Hey i'm a first year nuring student and i'm having a little trouble with a chf nursing diagnosis. My patient was admitted for decompensated CHF, but the day i took care of her she wasn't experiencing a whole lot of symptoms. I need some help coming up with a couple of acceptable priority nursing diagnoses without a lot to work with. Her edema that she had 2 days previous was gone. She had no SOB and clear, but diminished breath sounds. Her pulse ox was ranging from 90-95%. Her BP was hovering around 140/80 and pulses within normal limits. With all the lasix she had been given in the last couple of days, her urine output was 1600ml in about 7 hours. She was having a lot of pain in her lower legs and feet...she attributed that to the swelling she had the last couple of days although, like i said, that was gone by the time i was taking care of her. I can think of a couple of nur dx but i'm having trouble completing them... I guess i'm not the best at this part of the care plan.
1. Decreased cardiac output r/t impaired cardiac function AMB ?? (i can't think of any manifestations that would fit this for her symptoms that day)
2. Acute pain r/t ?? AMB pain rating 8/10 with numerical scale (i'm not sure what would be causing the pain... my instructor said that r/t previous edema in the lower extremities she isn't sure that was the cause) Her pain was really the only syptoms i was treating that day...
She was on bed rest so i was thinking about activity intolerance... and she c/o no bm's for 3 days so i could use constipation but i'm not sure those would be priority nur dx.
Thank you in advance for any help!