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:
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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.
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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.
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Baseline Changes:
- Step-by-Step Approach: Report any changes to baseline cardiovascular status to the attending physician.
- Monitoring Strategies: Regular assessments and documentation.
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Diet Compliance:
- Step-by-Step Approach: Provide diet as ordered and encourage compliance.
- Educational Efforts: Offer nutritional counseling and dietary education.
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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.
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Care Assistance:
- Step-by-Step Approach: Provide assistance with daily care as needed.
- Engagement in Diversional Activities: Encourage participation in gentle activities.
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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.
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Cardiac Medication Management:
- Step-by-Step Approach: Administer cardiac medications as ordered and monitor for side effects.
- Technological Aids: Use medication administration records (MAR).
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Exercise and Activity:
- Step-by-Step Approach: Encourage exercise and activities as tolerated within physician orders.
- Engagement in Diversional Activities: Offer suitable physical activities.
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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:
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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.
-
Chest Pain Monitoring:
- Staff will monitor for signs and symptoms of chest pain and notify MD/RNP if symptoms are present.
-
Baseline Changes:
- Staff will report any changes to baseline cardiovascular status to the attending physician.
-
Diet Compliance:
- Staff will provide diet as ordered and encourage compliance.
-
Lab Monitoring:
- Staff will draw labs as ordered, monitor results, and encourage diet compliance.
-
Care Assistance:
- Staff will provide assistance with daily care as needed.
-
Patient and Family Education:
- Staff will provide teaching and emotional support to the patient and family regarding the diagnosis.
-
Cardiac Medication Management:
- Staff will administer cardiac medications as ordered and monitor for side effects.
-
Exercise and Activity:
- Staff will encourage exercise and activities as tolerated within physician orders.
-
OT/PT Services:
- Staff will provide occupational therapy (OT) and physical therapy (PT) as ordered.
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