I need help writing a careplan please

[Steshawna]

My patient has a medical diagnosis of CCF and he has dullness to percussion in lungs,crackles, decreased excursion of diaphragm, abdomen distended, pitting edema,swelling in lower limbs, S3 sounds.my diagnostic label is excess fluid volume but I need a good related to factor and a measurable goal please.

[nursej22, MSN, RN]

Sorry, what is CCF?

As for a measurable goal for excess fluid volume? hmm, what can you measure related to volume....?

[Steshawna]

CCF is congestive cardiac failure...I just need a nursing diagnosis with excess fluid volume and a objective

[Steshawna]

I have excess fluid volume related to fluid shift from intravascular space to extra vascular space secondary to congestive cardiac failure... Is that ok

[Steshawna]

I have excess fluid volume related to fluid shift from intravascular space to extra vascular space secondary to congestive cardiac failure... Is that ok

[nursej22, MSN, RN]

I have excess fluid volume related to fluid shift from intravascular space to extra vascular space secondary to congestive cardiac failure... Is that ok

I think you are over thinking this. In heart failure, excess fluid is directly related to the heart's failure to effectively pump blood/fluid through the body, either because of a weak pump or an inability to fill.

The following is from Excess Fluid Volume – Nursing Diagnosis & Care Plan - Nurseslabs :

Here are some factors that may be related to Excess Fluid Volume:

Compromised regulatory mechanisms

Decreased cardiac output; chronic or acute heart disease

Excessive fluid intake

Excessive sodium intake

Head injury

Hormonal disturbances

Liver disease

Low protein intake

Malnutrition

Renal insufficiency

Severe stress

Steroid therapy

On that same site, you will find possible nursing goals and interventions.

[Steshawna]

My lecturer is very peticular she likes when the related to is the pathophysiology of the condition.I should also mention that my patient has a history of hypertension and he is diabetic.

[Steshawna]

My careplan is due on Wednesday so I really appreciate the input

[Steshawna]

At first I had excess fluid volume related to decreased contractility of the heart muscles secondary to congestive cardiac failure an my lecturer said it's not that alone its related to... Then I wrote a second one excess fluid volume related to compromised regulatory mechanisms secondary to congestive cardiac failure and my lecturer said I must read upon the pathophysiology of congestive cardiac failure.. So I don't know what else to write...

[Steshawna]

At first I had excess fluid volume related to decreased contractility of the heart muscles secondary to congestive cardiac failure an my lecturer said it's not that alone its related to... Then I wrote a second one excess fluid volume related to compromised regulatory mechanisms secondary to congestive cardiac failure and my lecturer said I must read upon the pathophysiology of congestive cardiac failure.. So I don't know what else to write...

[nursej22, MSN, RN]

Hmm, it looks as though she is trying to tie pathophysiology in with care planning.

I am not familiar with this method, sorry. Also, because I am not sure how in depth you are going, I hesitate to say more. Perhaps she wants you to cite the RAAS system/dysfunction?

[KrCmommy522, BSN, RN]

As nursej22 stated, "In HF, excess fluid is directly related to the heart's failure to effectively pump blood/fluid through the body, either because of a weak pump or an inability to fill." That is the pathophysiology.

So, if your instructor wants you to relate the pathophysiology in your diagnosis, I would say something about a compromised regulatory mechanism (i.e., the heart) not being able to pump the excess fluid - what is it in your pt - weak pump or inability to fill.

R/t factors as nursej22 stated, include

Compromised regulatory mechanisms

Decreased CO; chronic or acute heart disease

Etc.

I would find which ones of those is related to the pathophysiology of HF in your specific pt and use that. Maybe use your second diagnosis and say secondary to congestive cardiac failure compromising the regulatory systems and not able to pump excess fluid out? Or something along those lines? I never had an instructor want the pathophysiology in the diagnosis like that? When I was in school they definitely wanted us to know the pathophysiology of the disease processes, and how it led to our diagnoses (so on our care plans, we had an area for pathophysiology).

You stated that the instructor wanted you to read upon the pathophysiology of congestive cardiac failure - which the second diagnosis does, and it's an accepted nursing diagnosis using NANDA-I. I'm not sure what exactly your instructor wants. So, maybe someone else can provide more input! Good luck!