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This is a case study of an old female patient admitted in a medical-surgical unit due to decompensated heart failure. It aimed to identify, through the Outcome-Present State-Test (OPT) Model, a clinical reasoning model, the diagnosis, outcomes and nursing interventions. Data were collected using previously validated instrument and directed to cardiological conditions. Diagnoses, outcomes, and interventions were carried out with the use of the standardized nursing language of NANDA-I Inc., Nursing Outcomes Classification, and Nursing Intervention Classification. The main diagnosis was decreased cardiac output. The results and chosen interventions were related to cardiac and respiratory conditions, fluid overload, anxiety, fatigue, peripheral tissue perfusion, knowledge, and self-control of heart failure, vital signs, and improved sleep. The third generation of the Nursing process represented by the OPT helped to identify the patient́ s main needs and directed the planning of care based on the care priorities.

APPLICATION OF THE OUTCOME-PRESENT STATE TEST MODEL IN PATIENT WITH CONGESTIVE HEART FAILURE