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

1. 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.

2. 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.

3. 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.

4. Physical Activity and Rehabilitation

   • Encourage exercise and activities as tolerated, within physician orders.
   • Provide OT/PT as ordered to support physical function and rehabilitation.

5. 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

1. Monitoring and Reporting

   • Early detection and reporting of chest pain or changes in condition enable prompt intervention, reducing the risk of complications.

2. 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.

3. 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.

4. Physical Activity and Rehabilitation

   • Encouraging appropriate exercise and providing rehabilitation support improve cardiovascular health and overall physical function.

5. 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

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.