How to Answer Create Care Plan Questions (Complete Guide)

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create a care plan from example outline below with ICD 10 codes, NIC and Nanda. Rationales for interventions: Medical diagnosis: Heart failure (Must provide the ICD-10 Code.) Case of Heart Failure ASSESSMENT Subjective: Patient c/o increased SOA – Dyspnea, activity intolerance – fatigue, and inability to preform ADLs independently Objective: VS 97.1 temporally, 126/74, apical heart rate 60 bpm, RR 18, and 02 sats 96% on RA Person: S, O – Who receives the care, Mrs. X lives alone, 55 years Health: S, O – Patient experienced increased SOA Nursing: S, O – inability to preform ADLs independently – (Self-Care) – Actual / Potential – Supporting Environment (Internal & External): S, O – Risk for Falls, Safety, Emergency Depart, Home Care, Nursing Diagnosis Actual diagnosis – 3 – parts diagnostic label (NANDA-I): Decreased Activity tolerance related factors (etiology a part of pathophysiology) : related to imbalance between oxygen supply/demand defining characteristics: as evidenced/manifested by expression of fatigue and exertional dyspnea Decreased Activity tolerance related to imbalance between oxygen supply/demand as evidenced by expression of fatigue and exertional dyspnea. Secondary to congestive heart failure. Risk nursing diagnosis/Potential nursing diagnosis Risk for _______________ as evidenced by ____________________. Risk for Ineffective Activity planning as evidenced by insufficient social support. Health promotion diagnosis/wellness diagnosis – DISCHARGE nursing diagnosis / Health Education Readiness for Enhanced ____________ as evidenced by ________________. Readiness for enhanced Health self-management as evidenced by the client’s expressed desire to enhance choices of daily living for meeting health goals Syndrome diagnosis Decompensation – Outcomes/Planning (0306) Self-Care: Instrumental Activities of Daily Living (IADLs) Client Will (Specify Time Frame) – short term /long term (after discharge) Client will demonstrate increased tolerance to activity within 24 hours from (Scale 1 to 5) 4 = mildly compromised to 5 = not compromised. Nursing Interventions (0180) Energy Management 1. Independent Nursing Intervention (RN can perform w/o MD order) 1.1. Gradually increase ADLs, assist client with positioning, transferring, and self-care as able. EB: A reduction in plasma volume associated with bed rest impacts the physiological responses of autonomic control of circulation ( Dorantes-Mendez et al, 2013 ; Tibaldi et al, 2014 cited in XXXXXX, 2022). 2. Dependent Nursing Intervention (MD order) 2.1. Oxygen as ordered (__________). EB: _____________ 3. Collaborative/Supportive-Educative Nursing Intervention (Working with another health care team member/client) 3.1. Refer the client to physical therapy to help increase activity levels and strength. Evaluation: ACTUAL – PAST TENSE / EXPECTED OUTCOMES – FUTURE TENSE Goal Met/Partially Met/Not Met. Client demonstrated an increased tolerance to activity from (Scale 1 to 5) 4 = mildly compromised to 5 = not compromised. Medical diagnosis: Heart failure / I50.32 Chronic diastolic (congestive) heart failure Nursing Diagnosis Actual Nursing Diagnosis 3-part statement/phrase Risk Nursing Diagnosis / Potential Nursing Diagnosis Risk for ___________ (diagnostic label) as evidenced by ______________ (factors/associated conditions) Risk for decreased Cardiac tissue perfusion as evidenced by hypovolemia. Health promotion diagnosis Readiness for Enhanced __________ as evidenced by Readiness for enhanced Health self-management as evidenced by the client’s expressed desire to enhance choices of daily living for meeting health goals. Expresses desire to enhance acceptance of the condition; expresses desire to enhance choices of daily living for meeting health goals; expresses desire to enhance commitment to follow-up care; expresses desire to enhance decision making; expresses desire to enhance inclusion of treatment regimen into daily living; expresses desire to enhance management of risk factors; expresses desire to enhance management of signs; expresses desire to enhance management of symptoms; expresses desire to enhance recognition of disease signs; expresses desire to enhance recognition of disease symptoms; expresses desire to enhance satisfaction with quality of life Diagnostic Label: Decreased Cardiac output Related factors: related to alteration in preload Defining characteristics (signs/symptoms): as evidenced by edema (dyspnea) and fatigue (activity intolerance) Nursing Diagnosis Decreased Cardiac output related to alteration in preload as evidenced by edema (dyspnea) and fatigue (activity intolerance). Secondary to heart failure chronic, cancer, psychosis Outcomes/Planning Client Will Demonstrate adequate cardiac output as evidenced by decreased dyspnea and ability to tolerate activity without symptoms of dyspnea within 24 hours. (0400) Cardiac Pump Effectiveness (Scale 1 through 5) from 2 = substantial deviation from normal range to 4 = mild deviation from normal range. Interventions (4040) Cardiac Care 1. Independent Nursing Interventions (RN can perform w/o MD orders) 1.1. Monitor and report presence and degree of symptoms including dyspnea at rest, reduced exercise capacity, difficulty with activities of daily living, and fatigue. EB: These are symptoms and signs consistent with heart failure (HF) and decreased cardiac output ( Yancy et al, 2013 ). 2. Dependent Nursing Interventions (MD orders required) 2.1. Apply graduated compression stockings/leg sleeves as ordered. EB: Graduated compression stockings, alone or used in conjunction with other prevention modalities, help promote venous return and reduce the risk of deep vein thrombosis in hospitalized clients ( Sachdeva et al, 2014 cited in Poteet, 2022). 3. Collaborative Nursing Interventions (Working with other health professionals/health care team members/client) 3.1. Refer to a cardiac rehabilitation program for education and monitored exercise. EB: Exercise training or regular physical activity is recommended for HF clients. A systematic review of outcomes of exercise-based interventions in clients with systolic HF found that hospitalizations and those for systolic HF were reduced for clients in an exercise program and quality of life was improved ( Taylor et al, 2014 ). Evaluation-Actual / Expected Outcomes Goal Met/Partially Met/Not Met. Client demonstrated adequate cardiac output as evidenced by (0400) Cardiac Pump Effectiveness (Scale 1 through 5) from 2 = substantial deviation from normal range to 4 = mild deviation from normal range. References: Subjective: Patient c/o increased SOA, activity intolerance, and inability to preform ADLs independently Objective: VS 97.1 temporally, 126/74, apical heart rate 60 bpm, RR 18, and 02 sats 96% on RA Diagnosis: Congestive heart failure related to excess fluid volume as evidenced of SOA Pathophysiology: Congestive heart failure is a condition in which the heart cannot adequately pump enough blood to maintain the body’s metabolic needs. Congestive heart failure can cause symptoms such as cough, fatigue, edema of lower extremities and fluid retention. Goals: Short term Patient will be able to resume ADLs without exertions and independently. Patient will maintain normal heartrate between 60-100 bpm. Patient will verbalize understanding on treating or preventing fluid volume excess. Long term Patient will maintain balanced fluid volume by maintaining stable weight. Outcomes: Within 8hrs after admission, the patient will have relief of increased swelling of ankles and >1 pitting edema within lower extremities. Nursing Interventions Administer PO Lasix 20mg as prescribed to alleviate symptoms of excess fluid volume. Monitor apical heartrate and rhythm. Monitor for pitting edema of lower extremities. Rationale To relieve excess fluid from heart, lungs, and rest of body. To monitor for tachycardia and dysrhythmia that require intervention and treatment. To access for effectiveness of prescribed dose of diuretic in treating edema.

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