MP HF concept map PDF

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Summary

concept map HF...

Description

Rodshanna Cason Signs and Symptoms Medical Dx/ Reason for Admission/history/Age Age 61 year old female. Past Medical History *COPD *BOOP *chronic hypercapnic respiratory failure *Diastolic HF *HTN *Anemia *GERD Reason for Admission

Objective rhonchi heard on auscultation.Nonproductive cough. restless, fatigue. Temperature: 98 (36.6), Pulse: 83, Respiration Rate: 20 SpO2:99% (3L of o2)Blood Pressure: 93/67 Subjective Patient reported that she couldn't perform ADLS because she felt breathless. she also said that the DOE is worsening.

Nursing Diagnosis Impaired gas exchange related to heart failure as evidenced by patient reporting that she felt breathless. Nursing Interventions/ Rationales

Do

Short Term Goal 1. Patient's SOB should be relieved by end of shift 2. Patient sodium levels decreased to normal ranges within 72hrs Long Term Goal Patient tells nursing staff about exacerbation symptoms and when to call dr by discharge.

Evaluation

Acute respiratory failure

Nursing Interventions Assess * Assess the rate of PEEP qshift. *Assess respiratory rate, use of accessory muscles, cyanosis, and significant changes in vital signs. *Assess fluid volume status

Outcomes

patient was not successful in relieving SOB. The patient actually went into respiratory failure from being hypercapnic and had to be intubated. Pt intubated for 8 days then extubated. Pt is now on BIPAP with PEEP at night. Patient sodium levels were within normal ranges with 2 days. Pt understands that if she has any exacerbation symptoms ( weight gain, edema, DOE, cough, fatique, wheezing) she should call her doctor

Rationales for Nursing Interventions Assess* The peep helps the alveoli from collapsing by pushing air into lungs, the normal range is between 5-10. *These are warning signs of respiratory distress and requires immediate attention. *Ensure there isn't fluid retention, due to sodium build up.

Do *Relaxes the body and promotes comfort *Encourage patient to have adequate bed rest and sleep *Monitor patient for edema in lower extremities *Edema is a clinical manifestation in patients with HF *Admin. nitrates *Acts as a coronary vasodilators *Have an airway emergency equipment available at the bedside. *Just in case the patient goes into cardiac arrest Teach Teach *The low sodium diet will help minimize the amount of extra fluid around the heart, lungs, and the legs. *Teach patient to maintain a low sodium diet * If the patient is gaining weight rapidly it may indicate that he/she is * Inform patient to to call HCP if any weight gain of 3 pounds Ref: retaining fluid. over 2 days or a 3-5 pounds gain over a week. *Patient should be monitoring for edema, SOB, fatigue, and coughing. If *Teach importance to report exacerbation symptoms of HF and COPD. patient experiences these symptoms they should call HCP or call to ED. ). Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis's medical-surgical nursing: Assessment and management of clinical problems. Elsevier....