Fluid overload care plan

[Dirty_Scrubs]

I need help with my care plan. I do not fully understand how to make a care plan and I am not really sure if i did it correctly. Can someone please check it and give me feed back on the nursing diagnosis and interventions to make the correct changes.

Age: 50 Sex: Female HT: 173cm WT: 94.2/kg ALLERGY: NKA

Chief Complaint: SOB, chest pain, wt. gain, Admitting Diagnosis: Fluid overload

Pathophysiology: Fluid overload is an excess of body fluid. This is a problem of too much fluid intake or fluid retention greater than what the body needs. Problems result in excessive fluid in the extracellular fluid space.

PMHx: Fluid Volume overload, HTN, CKD, Anemia, Chole, C-section, atrial fibrillation.

Lab/Test Results:

CBC 5/3/18 5/1/18

WBC 7.97 4.37 L

RBC 3.71 L 4.14

Hgb 11.9 12.9

Hct 34.8 38.9

MCV 93.8 94

MCH 32.1 31.2

MCHC 34.2 33.2

RDW-CV 14.7 14.7

Platelet C 135 L 142

MPV 11.8 11.3

NRBC Auto Rel 0

NRBC A Abd

NRMC% 0.0

Automatic Differential 5/1/18

Neutrophil Rel 84.9 H

Lymphocyte Rel 11.7 L

Monocyte Rel 3.0

Immature Gran Rel 0.5

Neutrophil Abs 3.71

Lymphocyte Abs 0.51 L

Monocyte Abs 0.13 L

Immature Gran Abs

Routine Chemistry 5/3/18 5/1/18

Glucose Level 127 H 166H

Sodium Lvl 139 137

Potassium 4.4 5.3 H

Cholride 103 105

CO2 26 22 L

AGAP 14 15

Calcium 9.6 9.6

BUN 55 H 40 H

Creat Lvl 5.55 H 4.29 H

Albu Lvl 3.1 L 3.1 L

GRF Af A 9 L 13 L

GFR Non Af A 8 L 11 L

Mag 2.2 2.6

Phosphate 3.9 2.4

Pending procedures:

Assessment Findings:

Neuro: A&O x4, PERRLA

Cardio: 60 bpm at apical with regular heart rate and rhythm with occasional irregularity noted. Bilateral radial pulse strong at 60 bmp, bilateral weak pedal pulses at 58bmp. Abnormal ECG strip with no clear P waves. Denies chest pain.

Pulm: Bilateral lung sounds clear to auscultation, O2@98% roomair. Patient denies short of breath.

GI: Cardiac diet, 1500mL fluid restriction, abdomin soft round non-tender, normal bowel sounds to all 4 quads.

GU: No u/o, dialysis removal of 3.3 L.

MS: Pt. is independent, steady gait

Skin: Clean, dry, IV access to RUA and Right Sub-clavian with clear dressing intact, edema 3+ up to ankles, bilateral feet cool to touch.

IV Site: RUA powerglide, R permacath (dialysis only)

Vital Signs: Temp_97.6_ P _60__ R _20__ B/P __126/75_ SpO2 _98_% on _RA__ Pain ***_0/10_

Medications:

Acyclovir 200 mg 1 cap PO BID

Apixaban 2.5mg 1 tab PO BID

Calcitriol 0.25mcg 1 cap PO daily

Cholecalciferol 5,000 units= 1 tab PO daily

Cyanocobalamin vit 100 mcg 1 tab PO daily

Dexamethasone 40mg PO Daily

Colace 100mg 1 cap PO BID

Ferrous sulfate 325mg 1 tab PO daily

Folic acid 0.4mg 1 tab PO daily

Metropolol 50mg 1 tab PO Daily hold for HR

Multivvit 1 tab PO daily

Omega 3- poly 1000 mg 1 cap PO Daily

Sodium chloride NS flush 3ml inj IV push Q shift times 12hr

Vit E 1,000 units 1 cap PO daily.

Nursing Diagnosis #1:Decreased cardiac output R/T alteration in heart rate and rhythm AEB EKG showing abnormalities noted with no distinguishing P waves.

STG: By the end of the shift, the patient will Verbalize signs and symptoms of cardiac decompensation AEB pt. restating signs and symptoms of cardiac decompensation.

LTG: By discharge, the patient will continue to show no signs and symptoms of side effects regarding medications used to achieve adequate cardiac output AEB heart rate greater than or equal to 60.

1. Intervention/rationale/outcome: Teach patient to observe for and report chest pain or discomfort; note location, radiation, severity, quality, duration, and associated manifestations such as nausea, indigestion, or diaphoresis; also note precipitating and relieving factors. Rational: Chest pain/discomfort may indicate an inadequate blood supply to the heart, which can further compromise cardiac output. Clients with decreased cardiac output may present with myocardial ischemia. Those with myocardial ischemia may present with decreased cardiac output and HF.

2. Intervention/rationale/outcome: Teach patient to recognize primary characteristics of decreased cardiac output as fatigue, dyspnea, edema, orthopnea, and paroxysmal nocturnal dyspnea. Recognize secondary characteristics of decreased cardiac output as weight gain, jugular venous distention, palpitations, lung crackles, oliguria, coughing, clammy skin, and skin color changes. Rational: A nursing study to validate characteristics of the nursing diagnosis decreased cardiac output in a clinical environment identified and categorized related client characteristics that were present as primary or secondary.

3. Intervention/rationale/outcome: Monitor and report presence and degree of symptoms including dyspnea at rest or with reduced exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, distended abdomen, fatigue, or weakness. Monitor and report signs including jugular vein distention, S3 gallop, rales, positive hepatojugular reflux, ascites, laterally displaced or pronounced point of maximal impact, heart murmurs, narrow pulse pressure, cool extremities, tachycardia with pulsus alternans, and irregular heartbeat. Rational: These are symptoms and signs consistent with HF and decreased cardiac output.

4. Intervention/rationale/outcome: Check blood pressure, pulse, and condition before administering cardiac medications such as beta-blockers. Rational: It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medications.

EVAL/OUTCOME: MET patient was able to identify chest pain, fatigue, dyspnea, and weight gain as a sign and symptom of cardiac decompensation. Patient heart rate remained greater than or equal to 60.

Nursing Diagnosis #2: Excess Fluid Volume r/t compromised regulatory mechanism AEB peripheral edema.

STG: By the end of the shift, the patient will be able to demonstrate actions that are needed to treat excess fluid volume AEB patient adhering to fluid and diet restrictions.

LTG: By discharge, the patient will Show decrease excess fluid volume AEB decrease in peripheral edema less than or equal to 1+.

1. Intervention/rationale/outcome: Teach patient the importance of adhering to 1500cc fluid restriction. Adhering to fluid and diet restrictions may decrease intravascular volume and myocardial workload.

2. Intervention/rationale/outcome: Teach patient cardiac diet selections from menu. Adhering to fluid and diet restrictions may decrease intravascular volume and myocardial workload.

3. Intervention/rationale/outcome: Monitor location and extent of edema using 1+ to 4+ scale to quality edema. Rational: Causes of peripheral edema in patients with heart failure are related to medications, compensatory changes that influence hydrostatic pressure, and fluid retention, among other things.

4. Intervention/rationale/outcome: Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast. Body weight changes reflect changes in the body fluid volume.

EVAL/OUTCOME: Partially Met: Patient was able to adhere to fluid and diet restrictions. Ongoing due to patient with continued edema to bilateral extremities.

Nursing Diagnosis #3: Ineffective peripheral tissue perfusion r/t interruption of arterial flow AEB peripheral pulses less than apical pulse and bilateral lower extremities cool to touch.

STG: By the end of the shift, the patient will Identify measures needed to increase tissue perfusion AEB patient able to demonstrate measures.

LTG: By discharge, the patient will demonstrate adequate tissue perfusion to lower extremities AEB peripheral pulses equal to apical pulse, bilateral lower extremities warm to touch.

1. Intervention/rationale/outcome: Teach patient to avoid elevating legs above heart level, Results: indicate leg elevation above the heart decreases arterial blood supply to the legs.

2. Intervention/rationale/outcome: Teach patient exercise such as walking 30min per day will help increase perfusion to lower extremities. EB: Walking increases perfusion to lower extremities.

3. Intervention/rationale/outcome: Monitor peripheral pulses. If there is new onset of loss of pulses with color changes and extreme pain, notify health care provider. Rational: these symptoms are of arterial obstruction that can result in loss of limb in not immediately reversed.

4. Intervention/rationale/outcome: Keep patient feet warm, have patient wear socks and shoes when mobile. Rational: Keeping feet warm helps maintain vasodilation and blood supply. Do not apply heat. Heat application can easily damage ischemic tissue.

EVAL/OUTCOME: Partially met: Patient was able to demonstrate walking exercise for 30min. Patient able to avoid elevating legs above heart level. Patients peripheral pulses not equal to apical pulse.

Communication: Patient can read, write, and speak English. No concerns with communication.

Safety/Risk Assessment: The patient is at risk for electrolyte imbalance.

Learning Needs:

1. Teach patient the importance of adhering to diet and fluid restriction.

2. Teach patient the signs and symptoms of fluid overload as well as electrolyte imbalance and to report any changes.

3. Teach patient the importance of daily weights at the same time with the same clothes on the same scale.

Psychosocial Assessment: Patient appears to be psychologically stable and motivated. Patient agrees and makes sure she adheres to diet and fluid restriction. Patient appears motivated to learn and asks questions regarding diet choices.

Interdisciplinary Care: Cardiologist, dietician, and palliative care consult.

Discharge Plan: Patient will be discharged to home with home health services.

[MilliePieRN]

"Nursing Diagnosis #1 Decreased cardiac output R/T alteration in heart rate and rhythm AEB EKG showing abnormalities noted with no distinguishing P waves."

I'll take a stab at this one.

Your AEB (evidence/proof) should be pt symptoms/data that support your nursing diagnosis NOT evidence/proof that prove your r/t. This is a common mistake nursing students make.

Decreased cardiac output R/T cardiomyopathy and atrial fibrillation AEB dyspnea with minimal exertion, weight gain of 5lbs over 1 week, and pt report of increased fatigue.

(Just an example, not saying this dx suits your pt). The other dx you wrote don't have the same mistake.