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Medical Diagnoses: Post Cardiac Transplant, Readiness for enhanced therapeutic regimen management

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

       

Client indicated “I want to learn how to take care of this heart.”  “I want to take care of myself at home.”

       

Objective: 

-client was utilizing incentive spirometer without prompting

-client expressed desire to manage treatment

       

 

Problem:  Readiness for enhanced therapeutic regimen management

Long Term:

       

Client will demonstrate continued commitment to integration of therapeutic regimen into daily living.

-Identify contributing factors that may need to improve in future.  Health promotion and protection are complex behaviors that are difficult to implement on a daily basis (Pender et. al, 2006) by [date], 13:00.

       

*

Client was unable to identify factors that might need improvement in the future.  Goal not achieved.  Continued  education required.  Evaluation scheduled for [date], 13:00.


Continued evaluation of this intervention is set for 13:00, [date]. Intervention unsuccessful to date.  Further evaluation required.

R/T:

Treatment regimen post cardiac transplant

Short Term:

Client will describe integration of therapeutic regimen into daily living by [date], 10:00.

-Assess client’s current level of knowledge and current home routines.

-Support all efforts to self-manage therapeutic regimens.  Ongoing support and assistance from healthcare professionals is needed to identify and enhance factors that contribute to the likelihood of taking action for health promotion (Pender, et.al, 2006).

-Seek teachable moments to encourage health promotion.  The provision of information should not be restricted to just treatment information but also any information that prepares the client to manage health-related issues (Timmons, et. al 2006).

-Teach client their medication schedule, go over a check-off sheet for daily meds, how to say the names of the medications and what they are for.

-Teach client the importance of nutrition for maintaining health, how to guard against common community acquired infections, appropriate handwashing techniques and timing.  Education programs based on empowerment, client participation, and adult learning principles have demonstrated effectiveness (Kennedy, et. al, 2003).

-Teach the importance of the yearly flu vaccine

       

       

*

Client identified some lifestyle changes needed to ensure protection at 10:15 on March 25, 2008.  Client also identified his medications, what they were for, and the times of the day to take them at 10:20 on [date].

Interventions were successful, goal achieved on [date], .

AEB:

desire to manage treatment and prevent complications post cardiac transplant.

       



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References

Ackley, B. J., & Ladwig, G. B. (2008). Nursing Diagnosis Handbook. St. Louis: Elsevier.

Pender NJ, Murdaugh CL, Parsons MA: Health promotion in nursing practice, ed 5, Upper Saddle River, NJ, 2006, Pearson Prentice Hall.

Engelhart S, Glasmacher A, Exner M et al: Surveillance for nosocomial infections and fever of unknown origin among adult hematology-oncology patients, Infect Control Hosp Epidemiol 23(5):244, 2002.

Gould D: Systematic observation of hand decontamination, Nurs Stand 18(47):3944, 2004.

Kennedy A, Nelson E, Reeves D et al: A randomised controlled trial to assess the impact of a package comprising a patient-orientated, evidence-based self-help guidebook and patient-centered consultations on disease management and satisfaction in inflammatory bowel disease, Health Technol Assess 7(28):3, 1113, 2003.

Timmins F: Exploring the concept of information need, Int J Nurs Pract 12(6):375381, 2006.