Question

Two Nursing Diagnosis and interventions

PN 105 Fundamentals of Nursing I Concept Map -Congestive Heart Failure Mable Grant, a "frequent flyer", is admitted to the emergency room with a diagnosis of congestive heart failure. She was discharged from the hospital ten (10) days ago and comes in today stating "I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks". After further questioning you learn she strictly followed the fluid and salt restriction as ordered at her last hospitalization. She reports she has gained 1-2 pounds every day since her discharge. Vital signs are T100.2, P 104 and bounding, R 26 with audible crackles bilateral lower lobes, B/P 156/112. 02 sats 88. Height 5'8" Weight 159.5. She is placed on Lasix 20 mg by mouth daily, strict intake and output; 02 at 2L/min; bedrest with bathroom privileges; 2400mg sodium diet; and Toprol 12.5 by mouth daily Now complete your concept map. Revised 9/18 tcom es -

Answer 1

Nursing diagnosis 1-Decreased cardiac output

maybe related -to altered vascular resistance heart rate

Intervention

​​​​​​1. ​​​​​​​Asess heart rate ,rhythm, heart sound ,blood pressure.

2.monitor urine output, noting decreasing output .

3.encourage rest,semirecumbent in bed or chair.

4.elevate leg avoiding pressure under knee.

5.provide quiet environment help client to avoid stressful situations

6.administer oxygen a

7.administer medication such as loop diuretics , as prescribed by cardiologist.

Nursing diagnosis 2-.excess fluid volume

May be related to compromised regulatory mechanism intervention-

​​​​​​1.monitor​ urine output noting amount and colour.

2.change position frequently, elevate feet when sitting

3.monitor blood pressure and Central venous pressure.

4.monitor 24 hour intake and output.

5.establish fluid intake schedule if fluids are medically restricted

6.maintain chair rest or bed rest in semi fowler position 7.administer diuretics as prescribed by cardiologist