistance with daily care as needed.
   • Engagement in Diversional Activities: Encourage participation in gentle activities.

7. Patient and Family Education:

   • Step-by-Step Approach: Provide teaching and emotional support to the patient and family regarding the diagnosis.
   • Educational Efforts: Offer educational materials and support groups.

8. Cardiac Medication Management:

   • Step-by-Step Approach: Administer cardiac medications as ordered and monitor for side effects.
   • Technological Aids: Use medication administration records (MAR).

9. Exercise and Activity:

   • Step-by-Step Approach: Encourage exercise and activities as tolerated within physician orders.
   • Engagement in Diversional Activities: Offer suitable physical activities.

10. OT/PT Services:

    • Step-by-Step Approach: Provide occupational therapy (OT) and physical therapy (PT) as ordered.
    • Engagement in Diversional Activities: Integrate therapy into daily routine.

Rationale:

• Monitor Cardiovascular Status: Early detection of abnormalities allows for prompt intervention, preventing complications.
• Chest Pain Monitoring: Immediate response to chest pain can prevent severe cardiac events.
• Baseline Changes: Timely reporting of changes ensures appropriate adjustments to care plans.
• Diet Compliance: Proper nutrition supports cardiovascular health and overall well-being.
• Lab Monitoring: Regular lab tests provide critical data for managing cardiac health.
• Care Assistance: Adequate support in daily activities promotes safety and comfort.
• Patient and Family Education: Informed patients and families can better manage and support the treatment plan.
• Cardiac Medication Management: Monitoring side effects ensures medications are effective and safe.
• Exercise and Activity: Regular physical activity within limits improves cardiovascular health.
• OT/PT Services: Therapy aids in maintaining mobility and functionality.

Actions:

1. Monitor Cardiovascular Status:

   • Staff will monitor blood pressure, apical pulse, heart sounds, lung sounds, oxygen saturation, edema, skin color, peripheral pulses, temperature, and presence of pain.

2. Chest Pain Monitoring:

   • Staff will monitor for signs and symptoms of chest pain and notify MD/RNP if symptoms are present.

3. Baseline Changes:

   • Staff will report any changes to baseline cardiovascular status to the attending physician.

4. Diet Compliance:

   • Staff will provide diet as ordered and encourage compliance.

5. Lab Monitoring:

   • Staff will draw labs as ordered, monitor results, and encourage diet compliance.

6. Care Assistance:

   • Staff will provide assistance with daily care as needed.

7. Patient and Family Education:

   • Staff will provide teaching and emotional support to the patient and family regarding the diagnosis.

8. Cardiac Medication Management:

   • Staff will administer cardiac medications as ordered and monitor for side effects.

9. Exercise and Activity:

   • Staff will encourage exercise and activities as tolerated within physician orders.

10. OT/PT Services:

    • Staff will provide occupational therapy (OT) and physical therapy (PT) as ordered.