Question

PN 200 Fundamentals of Nursing II Concept Map: Fluid Volume Excess/Hypervolemia Ms. Helen Jones presented to the Emergency Room late one evening complaining of a "racing heartbeat". She is an overweight 69-year-old female, who has been experiencing increasing shortness of breath during the past two month, with marked swelling of the ankles and feet during the past three (3) weeks. She feels very weak and tired most of the time and has recently been waking up in the middle of the night with severe breathing problems. She has been sleeping with several pillows to keep herself propped up. She has been a three (3) pack per day smoker for 30 years but quit smoking 4 years ago when she coronary bypass surgery. She drinks alcohol infrequently. She has a nine (9) year history of hypercholesterolemia. Medical history includes diagnosis of osteoarthritis and gout. Her current medications include: Celecoxib Allopurinol Atorvastatin Clopidogrel

Answer 1

1) Nursing diagnosis: Fluid volume overload related to decreased cardiac output evidenced by lower limb edema, weakness, shortness of breath.

Nursing intervention: * provide oxygen to maintain oxygen saturation level.

                              * Weigh the patient daily.

                              * Maintain fluid balance by monitoring intake and output .

Positive outcome:    * There will be no evidence of edema within 48 hours.

                             * Maintain intact skin and mucous membranes.

Negative outcomes: There will be delayed wound healing, impaired bowel function.

Evaluation:           The patient feels comfortable and relieved from dyspnea, oedema etc.

2) Activity intolerance related to osteoarthritis evidenced by weakness,stress on joints, malaise .

Nursing intervention: * Assess the area and intensity of pain.

                               * Frequently change the position.

                               * Assist clients with physiotherapy.

                               * Encourage them to do range of motion exercise.

Positive outcomes: * Maintain or improve strength and function of the part of the body.

                             * Able to do techniques that help to do activities.

Negative outcomes: Patient will develop anxiety, depression,social isolation thereby reduce their quality of life.

Evaluation:          The patient will get relief from pain and will be able to move the parts of the body.