Clinical Communication Tool
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
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Fluid Management
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Goal: Reduce fluid retention to a safe level within the next 48 hours.
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Measurable Objective: Monitor daily weight; aim for a weight loss of 2-3 pounds within the next 2 days.
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Symptom Relief
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Goal: Achieve relief from shortness of breath during activities.
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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.
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Long-Term Goals
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Lifestyle Modification
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Goal: Educate the patient on heart-healthy diet changes by the discharge date.
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Measurable Objective: The patient will verbalize at least three dietary modifications to make by discharge.
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Medication Adherence
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Goal: Ensure the patient understands medication regimen and its importance.
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Measurable Objective: Patient demonstrates correct understanding of medications, including dosage and timing, before discharge.
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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
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Discuss heart failure and its implications.
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Provide written material on heart-healthy living.
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Schedule a follow-up appointment within one week of discharge.
Family Engagement
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Encourage family participation in education sessions.
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Provide resources for support groups.
V. Evaluation
Evaluation Criteria
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Fluid Management:
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Patient weight will decrease by 2-3 pounds.
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Symptom Relief:
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Patient reports decreased shortness of breath.
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Lifestyle Modification:
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Patient can articulate dietary changes.
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Medication Adherence:
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Patient accurately describes medication regimen.
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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].