Concept Map CHF PDF

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Veronica Neff

Concept Map Geriatrics (321)

Nursing Dx#1 Impaired gas exchange R/T accumulation of fluid in the alveoli capillary membranes AEB, difficulty breathing, crackles in lower lung fields, productive cough and light-yellow sputum. General Goal: Adequate ventilation. Behavioral Outcome: The patient will be able to complete ADL’s without experiencing dyspnea or excessive fatigue by end of shift. Primary Intervention: The nurse will educate both patient and family on causes of impaired gas exchange and the behaviors to prevent it. (independent). Rationale: Promotes decreased hospitalization[ CITATION Phe17 \l 1033 ]. Evaluation: Patient and care givers demonstrated understanding of signs and symptoms of impaired gas exchange by verbalizing four risk factors. Secondary Intervention: The nurse will administer 3L/min oxygen via nasal cannula as ordered. Monitor and record efficacy and adverse reactions to guide daily treatment regimen as per the provider’s order (dependent). Rationale: To enhance oxygenation and detect signs of decompensation. Older patients have a high incident of chronic cardiac and chronic pulmonary disorders and may need supplemental oxygen [ CITATION Hin18 \l 1033 ]. Detecting early change in condition allows for early intervention [CITATION Phe17 \l 1033 ]. Evaluation: Patient remained on oxygen 3L/min nasal cannula as ordered by the provider. Tertiary: The nurse will administer 2.5mg albuterol every 2hours via nebulizer and budesonide 0.5mg every 12 hours via nebulizer as ordered by provider (dependent). Rationale: To promote and maintain a patent airway [ CITATION Phe17 \l 1033 ]. Evaluation: Patient maintained an oxygen baseline at 90% with 3L oxygen via nasal cannula. Outcome Evaluation: Patient was able to complete ADL’s without dyspnea and fatigue by the third day of care.

Veronica Neff

Concept Map Geriatrics (321)

Nursing Dx#2 Fluid volume overload R/T decreased cardiac output AEB edema in lower extremities +2, bilateral crackles, low serum Na 130mEq/L and low hematocrit 32.3%. General Goal: Patient will decrease fluid volume. Behavioral Outcome: The patient will have decrease their +2-pitting edema to a +1-pitting edema in three days. Primary Intervention: The nurse will educate the patient and family members regarding fluid volume excess and its causes (independent). Rationale: Patient and care giver involvement promotes compliance [ CITATION Phe17 \l 1033 ]. Evaluation: Patient and care givers demonstrated understanding of restrictions by explaining the reasons for the fluid and dietary restrictions and planning a menu with permitted foods, such as those low in sodium and potassium and a 24- hour fluid intake schedule. Secondary Intervention: The nurse will weigh the patient daily before breakfast, as ordered, and check for signs and symptoms of fluid retention such a dependent edema in lower extremities (independent). Rationale: Weighing the patient every day at the same time provides consistent readings [ CITATION Phe17 \l 1033 ]. Evaluation: Patient’s pitting edema decreased from a +2-pitting edema to a +1-pitting edema. Tertiary Intervention: The nurse will give fluids, monitor IV flow rate carefully, and have the patient on a low sodium diet as per the doctor’s order (dependent). Rationale: Managing fluid volume and sodium intake enhances compliance of regimen and decreases fluid retention [ CITATION Phe17 \l 1033 ]. Evaluation: Patient was compliant with the fluid restriction regimen and low sodium diet. Outcome Evaluation: Patient has +1 pitting edema in their legs by the third day of care.

Veronica Neff

Concept Map Geriatrics (321)

Nursing Dx#3 Decreased cardiac output R/T pump failure AEB Heart Failure, HTN, and NT Pro BNP 6,921. General Goal: Improve patient’s respiratory status. Behavioral Outcome: Patient will maintain respiratory status within established parameters within three days. Primary: Teach the patient the symptoms of possible cardiac problems: dizziness, indigestion, nausea, retrosternal pain, shortness of breath, and unusual fatigue and weakness (independent). Rationale: Showing the symptoms of decreased cardiac functioning gives the patient a sense of greater control over the situation and encourages compliance with the treatment plan [ CITATION Phe17 \l 1033 ]. Evaluation: Patient demonstrated understanding of decreased cardiac functioning by being able to identify symptoms and prescribed therapeutic regimen. Secondary: Administer 3L/min oxygen via nasal cannula as ordered by the provider especially after the patient eats or during increased activity (dependent). Rationale: To increase oxygenation of the brain and heart[ CITATION Phe17 \l 1033 ]. Evaluation: Patient can eat and perform activities with fewer dyspneic episodes. Tertiary: Nurse will monitor vital signs and perform daily weights and monitor new lab values (independent). Rationale: Monitoring vital signs and lab values for biomarkers provides a better understanding of the progression of the disease [ CITATION Mag18 \l 1033 ]. Evaluation: Patient maintained constant vital signs during the day and received one new lab value (Troponin levels increased from 0.09 to 0.9 ng/mL) Elevated troponin levels are related to CHF[ CITATION Mag18 \l 1033 ] . Outcome Evaluation: Patient maintains normal respiratory status by the third day of care.

Veronica Neff

Concept Map Geriatrics (321)

References Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins. Magnussen, C., & Blankenberg, S. (2018). Biomarkers for heart failure: small molecules with high clinical relevance. The Association fot the Publication of teh Journal of Internal Medicine, 530-543. doi:10.1111/joim.12756 Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Nursing Diagnosis Reference Manual. Philadelphia: Lippencott Williams & Wilkins.

Veronica Neff S: Patient states, “I have to stop eating. My chest is congested, and it is difficult to breathe.” Patient coughs then uses the suction to remove sputum from mouth O: Fatigue, SPO2 90%, productive cough, pale conjunctiva, nail beds, and poor skin turgor, crackles upon auscultation. Dx: Impaired gas exchange R/T accumulation of fluid in the alveoli capillary membranes AEB, difficulty breathing, crackles in lower lung fields, productive cough, and light-yellow sputum. Treatments: Bed or chair rest to reduce O 2 demand, oxygen therapy (3L O2via nasal cannula), increase fluids to loosen sputum, cluster care to preserve patient energy.

Concept Map Geriatrics (321) Patient: 97 YO male Vitals: T: 101.3°F, 97.3°F, P: 56, RR: 18, BP: 129/63, SpO2: 90%, Pain Score: 3 Allergies: Seasonal Code Status: DNR/DNI Dx: Pneumonia due to infectious organism, unspecified laterality, unspecified part of lung, CHF unspecified HF chronicity Special Precautions: DVT

S: Patient state, “I have been short of breath for several days, I’m tired, and I have some swelling in my hands and feet.” O: Edema in lower extremities +2, bilateral crackles, NT Pro BNP of 6,921, low serum Na 130 mEq/L and low hematocrit 32.3%. Dx: Fluid volume overload R/T decreased cardiac output AEB edema in lower extremities +2, bilateral crackles, low serum Na 130 mEq/L and low hematocrit 32.3%. Treatments: low sodium diet, oxygen therapy, 3L O2 via nasal canula, and obtain daily weights. Meds: Lasix (given in ED), Metoprolol, (nitrates) isosorbide.

Meds: Albuterol, Budesonide, and Guaifenesin.

Chief Complaint: Shortness of breath, Cough, and Fever of 101.0 °F

S: Patient states, “I need to sit here at the side of the bed a while before I can move over to the chair because I am out of breadth and my chest hurts.” O: Bilateral crackles, orthopnea, activity intolerance, orthostatic hypotension, and arrhythmias. Dx: Decreased cardiac output R/T pump failure AEB Heart Failure, HTN, and NT Pro BNP 6,921. Treatments: low sodium diet, oxygen therapy, 3L O2 via nasal cannula, and obtain daily weights. Meds: Lasix (given in ED), metoprolol, (nitrates) isosorbide, ASA platelet aggregation inhibitor, clopidogrel platelet aggregation inhibitor.

Key Assessments: Lab Values (CBC: WBC, Neutrophils, Lymphocytes, Bacterium sputum culture and gram stain, Vital signs, Lung Sounds, Skin, nutrition and fluids. Client Stressors: Intrapersonal: chronic illnesses CHF, HF, CAD, HTN, hyperlipidemia, CKD, BPH, anxiety due to difficulty breathing Extrapersonal: Loss of wife, decreased agility, and ability to complete ADL’s Interpersonal: Supportive children and friends, Pt has family which come to visit him regularly at the nursing home and hospital.

Past Medical History: Acute or chronic diastolic HF, CAD, essential HTN, Hyperlipidemia, BPH Past Surgical History: CABG Meds: vitamin D supplement 500mg PO 2xdaily with meals ceftriaxone 1g/50mL IV every 24 hours acetaminophen 1,000mg PO every 8 hours PRN amlodipine 5mg PO 2xdaily ASA 81mg PO 1xdaily benzocaine methanol 15mg lozenge PO every 2hours PRN bisacodyl suppository 10mg rectal PRN budesonide 0.5mg nebulizer every 12 hours albuterol 2.5mg nebulizer every 2 hours clopidogrel 75mg PO daily clotrimazole-betamethasone cream 2xdaily topical finasteride 5mg PO daily guaifenesin 600mg PO 2xdaily heparin 5,000units/mL sc 2xdaily isosorbide 30mg PO daily menthol-zinc oxide ointment 1 application in the AM daily miconazole 2% powder 1 application daily polyethylene glycol 17g PRN daily rosuvastatin 5mg PO given at night 1xdaily tamsulosin 0.4mg PO 2xdaily

Veronica Neff

Concept Map Geriatrics (321)...