CHF care plan

UM Review RN, ASN, RN · Feb 27, 2009

If you can tell us which ones you have and in which order you think they should go, we'll be happy to help you.

Daytonite, BSN, RN · Feb 27, 2009

sounds like a sick guy. i can't help you. all you listed is this man's medical diagnoses and medical treatment. nursing diagnoses are based on the abnormal assessment data obtained during a review of the patient's chart, signs and symptoms of the chf, pulmonary edema and postop heart surgery that are present, your physical assessment (example: lung sounds, heart sounds, blood pressure, etc,), ability to perform adls, and any signs, symptoms and side effects of the medications/treatments he is receiving. once you post that information i can do more for you.

by the way, where are these nursing diagnoses you came up with? i can at least prioritize the list for you. or, you can do it yourself if you like: http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs

Jessicalk05 · Feb 27, 2009

Patient complained of decreased energy, decreased appetite, and increased lower extremity swelling. Had no chest pain, no N &V, some fever, normal BM, cough with sputum, no increase in fluids or diet intake. Smoker and drinker. When I took care of him he was alert, no jvd, normal heart rate, s3 not present, rhonchi and rales present, abdomen was slightly distended, he had 2+ pitting edema in his lower extremities, and generalized edema, he was recieving tube feeding through an OG tube. His ABGs were pH-7.55, PO2-58.7, PCO2-35, HCO3-30.8. His vitals were 98.4, 89, 14, 112/73. EKG shows a 1st degree AV block. I'm not sure what other information you need.

The nursing Dx I have are:

Decreased cardiac output r/t imparied cardiac function AEB 2+ lower extremity edema, generalized edema, and an ejection fraction of 25%.

Excess fluid volume r/t impaired excretion of sodium and water AEB edema, pulmonary edema and rales.

Ineffective health maintenance r/t deficient knowledge regarding self-care and treament AEB (I still have to find a way to phrase this. But him and his family didn't realize that water was a fluid and thats one of the reasons why he wa fluid overloaded when he came into ER)

Imaired gas exchange r/t inadequate cardiac function secondary to heart failure AEB rales and pulmonary edema.

I need at least the 1 pychosocial.

Thanks!

Daytonite, BSN, RN · Feb 28, 2009

use the nursing process to help you problem solve (care plan) this.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology of stemis, chf and pulmonary edema - what signs and symptoms of chf and pulmonary edema does the patient have?

had a stemi a month ago
chf
pulmonary edema
history of smoking and drinking
- medical treaments
  - balloon pump and stenting
  - intubated - what specific monitoring and complications are associated with mechanical ventilation
  - tube feeding through an og tube - what specific monitoring and complications are associated with tube feedings

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - i have oragnized the abnormal data that you posted and grouped them into the problems they are a part of. did you look up congestive heart failure? did you look up what a bnp was and what such a high result meant? with the low o2 was there any evidence of hypoxia? to have a psychosocial diagnosis there must be evidence of a psychosocial symptoms to support one. the most commonly used with heart and respiratory patients is anxiety because of their breathing problems (the sob they have). see a nursing diagnosis book for the symptoms of this diagnosis.

rhonchi and rales
cough with sputum
abgs were ph-7.55, pco2-35, hco3-30.8 - this is metabolic alkalosis
po2-58.7
2+ pitting edema in his lower extremities and generalized edema
ejection fraction is 25%
troponins positive
bnp (b-type natriuretic peptide) was 3035
ekg shows a 1st degree av block
abdomen was slightly distended
decreased appetite
fever
complained of decreased energy
him and his family didn't realize that water was a fluid

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

impaired gas exchange r/t ventilation perfusion imbalance aeb abnormal abgs with ph of 7.55, pco2 of 35, hco3 of 30.8, and po2 of 58.7.
ineffective airway clearance r/t intubation, retained secretions and smoking aeb rhonchi and rales and a cough with sputum
decreased cardiac output r/t altered stroke volume and altered electrical conduction aeb 2+ pitting edema in his lower extremities and generalized edema, ejection fraction is 25%, positive troponins, bnp (b-type natriuretic peptide) of 3035, and 1st degree av block on ekg tracings.
excess fluid volume r/t impaired hydrostatic/oncotic interstitial fluid pressures aeb generalized body edema and bnp (b-type natriuretic peptide) of 3035.
hyperthermia r/t increased metabolic rate aeb fever
fatigue r/t stressful situation aeb patient's complaint of decreased energy
deficient knowledge, fluid restriction r/t information misinterpretation aeb verbalized information from patient that he misunderstood previous discharge instructions regarding fluids allowances.

there is no assessment that provides diagnoses to care for the feeding tube.

decreased cardiac output r/t impaired cardiac function aeb 2+ lower extremity edema, generalized edema, and an ejection fraction of 25%.

by using

decreased cardiac output

we know that "

impaired cardiac function

" is the problem and that is just restating the problem and not telling us what the cause of the problems are.

excess fluid volume r/t impaired excretion of sodium and water aeb edema, pulmonary edema and rales.

the cause of the fluid retention is the failure of the heart. the reason the fluids are collecting in the tissues is because the oncotic pressures of the tissues are greater than the hydrostatic pressure in the vessels so the water is pulled and kept in the tissues. this is a chemical principle. "

pulmonary edema

" is a medical diagnosis and cannot be used as evidence of this diagnosis. "

rales

" in the lungs are evidence of a respiratory and breathing problem and not a fluid retention problem.

ineffective health maintenance r/t deficient knowledge regarding self-care and treatment aeb (i still have to find a way to phrase this. but him and his family didn't realize that water was a fluid and that's one of the reasons why he was fluid overloaded when he came into er)

i understand what you want to get at.

ineffective health maintenance

is used when the patient knows they are supposed to do something but don't do it. in this case, the patient didn't know or didn't understand that they were supposed to restrict their fluid intake so it is a knowledge deficit.

impaired gas exchange r/t inadequate cardiac function secondary to heart failure aeb rales and pulmonary edema.

gas exchange can only be impaired because something is preventing oxygen and carbon dioxide from being exchanged in the alveoli (the air cells of the lungs where carbon dioxide and oxygen exchange takes place). it has nothing to do with cardiac function. when impaired, the alveoli are blocked by exudates or altered by disease processes (as in copd). again, you can't use a medical diagnosis (

pulmonary edema

) as evidence that this problem exists.

rales

are not appropriate evidence that this problem exists either. when carbon dioxide and oxygen are not being exchanged efficiently in the alveoli the patient will have abnormal abgs, become cyanotic, get diaphoretic and show symptoms of hypoxia or hypercapnia.