Help with possible NANDA'S and care plan

[everydaytr]

Help with possible NANDA'S and care plan please for the following:

A 74-year-old woman is admitted to the hospital with heart failure. She had been growing progressively weaker and had ankle edema, dyspnea on exertion, and three-pillow orthopnea. On admission, she is severely dyspneic and can answer questions only with one-word phrases. She is diaphoretic, with a heart rate of 132 beats/min, and blood pressure 98/70. She is extremely anxious.

The nurse performs a physical assessment of the client with heart failure and defers questions until the client has gained some relief as a result of emergency interventions. The priority assessments are as follows:

Focused assessments of the heart and lungs

Pulse oximetry

Capillary refill

Presence of cyanosis

Hydration

Evaluation for edema

Level of anxiety

Your client's presenting symptoms are as follows:

weakness caused by diminished cardiac output

Ankle edema caused by ineffective circulation and poor venous return

Three pillow orthopnea resulting from the need to keep a high recumbent position for ease of breathing

severe dyspnea resulting from rising pulmonary venous pressure and pulmonary congestion

tachycardia caused by impaired mycardial perfusion

hypotension related to the shift of vascular fluids

anxiety resulting from hypoxia

[TheCommuter, BSN, RN]

Is this a homework assignment? Have you been able to think of any possible NANDAs that might apply to the aforementioned case study?

One of the purposes of learning how to formulate plans of care is to encourage nursing students to develop and refine critical thinking skills that will serve them well for the remainder of their healthcare careers. So, what have you come up with so far?

[everydaytr]

It is a case study that our class is working on. My problem is that I thought that the NANDA as stated in the taxonomy would be Cardiac Output, Decreased, but this seems very vague. I am wondering if it would be better to say something like:

Activity intolerance related to decreased cardiac output or activity intolerance or self care deficit since she can only answer with one word and can not seem to care for herself.

I don't know if I am on the right track or way off clue.

[everydaytr]

I also was thinking that a NANDA of Communication: verbal impaired might be in order. I am way off or would this apply?

[everydaytr]

I also thought of a NANDA of Fluid Volume, Excess.

[tnbutterfly - Mary, BSN]

Moved to Nursing Student Assistance for more response.

[Esme12, ASN, BSN, RN]

OP......do you still need help with your care plan????