CHF Careplan Priorities

[shelliemarie]

Ok, so I am near the end of 1st semester LPN school. I am doing my last case study, on a patient with CHF. Patient has had CHF and HTN for awhile, and has just been re-hospitalized. The Assessment data is RR28, Crackles in bilateral lower lobes, Short of Breath with minimal exertion,and on oxygen 4/L/Min, HR 85 w/regular rhythm, BP 154/89,Cap Refil less than 3 sec, 3+ pitting edema in bilateral lower extremities, Has a foley cath, Moves all extremities well, and has no wounds, etc, all skin is warm dry and intact. Now I have to have 3 diagnoses, and in my NCP book it says the priority is Decreased cardiac output, which is causing all of the abnormal assessment data such as the Crackles, SOB, Edema, etc. So I think this is my priority Diagnosis, however; You always prioritize as Airway Breathing Circulation, and in my opinion this patient is having alot of trouble breathing. So would I diagnose Ineffective airway clearance, or the Decreased Cardiac output??? The Decreased Cardiac Output and Excess Fluid Volume are what is causing the Crackles and SOB, so If I used those as priority then I would like to think that would address the breathing issues, but I am just unsure, I figured if I address the cause of the problem, then that would be better. If her cardiac output was increased and the excess fluid volume would get to regular parameters, then that would address/remedy the crackles and SOB?? I really need to do awesome on this plan to. So Please help me if you can! Thanks

[SuesquatchRN, BSN, RN]

Well, are they even having trouble clearing their airway? That isn't necessarily the cause of SOB. :)

[shelliemarie]

I don't think they are, this is a "scenario" on a simulated manican (don't know if I spelled that right). They give us an assessment data sheet and why they were admitted age/sex and then we have to do the Nursing Care Plan. I think what I meant earlier was impaired gas exchange. So I have 4 diagnosis to choose from, I only need 3. Decreased Cardiac output R/T impaired myocardial contractibility AEB 3+Pitting Edema to Bilat. Lower extremities, Crackles in Bilat lower lobes and HTN 154/89. Next is Excessive Fluid Volume R/T decreased cardiac output AEB 3+ pitting edema, crackles. And then I have Activity Intolerance R/T Insufficient Oxygen AEB SOB w/Minimal exertion. I want to know If I should use Impaired Gas Exchange R/T Alveolar Edema AEB Crackles in Bilat. Lower Lobes, SOB w/minimal exertion,RR28. I was always taught ABC ABC ABC sometimes the NCP book is not going by Abc, like they will put a psychosocial before a physiological need. In my book it has Risk for impaired gas exchange as the last diagnosis, but I don't think its a risk because shes on oxygen and on Bedrest and her respirations are still high, as well as she gets SOB so easily. That makes me think somethings now right! HELP! I spent all day yesterday trying to figure it out, which one comes first?

[DolceVita, ADN, BSN, RN]

Think gas exchange.

[shelliemarie]

You think so? So then Impaired Gas Exchange R/T Alvolear edema AEB SOB W/minimal exertion and RR 28, Then next Decreased Cardiac Output R/T Impaired myocardail contractibility AEB 3+ pitting edema To Bilat. Lower extremeties, Crackles in Bilat. Lower Lungs. And then the last one would be Excess Fluid Volume R/T Decreased Cardiac Output AEB 3+ pitting edema, Crackles. Does that sound right? Then Director of nurses is grading this one lol, so I really want to be right. Thanks for ANY comments/Help VERY much appreciated

[SuesquatchRN, BSN, RN]

Sounds very good. I would, however, go with Decreased cardiac output as that is the root of it all, then fluid retention because that's the cause of the lungs problems leading to impaired gas exchange. But I have never understood how nursing instructors grade, so don't go by me.

:)

[shelliemarie]

They grade us on the order of priority for the patient. So if theres 3 diagnosis, they want them in order from the most important down. So Decreased Cardiac Output is the main diagnosis, then Excess Fluid Volume, then Impaired Gas Exchange? lol Thats what I had in the beginnig, and i have been killing myself all weekend over this plan. So I hope that is right, because like I said the director is grading it, so I really want it to be right. Thank you!