Having trouble with my nursing care plan

[CilliansMommy06]

Ok, so I will briefly tell you about my client:

48 yr old male

admitted for dyspnea

medical history of CHF and secondary to noncompliance and CAD

stent put in left anterior descending artery

complains of leg pains but theres no presence of edema

rales heard in lungs on admission, but were clear when I listened to them

bp 142/84

apical pulse 90

RR 26

pulse ox 95%

smokes 3/4 PPD

drinks occasionally

intake 320 ml

output 160 ml

he is depressed and been stressed out for some time

Ok, so now I have to come up with as many diagnosis as I can and pick the primary one. I have come up with many but the one I think would the be the primary is decreased cardiac output r/t impaired cardiac output AMB shortness of breath, elevated bp, and respiratory rate above normal limits. My outcome is client demonstrates adequate cardiac output as evidence by blood pressure, pulse rate, and respiratory rate within normal limits. So, my question is am I right with this? This is my first nursing care plan and I am not sure if I am doing this right =/. Any input would be appreciated!

[Blue Cat]

I think I would make the priority either impaired gas exchange or ineffective breathing pattern. He was admitted for dyspnea, RR is 26 and his O2 sats are low.

Blue

[Somewherenear]

I agree with Blue... you're biggest concern with this patient is with his breathing since that is the reason for seeking care, and as always ABCs - airway, breathing, circulation.

Also, dypsnea is a big concern with a lot of CHF patients.

Here's a sample diagnosis you could right.

Altered respiratory status related to diagnosis of CHF as evidenced by O2 sat at 95%, respiratory rate at 26, patient reports difficulty breathing with minimal exertion (?), tripod position (?) and when laying flat(?), rales heard bilaterally.

Goals: Client will report no respiratory distress, O2 sat will normalize, and respriatory rate will be within normal range.

Interventions:

- cardiovascular and respiratory assessments to establish baseline data

- elevate head of bed up to reduce pressure on chest and allow for lung expansion

- encourage/teach smoking cessation

- monitor intake and output

Good luck to you!