Atrial Fibrillation (AF)

Rapid A.F
Controlled A.F (Chronic)
Acute A.F

Assessment/nu Planning Implementation Evaluation of Date ceased

rsing diagnosis goals/expected of nursing care
outcomes interventions
Assess vital signs Vital signs collected Implementation Changes
and documented as per doctors reported to
hourly (done as per standing orders doctor
standing order)

Changes reported
to doctor
Collect patients Risk factors Alcohol/drug use Dietitian
history identified Caffeine intake counseled
Talk to dietitian patient

Patient aware of
risk factors

Falls risk Patient is aware Patient has Patient uses

that they are a falls emergency button button before
risk moving out of
Lowered bed bed
Prevent falls
Sensor mat Patient has had
no falls
Moved closer to
nurses station
(visible from
station
Patient has been 30 minute Session 1
educated on their education session completed,
condition and self on day 1 patient rephrase
management back to you their
strategy understanding
 Heart failure

Assessment/nursing Planning Implementation Evaluation of Date

diagnosis goals/expected of nursing care ceased
outcomes interventions
Assess vital signs Vital signs collected Implementation Changes
and documented as per doctors reported to
hourly (done as per standing orders doctor
standing order)

Changes reported to
doctor
Patient history Daily weight
(Smoking history, Bmi, check
Alchohol intake,
Exercise pattern, wait Patient
circumference) commences on a
low fat no added
salt diet (LFNAS
diet)

Fluid restrict
FR<1.5L a day

Educate on risks
of smoking

Fluid intake and

output strictly
monitored
 Gall bladder

Assessment/nursing Planning Implementation Evaluation of Date

diagnosis goals/expected of nursing care ceased
outcomes interventions
Severe pain Pain will be Pain scale Evaluate post
(Fever, Vomiting) manageable meds 20 mins +
q4 (every four
Administer hours)
medication as per
medication chart

Vital signs Vital signs wthin Report temp, Vital signs

(tachycardia and patient normal limits heartrate to within normal
fever) doctor limits
Afebrile <37.5
degrees celcius

monitor vital signs

q4
Patient history assess Evaluation of risk Dietitian has
risk factors factors educated
patient on diet
post op