Clinical Communication Tool

I. Patient Information

Patient Name: Allene Tillman
Date of Birth: January 15, 1975
Admission Date: March 5, 2050
Diagnosis: Congestive Heart Failure

II. Goals of Care

Short-Term Goals

Fluid Management
- Goal: Reduce fluid retention to a safe level within the next 48 hours.
- Measurable Objective: Monitor daily weight; aim for a weight loss of 2-3 pounds within the next 2 days.
Symptom Relief
- Goal: Achieve relief from shortness of breath during activities.
- Measurable Objective: The patient reports a decrease in dyspnea to a level of 2 or less on a scale of 0-10 within 24 hours.

Long-Term Goals

Lifestyle Modification
- Goal: Educate the patient on heart-healthy diet changes by the discharge date.
- Measurable Objective: The patient will verbalize at least three dietary modifications to make by discharge.
Medication Adherence
- Goal: Ensure the patient understands medication regimen and its importance.
- Measurable Objective: Patient demonstrates correct understanding of medications, including dosage and timing, before discharge.

III. Care Plan and Interventions

Nursing Interventions

Intervention	Frequency	Responsible Nurse
Assess vital signs	Every 4 hours	[Your Name]
Monitor intake and output	Daily	[Your Name]
Administer diuretics as prescribed	As per physician order	[Your Name]
Provide education on dietary restrictions	Daily during meals	[Your Name]

Multidisciplinary Team Collaboration

Team Member	Role	Contact Information
Dr. Emie Howell	Attending Physician	emie@you.mail
Tracey Gleason	Nurse	tracey@you.mail
Kitty Johns	Nurse	kitty@you.mail
Adelia Harber	Nurse	adelia@you.mail

IV. Patient and Family Involvement

Education Plan

Discuss heart failure and its implications.
Provide written material on heart-healthy living.
Schedule a follow-up appointment within one week of discharge.

Family Engagement

Encourage family participation in education sessions.
Provide resources for support groups.

V. Evaluation

Evaluation Criteria

Fluid Management:
- Patient weight will decrease by 2-3 pounds.
Symptom Relief:
- Patient reports decreased shortness of breath.
Lifestyle Modification:
- Patient can articulate dietary changes.
Medication Adherence:
- Patient accurately describes medication regimen.

For further information or inquiries, please feel free to reach out to me, [Your Name], at [Your Email]. You can also contact [Your Company Name] at [Your Company Email]. We are located at [Your Company Address], and our contact number is [Your Company Number].

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