Question

What would be three nursing diagnosis for this assessment?

Assessment of the Patient: A 68 year old male admitted to ER with acute respiratory distress, has history of congestive heart failure (CHF). Patient complains of shortness of breath, weight gain, fatigue, and bilateral ankle edema. Crackles heard 1/2 way up from bases. placed on NC @ 4L. O2 sat 93%. IV started in R arm, labs drawn and sent to lab. Chest X ray done, EKG done, showing sinus tachycardia, echo done @ bedside.

Answer 1

1.Decreased cardiac output related to altered contractility, altered preload ,altered stroke volume as evidenced by decreased ejection fraction .(45%)

Intervention :

• Note sign and symptoms of decrease cardiac output (e.g.chest pain,s3,s4,jugular venous distension )
• Monitor fluid balance (e.g. intake and output, daily weight checking )
• Perform a comprehensive assess of peripheral circulation (check peripheral pulse, capillary refill, edema, color and temperature of extremity )
• Continuously monitoring cardiac rhythm for detect dysrhythmias.

Monitor for dyspnea, fatigue, tachypnea,and others related to respiratory system.

2.Impair gas exchange related to increased preload and alveolar capillary membrane changes as evidenced by normal oxygen saturation, hypoxia, dyspnea.

Intervention :

• Monitor pulse oximetry ,respiratory rate, rhythm and depth.
• Auscultate breath sound , noting areas of decreased or absent ventilation, presence of pulmonary edema is detect.
• Monitor for increased restlessness, anxiety and work of breathing.
• Supplemental oxygen or other noninvasive ventilator support (bipap) is given.
• Positioning the patient (semifowler position ) to alleviate dyspnea.

3.Excess fluid volume related to increased venous pressure secondary to congestive heart failure as evidenced by rapid weight gain,edema.

Intervention :

• Therapeutic effect of diuretic (e.g.increased urine output, decreased CVP)is assessed.
• Diuretic prescribed as per doctor ordered is to be administered.
• Monitor potassium level after diuresis is to be detect excessive electrolyte loss.
• Intake output chart is to be maintained .
• Peripheral edema is to be assessed.