Appendix A Plan of Care


Student Name________________________________________________Date _________________________


Patient initials _______________________ Patient Age: ________Room Number ______________________


Admitting Diagnosis: _______________________________________________________________________


(Document pathophysiology of one medical diagnosis that your patient has, including medical treatment,

nursing management. Please use a separate page for this section)


Chief Complaint: ___________________________________________________________________________


Past Medical History: ________________________________________________________________________


Vital Signs:  BP______P_____R____T____SAO2______ Pain Score: _______  Wt _______Height: _________


Tests or procedures and analysis of lab values pertinent to admitting diagnosis, include and explain abnormal results:











Medications: generic/trade


Indications: underline your patient’s indication!!! Significant Side effects Patient’s dose, route and frequency; Normal dose range Indicate whether your patient’s dose is in range. Nursing responsibilities

(Example: can the medication be crushed?)





























Assessment: (complete assessment every day): Include subjective and objection data

















Psychosocial/ Emotional






Discharge Planning:



Patient/Family educational needs:


Strengths and weakness



Patient Goals for the day:


Medical Plan of care:

This may be listed as a problem list with 1) name of problem, 2) assessment of problem 3) treatment/outcomes. Example: 1) COPD 2 )x-ray ordered; lab tests ordered 3) patient receiving nebulizer treatment q6h; Nasal Cannula 2L; Prednisolone ordered q12h; pulse ox q8h



Nursing Plan of Care: any abnormal assessment finding should generate a possible problem. Two problems MUST be identified; one primary and one secondary problem.



Include your patient’s defining characteristics, risk factors, Signs and symptoms


NANDA 2 part statement (Diagnostic label related to…)

Patient safety issues

Identify potential complications and explain how it is related to the identified nursing diagnosis

Planned outcomes

Long term/short term goals. Must be measurable including a time frame




Rationale for Interventions

(Must include scientific rationales/ citations)













Note: Write a focused nursing note on the back of this page using the format of your facility reflecting your patient’s priority problems and their responses to the Plan of Care.


Plan of Care Guidelines


A typed Plan of Care (POC) will be handed in to your clinical instructor once during the semester.  Your POC must be evidence based as demonstrated by use of references throughout the document- particularly in the “Rationale for Intervention” column.  You must include a reference page at the end of the document.

Medical Diagnosis (10 points)

Document pathophysiology, medical treatment, nursing management. Please use a separate page for this section.

Labs (5 points)

Tests or procedures and analysis of lab values pertinent to admitting diagnosis, include and explain abnormal results:

Assessment (25 points)

Document your head to toe assessment and include any subjective data that you obtained.  The assessment should be organized and focus on the patient’s priority problem, such as why they are admitted to the hospital, etc. This may not be the problem today.


Medical/Interdisciplinary Plan of Care (5 points)

Document the medical diagnoses and plan of care identified by the health care provider and other disciplines.


Nursing Plan of Care (30 points)


Assessment findings: 5 points

These assessment findings should support your choice of patient problem.  What did you find in your assessment of the patient that supports your nursing diagnosis?


Nursing Diagnosis (Problem label and etiology): 5 points

Should be clear and concise. You can use NANDA if it fits or describe the problem.  i.e. acute pain: abdomen r/t post op appendectomy (date) or if the etiology is not known


Patient Safety issues: 5 points

Identify any possible safety issues or complications that may occur as a consequence of the problem and etiology identified.  i.e. acute pain: abdomen r/t unknown  possibly a bowel obstruction or a perforated bowel or maybe they cannot take a deep breath and atelectasis is a possibility.


Desired Outcomes: 5 points

What was your goal for the patient? Should be measureable and be directly related to the problem, etiology, S&S, and patient safety issues.  i.e. pain reported 0-3/10; abdomen soft, no N/V, BP and P stable, temp and SAO2 >94% on room air


Interventions: 5 points

What did you do? Should be specific and address each desired outcome.  Imagine drawing a line from each desired outcome to an intervention.  Note that one intervention may help the patient achieve multiple desired outcomes.  Include the rationale with a reference for each intervention (or group of interventions)


SOLUTION FOR : Nursing Care Plan For Heart Failure


 Plan of Care For Heart Failure


Student Name________________________________________________Date _________________________


Patient initials __MN__________________ Patient Age: _66_______Room Number ___2__________________


Admitting Diagnosis: Heart Failure


Heart Failure is common public health problem that causes unplanned hospital admissions especially among individuals aged 65 years and above. The condition occurs when the heart is unable to provide adequate blood flow to meet the metabolic demands of the body (Kemp & Conte 2012). Heart failure may be categorized into three classes including reduced ejection fraction also known as systolic heart failure, preserved ejection fraction also diastolic heart failure, and mid-range ejection fraction. Schwinger (2021) argues that advanced age, being a female, obesity, a history of high blood pressure, and atrial fibrillation often causes preserved ejection fraction (Workman, 2016).  On the other hand, patients with reduced ejection fraction show up with disorders such as valve disease, coronary heart disease, and high blood pressure. Classification of heart failure may also be based on the affected circulatory system (either left or right-sided) or the underlying pathophysiological factor leading to heart failure (Schwinger, 2021).

Heart failure occurs when the myocardium is injured. These injuries may be due to diseases such as hypertension, diabetes, valvular diseases, infections, and toxins. During a heart failure episode, patients may present with dyspnea peripheral edema, reduced appetite, fatigue nausea, and ascites (Kemp & Conte 2012). Reduced cardiac output leads to compensatory mechanisms aimed at redressing the already created imbalance. Such mechanisms include as increased cardiac output, increased volumes of the ventricles, and wall thickening. However, as time progresses, these mechanisms fail, resulting to worsened cardiac output and heart failure. Several systems are activated when the cardiac output in reduced. They include the renin-angiotensin-aldosterone system (RAAS), sympathomimetic nervous system (SNS), and the natriuretic peptide system (NPS). This activation leads to reduced renal perfusion, which further stimulates the kidneys to release renin that converts angiotensinogen to angiotensin I and II (Wright & Thomas, 2018). These changes cause arteriolar vasoconstriction, cardiac remodeling, myocardial contractility, salt and water retention, and increased overload.

Medical Treatment and Nursing Management

Pharmacological treatment of heart failure is critical to improved quality of life, reduced mortality, morbidity, and hospitalization, and healthcare costs. Diuretics are the first line treatment for heart failure as they assist in reducing fluid retention and congestion. This medication also helps prevent or delay admission to emergency departments (Wright & Thomas, 2018).  Furosemide is often used as the first-line loop diuretic (Wright & Thomas, 2018). Other medications may also be combined with diuretics for better outcomes. They include angiotensin-converting enzyme inhibitors, beta blockers, and angiotensin receptor blockers. All the medications used must be titrated to the maximum tolerated doses to maximize their effects. The medication should be started at low doses and gradually doubled at intervals of no quicker than two weeks. Lifestyle modification such as losing excessive weight, abstaining from tobacco and alcohol use, and regular exercises can also support in managing heart failure and its comorbidities. Nurses have to carry several management procedures within the healthcare facility to ensure that the patient in the case has been stabilized. Some of the nursing management activities for heart failure include assessing signs and symptoms, exploring whether the patient understands HF, undertaking physical examination, diagnosing the patient, addressing risk factors, and aggressively treating comorbidities. Other nursing management includes supporting the patient to adhere to the established nursing interventions to address HF and other medical conditions.

Chief Complaint: Lower extremity edema, chest pain, irregular heart rhythm, tachypnea, and shortness of breath

Past Medical History: The patient has a history for atrial fibrillation, hypertension, overweight, and type 2 diabetes.

Vital Signs:  BP=165/75, P= 106bpm, RR=22, T=98.8 F, SAO2=88%, Pain Score: 7/10, Wt =128kg, Height: 5.3 feet

Tests or procedures

  • CBC and serum electrolyte: To check for elevated cardiac troponins. Findings of this tests showed that the CBCs were within the normal ranges. Brain natriuretic peptide (BNP) were elevated, an indication of heart failure.
  • Chest X-ray: The results of this test showed pulmonary congestion and excessive fluids buildup
  • Transthoracic echocardiogram (TTE): to assess valvular and heart functioning. The test revealed decreased left ventricular ejection
  • Electrocardiogram (ECG) was also undertaken to assess for ischemic abnormalities. Results revealed atrial fibrillation with a heart rate of 106bpm.

Medications for the Patient


Medications: generic/trade


Indications: underline your patient’s indication!!! Significant Side effects Patient’s dose, route and frequency; Normal dose range Indicate whether your patient’s dose is in range. ·       Nursing responsibilities

·       (Example: can the medication be crushed?)

1. Trade name: Furosernide

Generic name: Lasix

Classification: Loop diuretic





The medication is used to treat heart failure and lower extremity edema. The use of this medication is associated with significant side effects that frequent urination, electrolyte imbalances, hypotension, kidney impairment, nausea, vomiting, and dizziness (Thomas & Wright 2018). 50 mg PO BID. Normal dosage is 40-80 mg daily (Thomas & Wright 2018). ·       Nurses have a responsibility to assess fluid status, monitor patient’s weight, edema, and mucous membranes.

·       The nurse should assess and report any signs of reduced circulating blood volume, hypotension, excessive weight loss, and kidney failure to the multidisciplinary care team.

·       Nurses should assess patients for diuretic resistance so as to add another medication to reduce fluid overload.

·       Nurses to provide high-dose intravenous diuresis if the patient fails to respond to diuretics.

2    Trade name: Enalapril

Generic name: Vasotec

Classification: ACE inhibitors




To reduce blood pressure and treat heart failure Common side effects include hypotension, rapid fall in blood pressure, headache, dizziness, neutropenia, nausea, and stomach pain. 5mg PO qDay. The recommended starting dose for treating hypertension is 2.5-5 mg PO qDay while the maintenance dose should be 5-20mg/day PO qDay. ·       Assess the patient for changes in skin color, lesions, turgor, reflexes, and sensation.

·       Nurses should monitor blood pressure, reduced fluid volume, dehydration, vomiting, and hypotension after the first few doses

3. Flecainide

Generic name: Sotalol

Classification: Beta Blocker





To treat irregular heart rhythm, shortness of breath, and atrial fibrillation Common serious side effects include dizziness, blurred vision, headache, muscle weakness, stomach pain, and constipation. 50 mg PO BID. Maximum dosage should be 300mg/day ·       Nurses should monitor vital sings since the medication may cause non-fatal cardiac arrest.

·       Monitor the patient’s serum potassium ion concentration frequently to reduce instances of adverse effects.


4. Glumetza

Generic name: Metformin

Classification: Biguanides




To treat type 2 diabetes and its symptoms Common side effects of metformin include acidosis abdominal discomfort, nausea, agitation, headache, fatigue, anorexia, and diarrhea. Maximum of 200 mg once daily. ·       Nurses should monitor the fasting blood glucose and ketone levels to assess the effectiveness of the medication

·       Educate the patients using sustained-release tablets to swallow whole and not chew or crush.

·       Nurses should educate the patient on the need to withdraw the medication immediately in case of acidosis.

·       Educate the patient not to use alcohol since it increases the risk for lactic acidosis and acute renal failure.


Assessment: (complete assessment every day): Include subjective and objection data


Neuro: The patient is awake, alert, and oriented to place and person and not to time. The patient is poorly dressed and his hair unkempt.


Cardiovascular: Irregular heart rhythm and not within the normal range. The patient also complains of chest pains, shortness of breath, and tachycardia.




Respiratory: inspection of the patient’s chest shows that they are symmetric, although a slight change in anteroposterior lateral ratio 1:1.5 is noted. No lesions are seen or murmurs.  Bibisal rales are heard on auscultation of the lungs. Abnormal S3 and S4 heart sounds are heard.



GI: The abdomen is soft, mildly distended. Auscultation of bowel sounds reveals 5-15 sounds/min in each quadrant. No bruit or lesions are seen. The patient’s liver is normal.
GU: Bowel sounds heard in all the four quadrants. No scar seen. Bowel movements are normal.  No lesion or drainage seen on external genital inspection.


Musculoskeletal: has a strong hand grip. Slight decrease in ROM. Muscle strength against gravity and resistance is 5/5.  Inguinal nodes are not palpable.



Psychosocial/ Emotional: the patient lives with his granddaughter and does not have adequate emotional support.



Skin: the skin is dry, warm, and intact, without lesions.
IV. The patient is put under an intravenous IV catheter on his left arm. The insertion site is not well cleaned or disinfected.



Safety: the patient is not safe as she is older and has a higher risk for falls due to diminished mobility and other comorbid conditions.
Discharge Planning: The patient will be admitted for medication and monitoring. Once discharged, a carer will be provided to support the patient with daily activities and to support the patient to adhere to the established treatment plan and medication regime.



Patient/Family educational needs: The patient should be educated on the importance of medication adherence and the need to avoid risk factors for the different healthcare conditions she is suffering from.


Strengths and weakness: The patient has been provided with medication and her response is improving based on her vital signs. However, she needs support to move from one point to another.


Patient Goals for the day: The goal for the day is to support the patient take medications and avoid complications since the patient is suffering from multiple comorbidities.


Medical Plan of Care

Name of problem Assessment Treatment
Heart failure CBC, blood tests, chest-x-ray, serum electrolyte, and transthoracic echocardiogram (TTE) ordered Supplemental oxygen provided and Furosernide 50 mg PO BID prescribed.
Blood pressure Blood pressure measurement, Heart exam, blood and urine tests ordered Intravenous nitroglycerine provided as the case is an emergency case. Later the patient is put under Enalapril 50mg 5mg PO qDay.
Atrial fibrillation and irregular heart rate Electrocardiogram (ECG) to detect evidence of ischemic abnormalities Patient put under oxygen therapy and later provided Flecainide 50 mg PO BID.
Type 2 Diabetes Blood tests ordered Patient put on oxygen therapy, intravenous IV provided, and 200 Mg PO once daily of metformin administered.


Nursing Plan of Care



Include your patient’s defining characteristics, risk factors, Signs and symptoms


NANDA 2 part statement (Diagnostic label related to…)

Patient safety issues

Identify potential complications and explain how it is related to the identified nursing diagnosis

Planned outcomes

Long term/short term goals. Must be measurable including a time frame




Rationale for Interventions

(Must include scientific rationales/ citations)

Signs and symptoms: Elevated cardiac troponins, pulmonary congestion and excessive fluids buildup, Heart rate of 106bpm, and decreased left ventricular ejection. These sings show that the patient is suffering from revealing atrial fibrillation.

Risk factors for this condition include being overweight, hypertension, having Type 2 diabetes, and higher cholesterol levels.



Decreased cardiac output related to increased afterload, impaired myocardial contractility, medications side effects, and altered heart rate. These are evidenced by increased heart rate, tachypnea, decreased peripheral pulses, dry skin, shortness of breath, changes in levels of consciousness, fatigue, abnormal S3and S4 sounds, and edema. Heart failure can cause significant complications to patients including arrhythmias, stroke and thromboembolism, hepatic congestion and dysfunction, muscle wasting, pulmonary congestion, respiratory muscle weakness, valvular dysfunction, reduced quality of life, and decreased functional capacity (Malik et al., 2023). The long terms goal is to support the patient to have adequate cardiac output which will be evidenced by normalized blood pressure, pulse rate, and rhythm, reduced chest pain, and tachypnea.  The second goal is to ensure that the patient is free from medication side effects and complications either form the medications or other comorbidities.    Lastly, it is to support the patient to understand risk factors and take precautionary measures to reduce exposure. ·       Nurses should provide supplemental oxygen to address the patient’s shortness of breath and to improve her oxygen saturation,

·       Secondly, it is to limit fluids and sodium intake and closely monitor fluid intake (Wayne, 2023).

·       Administer medication as prescribed (Workman, 2016).

·       Provision of supplemental oxygen ensures adequate oxygen to the myocardium and reduces pulmonary congestion, which in turn results to decreased symptoms (Wayne, 2023).

·       Reducing fluid intake will help decreased fluid volume, thus minimizing the demands of the heart.

·       Medications help relieve symptoms, control body fluids, and improve vitals to normal limits.


·       This intervention will be evaluated by assessing the patient’s vitals such as an increase in SAO2 concentration to above 92%, lowered blood pressure to within the normal ranges, reduced chest pain, and regular heart and pulse rates.


Risk factors include altered circulation, edema, prolonged sitting and bed rest, and decreased activity level.



Impaired skin integrity as evidenced by dry and reduced skin turgor Potential complications include increased chances of infection, reduced mobility and decreased functioning of limbs. Maintain skin integrity and demonstration of behaviors for improving skin turgor.


·       Provide gentle massage around reddened area.

·       Encourage the patient to change her position after few hours Vera, 2023).

·       Provide skin care by reducing moisture and excretion form coming into contact with the skin Vera, 2023).


·       This is critical as it enhances blood flow and reduces risk for tissue hypoxia Vera, 2023).


·       This reduces pressure on tissues positioned on one side.

·       Excessive moisture may result to further breakdown of the skin Vera, 2023).


·       Reduction in redness of areas of the skin

·       Improved skin turgor

The patient’s characteristics include weakness, fatigue, dyspnea, immobility, and abrupt changes in vital sings. Risk for activity intolerance related to imbalanced oxygen supply and demand, excessive sleep, immobility, and general weakness. Shortness of breath, increased heart rate and blood pressure, lowered self-esteem, sleep disturbances, and depression. The desired goal is to use interventions that permit the patient to participate in activities of daily living, reduce fatigue, and weakness. ·       Nurses should assess vital sings and evaluate the client’s response to activities

·       Assist the client with self-care activities. Furthermore, it is important to support the patient to be independent in undertaking activities of daily living (Vera, 2023)

·       Develop and implement interventions to support in improving activity tolerance.

·       Assessing vital sings and evaluating response to activities is critical in understanding the activities that can be tolerated by the patient and to implement measures for supporting tolerance to activities.

·       Some patients may be vulnerable to falls and injuries due to old age and comorbidities and must be supported to undertake self-care activities to minimize the risk for injuries (Vera, 2023).

·       This reduces risk for injury and encourages the patient to continue with activities of daily living.



Focused Nursing Note

            This care plan is for MN, a 66-year-old woman who has been admitted with complaints of worsening lower extremity edema, fatigue, tachypnea, and shortness of breath. The patient is diagnosed with heart failure. Her vitals at admission BP=165/75, P= 106bpm, RR=22, T=98.8 F, SAO2=88%, and pain Score: 7/10. Therefore, the priority nursing intervention for the patient should target  on improving cardiac output and skin integrity, lowering blood pressure, and respiratory rate, and increasing her oxygen concentration. Nursing interventions provided included providing supplemental oxygen to increase oxygen to the myocardium thus relieving symptoms, and providing physical and medical care to minimize symptoms since the patient is suffering from multiple medical disorders. After the interventions, the patient’s blood pressure decreased to 140/65, SAO2 concentration increased to 95%, and chest pains reduced to 2/10. Furthermore, these interventions addressed the patient’s lung rales, tachycardia, and shortness s of breath.



Kemp. C. & Conte, J. (2012). The pathophysiology of heart failure. Cardiovascular pathology, 21(5), 365-371.     DOI: 10.1016/j.carpath.2011.11.007

Malik, A., Brito, D., Vaqar, S. & Chhabra, L. (2023). Congestive Heart Failure. [Updated 2022 Nov 7]. In: StatPearls [Internet]. Treasure Island    (FL): StatPearls Publishing;

Podvorica, E., Bektechi, T., Orugi, M. & Kalo, I. (2021). Education of the people living with heart disease. Journal of the Academy of Medical       Sciences of Bosnia and Herzegovina, 33(1), 10-15. DOI: 10.5455/msm.2021.33.10-15


Schwinger, R. (2021). Pathophysiology of Heart failure. Cardiovasc Diagn Ther, 11(1), 263-276.

Salvador, K. & Wagner, M. (2023). Atrial fibrillation: Nursing diagnoses, care plans, assessment, and interventions.       fibrillation-nursing-diagnosis-care-plan/


Thoma, M. & Wright, P. (2018). Pathophysiology and management of heart failure. The Pharmaceutical journal. Available on      https://pharmaceutical-  

Vera, M (2023). Heart failure nursing care plans.

Workman, I. (2016). Medical-surgical nursing: Patient-centered collaborative care (8th ED). Elsevier: USA.

Wright, P. & Thomas, M. (2018). Pathophysiology and management of heart failure. The Pharmaceutical Journal, 10 (12), 1-27.


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