CHF Data Analysis Page & Careplan forms Word Version PDF

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Download CHF Data Analysis Page & Careplan forms Word Version PDF

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Data Analysis Page: In this stage of the nursing process, the nurse analyzes the assessment data to formulate a nursing diagnosis. Using the following grid, place relevant assessment findings into the appropriate NANDA category. Identify nursing diagnoses (potential, actual, and wellness) in each category, along with the Maslow’s level (using the number system and chart to the left). Some categories may have several and some might have none, depending on your client’ needs. Use positively stated nursing diagnoses as well as illness based as appropriate. Be sure to consider your client’s perspective as well as your own.)(Ref: appendix A – Wilkinson & Ahern)

Fluid & Electrolyte/Acid Base

Digestion/Metabolism/Nutrition

Elimination

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient is diagnosed with RVF and LVF

Patient is type II diabetic, glucose is 142

Patient is on 2000 ml/24 hr fluid restriction

Patient is type II diabetic Patient has been prescribed Lasix and potassium Patient’s sodium, potassium, and chloride lab values are low, BUN is elevated, Serum creatinine is 2.0, glucose is 142, HCT is low, HGB slightly low, PaO2 is low, PaCO2 is elevated Patient complains of dyspnea and heaviness in her chest

Patient is on NS 150 ml/hr Patient has foley in place

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Excess fluid volume

physiologica l

Risk for unstable blood glucose

physiological

Excess fluid volume

physiological

Perfusion/Oxygenation

Sexuality/Reproduction

Mobility

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient complains of dyspnea and chest heaviness

Patient is a widowed female and has an adult daughter

Patient is on complete bed rest Patient complains of dyspnea

Patient is diagnosed with RVF and LVF EF is 35% Chest xray indicates cardiomegaly Patient has history of hypertension Patient has history of MI 7 months ago and is S/P 2 cardiac stents Patient is a smoker (50 years) PaO2 is low, PaCO2 is elevated Patient has been ordered Oxygen via FM at 2 lpm; increase by 2 until sats >90% Pulse ox 87% Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Decreased cardiac output

physiological

None

Love/belonging

Risk for falls

safety

Tissue Integrity

Comfort/Pain

Stress/Coping

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient is on complete bed rest

Patient complains of dyspnea and chest heaviness

dyspnea

Patient is a smoker x 50 years Patient diagnosed with RVF and LVF EF is 35% IV LFA Braden score is 18 mild risk

Patient rated pain at “0”

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Ineffective tissue perfusion

Physiologica l safety

none

physiological

anxiety

Sleep/Rest

Inflammation/Infection/Immunity

Maslow’s

safety

Spirituality/Values

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient was brought in by ambulance at 0300 which is indicative of sleep disturbance related to diagnosis.

Patient’s temp is 99

Patient is protestant

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

insomnia

physiological

Risk for infection

Physiological safety

none

Love/belonging Esteem

Patient has hx of smoking x 50 years Glucose 142 Patient has foley catheter Patient has an IV

Selfactualization

Sensory/Safety Data from Assessment: Patient is on O2, IV fluids, and has a foley. Complete bedrest has been ordered.

Nursing Diagnoses Risk for falls

Maslow’s

safety

Mood/Affect/Anxiety

Family/Role Relationships

Health/Wellness/Illness

Data from Assessment:

Data from Assessment:

Patient is a widowed female, retired teacher

Patient has hx of hypertension, DM II, MI, S/P stents x2, LVF and RVF, HTN

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

none

Love belonging

Ineffective therapeutic regimen management

Physiological

Esteem Self actualization Developmental

safety

Patient Education

Data from Assessment: Patient has dyspnea

Data from Assessment: Patient is a retired teacher with an adult child

Discharge teaching topic that should be completed before the patient leaves the hospital. The patient will: (list) Teach patient to monitor weight daily at same time, same scale, similar clothing.

Nursing Diagnoses Anxiety

Maslow’s

Esteem physiological

Nursing Diagnoses

Maslow’s

none

Love belonging Esteem Self actualization

Teach patient about medication regimen: times, dosages, side effects, missed doses. Teach patient about diuretics and electrolytes. Teach patient about diet and fluids. Teach patient about exercise and activity and gradual increase to appropriate level. Teach patient symptoms of CHF and when to call physician. Educate patient on negative effects of smoking related to diagnosis and on smoking cessation.

Priority Nursing Diagnosis Identify the priority nursing diagnosis: (This is what your care plan should be on, unless you have already used this nursing diagnosis for a previous care plan. If so, state the priority, state you have used this nursing diagnosis in the past and then list the next highest priority and do the care plan on it.) Potential complication of decreased cardiac output: Excess fluid volume

Rationale for this choice in your words (consider patient’s thoughts as well) Decreased heart function is causing other systems to become impaired; kidney function is impaired, leading to electrolyte imbalance and fluid excess, tissue perfusion is impacted, lung function is impaired. It appears to me that if cardiac output can be improved these other issues would be reduced, however, there are no independent nursing interventions for decreased cardiac output nor can a nurse make this diagnosis (per the Nursing Diagnosis Handbook), so the second diagnosis in priority would be fluid volume excess, which again, if addressed, would positively impact the other symptoms. It should also help relieve the dyspnea, which I would suppose is the patient’s major concern.

NURSING CARE PLAN Nursing Diagnosis(include qualifier if needed):

Related Factors:

Excess fluid volume related to Decreased cardiac output

Patient complains of dyspnea and chest heaviness. Decreased HGB and HCT. Patient’s sodium, potassium, and chloride lab values are low. Pulse is 110. BP is 168/88. Respirations are 28.

Diagnosis Definition (Ref Page #): Increased isotonic fluid retention Page 347

Identify the NANDA defining characteristics that your client exhibits:

Expected Outcome: (Format: Client will____(timeline) AEB: (factors that prove the client

Changes in respiratory pattern, electrolyte imbalance, decreased HGB and HCT, dyspnea,

Patient will, by end of shift, Demonstrate stabilized fluid volume as evidenced by balanced intake and output, breath sounds clear/clearing, and vital signs within acceptable range.

Nursing Assessments:

statement was met)

Nursing Actions Rationale for each Nursing Assessment:

(Actions that require gathering &/or monitoring of

information)

1.

Monitor and calculate 24-hour intake and output (I&O) balance. 2. Assess for crackles in the lungs, changes in respiratory pattern, shortness of breath, and orthopnea. 3. Assess for presence of edema by palpating over the tibia, ankles, feet, and sacrum.

(if one rationale is meant for more than one assessment, indicate with numbering system) Ref and page# required.

1.

Diuretic therapy may result in sudden increase in fluid loss even though edema or ascites remain. 2. These signs are caused by an accumulation of fluid in the lungs. 3. Excessive fluid retention may be manifested by venous engorgement and edema formation.

Independent Nursing Interventions: (Actions by the nurse that require care, teaching, or collaboration with other HCP’s; do not use dependent interventions)

1, Maintain bed rest in semi-Fowler’s position. 2. Instruct patient, caregiver, and family members regarding fluid restrictions, as appropriate. Monitor fluid intake. 3. Elevate edematous extremities, and handle with care.

Rationale for each Nursing Interventions: 1.

Raising the head of bed provides comfort in breathing.

2. This enhances compliance with the regimen. 3. Elevation increases venous return to the heart and, in turn, decreases edema. Edematous skin is more susceptible to injury.

Process Evaluation: The client met the expected outcome completely

partially

not at all

as evidenced by: (you must

address each outcome AEB criteria and use the same order and numbering system as on outcome)

At end of shift, patient’s oral fluid intake was 420 ml, 1800 ml of NS IV. Urine output was 1250ml. On auscultation, patient had wheezing bilaterally. +2 pitting edema BLE. Patient reported some improvement in dyspnea. Respirations were 22, pulse 98, BP 156/86.

Process Evaluation: Discuss the effectiveness of each independent intervention in assisting the client to meet the expected outcome: (again, use the same order and numbering system as used with the interventions) 1. Patient reports improvement in dyspnea but continues to have difficulty breathing. 2. Patient is approaching fluid balance, but output is still less than intake. Patient adhered to fluid restriction. 3. Patient has +2 edema in both lower extremeties.

Disposition of the Plan of Care: I will continue

modify

terminate

the nursing care plan as follows:

I would continue the plan of care with the following modification: Assessment: Monitor lab results relevant to fluid retention Interventions: (collaborative): Consult physician if signs/symptoms of excess fluid volume persist or worsen. Administer prescribed diuretics as appropriate.

Rationale for Disposition of Care: Plan would be continued based on patient’s condition showing improvement toward desired outcomes....