4100 concept map on Heart Failure PDF

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Summary

concept map on heart failure for 4100 med surge 3 (BSN) clinical assignment...

Description

NSG 4100 CONCEPT MAP

Age:82 Gender: male Allergies: statins Code status: FULL

PATIENT INFORMATION Height:167cm Weight: 81 kg Diagnosis: syncope/chf Diet: Honey pure

REASON FOR COMING TO HOSPITAL Episodes of syncope and urinary retention PAST MEDICAL HISTORY History of CHF, CAD, hypertension and dyslipidemia PHYSICAL ASSESSMENT (Subjective and Objective) VS: BP: 139/76, RR: 18, PULSE: 95, O2:95, TEMP: 36.6 Abnormal lab values: elevated WBC and HGB, low RBC IV site/fluids: None Tubes/drains: None Neuro- oriented X2 Respiratory- clear lung sounds Cardiac- regular rhythm Gastrointestinal- pain in belly, active bowel sounds Genitourinary- none reported Integumentary-warm, dry and intact Musculoskeletal-weak Pain: 9/10 in lower abdomen

Student: Maria Diaz Date: 11/20/21

Assessment Data (things to watch for, or present in patient):

Concept Map Heart Failure

Chest pain, Altered Mental status, Anxiety, Shortness of breath, increased respiratory rate, cardiac monitoring, Medication history, NPO is maintained until patient is stable. Observe for nausea/vomiting, intake and output.

Disease Process: Etiology Pathophysiology of Disease Process Condition: A partial blockage of blood flow to the heart may be due to arteries that have narrowed, thickened walls. The thickening is caused by a gradual build-up of plaque in a process called atherosclerosis > Ischemia symptoms and loss of myocardium.

Expected Treatment Regimen: Provide a calm environment -Oxygen 2-4 L/min via nasal cannula Educate patient on smoking cessation, medications, Follow up. -Cardiac rehabilitation -Advise on healthy diet and maintaining healthy -Advise to resume activities such as exercise and watching weight.

Relevant Labs:

Signs/ symptoms Shortness of breath, substernal chest pain, pain in the jaw/neck, nausea, anxiety, chest tightness, heartburn, indigestion.

Troponin levels, B type natriuretic peptide (BNP), CKMB, CMP, CBC, PT, PTT

Nursing Considerations: Continuous Tele monitor and hourly BP monitoring until stable. Then Monitor BP Q 4 h. Patient is instructed to monitor and keep a log of the BP readings and show it to the PCP during follow up. Educate on avoiding stress, consider lifestyle changes, diet modifications, exercise, sleep patterns, sodium restriction of 2 g/day etc. Educate on smoking cessation. Take medications as prescribed. Enroll in Cardiac rehab. Patient should f/u with Cardiologist and PCP as scheduled. Educate patient to not discontinue medications without the doctor’s supervision.

Diagnostic Tests/Procedures: ECG, Echo, chest X-ray, stress test

Expected/Actual medications taken by pt. Nitroglycerin-Helps relieve chest pain Beta Blockers-Slows the heart rate, reduce BP (use caution in bradycardia). Ace Inhibitors- Reduces BP, decreases stress on heart. Anticoagulants- Blood thinners, reduce clotting (Heparin drip, then Heparin or Lovenox or Warfarin).

Morphine/ Pain medications

References (APA citation of all referenced material): Hinkle, J. L., & Cheever, K. H. (2014). Medical Surgical Nursing (13th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Nursing Diagnoses (3) 1. NANDA #1 Alteration in comfort, chest pain, R/T cardiac tissue ischemia as evidenced by sweating, restlessness and report of chest pain. ST Goal: Verbalize relief of chest pain with administration of medication ST Goal Met/Not Met/Partially Met (and how?): Partially met- Patient still have 7/10 pain LT Goal: Demonstrate use of relaxation techniques LT Goal Met/Not Met/Partially Met (and how?): Partially met. Patient reports reduction in chest pain.

 Use NANDA verbiage (R/T & AEB)  Two per NANDA patient goals: achievable, measurable, and time limited (i.e. by end of shit…)  Evaluate STG only

ation of insulin and care of equipment. NANDA #3

d NANDA #2 Risk for decreased cardiac output (Risk factors: Changes in rate, rhythm, electrical conduction).

Anxiety related to Threat to or change in health and socioeconomic status as evidenced by apprehension, increased tension, restlessness, facial tension ST Goal: Identify causes, contributing factors.

ST Goal: Maintain hemodynamic stability, e.g., BP, adequate cardiac output, adequate urinary output, absence of dysrhythmias ST Goal Met/Not Met/Partially Met (and how?): Partially met- Sinus rhythm noted LT Goal: Demonstrate an increase in activity tolerance LT Goal Met/Not Met/Partially Met (and how?): Not met- Patient is on bed rest

ST Goal Met/Not Met/Partially Met (and how?): Partially met-appears less anxious. LT Goal: Demonstrate positive problem-solving skills LT Goal Met/Not Met/Partially Met (and how?): Not met. Patient still moderately anxious.

Interventions (at least 3): Interventions (at least 3):

1.Assess for chest pain, monitor and document the characteristics of pain and non-verbal cues. 2.Monitor vital signs, Telemetry, labs.

Interventions (at least 3):

3.Administer Oxygen 2-4 L/min via nasal cannula. 1.

Monitor v/s, observe for fluctuations in BP

2.

Administer Oxygen as ordered

3. Administer anti arrhythmic drugs as ordered

1.Identify and acknowledge patient’s perception of threat and situation. Encourage expressions of emotions. 2.Observe for verbal and nonverbal signs of anxiety (restlessness, changes in vital signs), and stay with patient. Intervene as needed. 3.Answer all questions factually, provide consistent information and repeat if needed...