| Problem
| Treatment Goal
| Intervention
| Disciplines Involved
| Time Frame
|
| Recurrent problems with symptoms of uncontrolled CHF and COPD
| Successful outpatient treatment of CHF and COPD
| O2 @ 2L/ nasal cannula;O2 saturation readings per oximeter every week; daily
check of weight, abdominal girth, and pedal edema
| Medicine
Pharmacy Nursing | ASAP
|
| Ineffective use of medications
| Patient following appropriate drug regimen
| Medication assessment
Establish plan for medication administration and monitoring | Pharmacy
SW Nursing |
|
| Poor nutrition
| Patient/family able to plan and provide proper diet
| Home assessment
Nutrition assessment Nutrition education specific to Mr. Green's needs and resources for help | SW
Dietitian Nutritionist Nursing |
|
| Health risks in the physical and social environment
| Mr. Green residing in supportive environment with reduced risk factors
| Home assessment
Family assessment Identify community resources for patient and family Financial assessment | SW
Nursing |
|