Care Plan for Cardiac History Management
Care Plan for Cardiac History Management
Category / Primary Body System
- Cardiovascular System
Problem
- Patient has a cardiac history, including [specific conditions, e.g., myocardial infarction, heart failure, arrhythmias].
Goal
- Patient will not experience side effects from cardiac medications or chest pain for 90 days.
Plan/Approach
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Monitoring and Reporting
- Monitor for onset of signs and symptoms of chest pain; notify MD/RNP immediately if symptoms are present.
- Report any changes from baseline to the attending physician promptly.
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Dietary and Nutritional Management
- Provide diet as ordered and encourage adherence to dietary recommendations.
- Draw labs as ordered to monitor cardiac markers and electrolytes, and ensure compliance with dietary guidelines.
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Medication Management
- Administer cardiac medications as ordered, monitoring for side effects.
- Educate the patient and family on the importance of medication adherence and potential side effects.
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Physical Activity and Rehabilitation
- Encourage exercise and activities as tolerated, within physician orders.
- Provide OT/PT as ordered to support physical function and rehabilitation.
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Assistance and Support
- Provide assistance with daily care as needed to ensure safety and comfort.
- Offer teaching and emotional support to the patient and family regarding the diagnosis and management.
Rationale
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Monitoring and Reporting
- Early detection and reporting of chest pain or changes in condition enable prompt intervention, reducing the risk of complications.
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Dietary and Nutritional Management
- A cardiac-friendly diet helps manage underlying conditions, reducing the risk of complications.
- Regular lab monitoring ensures that any imbalances or issues are addressed promptly.
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Medication Management
- Proper administration and monitoring of cardiac medications prevent side effects and ensure therapeutic effectiveness.
- Educating the patient and family promotes understanding and adherence to the treatment plan.
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Physical Activity and Rehabilitation
- Encouraging appropriate exercise and providing rehabilitation support improve cardiovascular health and overall physical function.
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Assistance and Support
- Providing assistance with daily activities ensures that the patient remains safe and comfortable.
- Emotional support and education help the patient and family cope with the diagnosis and adhere to the care plan.
Actions
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Monitoring and Reporting
- Regularly assess the patient for signs of chest pain, including discomfort, pressure, or tightness in the chest.
- Document and report any changes from baseline (e.g., new or worsening symptoms) to the attending physician immediately.
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Dietary and Nutritional Management
- Ensure the patient receives the prescribed diet, focusing on cardiac-friendly foods.
- Encourage the patient to adhere to dietary guidelines, providing education on the importance of a heart-healthy diet.
- Perform lab tests as ordered, monitoring cardiac markers and electrolytes, and report any abnormalities.
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Medication Management
- Administer prescribed cardiac medications on schedule, monitoring for any side effects such as dizziness, hypotension, or gastrointestinal symptoms.
- Provide education to the patient and family on the purpose of medications, potential side effects, and the importance of adherence.
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Physical Activity and Rehabilitation
- Encourage the patient to engage in prescribed exercise and activities, ensuring they do not exceed their tolerance level.
- Coordinate OT/PT sessions as ordered, assisting the patient with exercises and activities designed to improve cardiovascular health and physical function.
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Assistance and Support
- Assist the patient with daily activities as needed, ensuring they are comfortable and safe.
- Provide emotional support by listening to the patient's concerns and providing reassurance.
- Educate the patient and family on managing the condition, recognizing symptoms that require medical attention, and maintaining a healthy lifestyle.
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