Pt with CHF, COPD and edema!!! HELP?!?!

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I am writing a care plan for a pt. A little hx is that he has COPD, CHF, kidney disease, hypertension and on assessment he has bilateral 2+ pitting edema in his lower extremities. He has been a smoker for most of his life but quit about 2 years ago. He has thromboangiitis obliterans (Buerger's disease) as well but it has been quiescent since he stopped smoking.

This is one of the nursing Dx I came up with:

Ineffective peripheral tissue perfusion r/t compromised blood flow secondary to congestive heart failure, chronic obstructive pulmonary disease, and thromboangiitis obliterans manifested by lower extremity edema, cool hands and feet, and diminished peripheral pulses.

I am trying to come up with nursing interventions and I'm having a hard time...maybe it's just lack of sleep. The pt is on bed rest due to his edema. Should he be doing range of motion exercises? But only to his unaffeced extremities (a.k.a his arms, head...). Should he keep his legs in a dependent position and keep them warm? I don't think his legs should be elevated since since this could be a contraindication due to his CHF/COPD..

I only need to come up with 2 interventions..Any other ideas?

I also did have another diagnosis of:

Activity intolerance r/t compromised oxygen transport system secondary to congestive heart failure and chronic obstructive pulmonary disease manifested by weakness, and dyspnea with exertion

Is this a good diagnosis for him? What type of interventions could I use??

My last diagnosis had to do with impaired gas exchange and I got that one all figured out already.

Any help would be appreciated!!!!!!!!!!

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I would go with your first diagnosis of: Ineffective peripheral tissue perfusion r/t compromised blood flow secondary to congestive heart failure, chronic obstructive pulmonary disease, and thromboangiitis obliterans manifested by lower extremity edema, cool hands and feet, and diminished peripheral pulses.

However, that one seems a little lengthy to me with the secondary to list. I think I would just go with CHF and thromboangiitis obliterans.

As far as interventions: TEDS for edema, teach low salt diet to prevent further water retention, his legs should be kept elevated.

I would think he would want to do ROM exercises to promote circulation (passively or otherwise), stopping of course if the patient experiences any pain. The only time I would think not to do exercises would be if the patient had orthopedic surgery in which the joint needs to stay aligned. That's my thought as a fellow student anyways. Good luck.

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Oh...some other tidbits I thought of off the top of my head. If he has poor peripheral tissue perfusion to his extermities, he might not be able to sense whether or not water is hot or cold. Teach him other ways to test for water temperature to prevent him from burning himself, which could lead to skin breakdown. And of course, teach him the importance of good skin care as he is more prone to skin breakdown with poor perfusion to his extremities.

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I would go with your first diagnosis of: Ineffective peripheral tissue perfusion r/t compromised blood flow secondary to congestive heart failure, chronic obstructive pulmonary disease, and thromboangiitis obliterans manifested by lower extremity edema, cool hands and feet, and diminished peripheral pulses.

However, that one seems a little lengthy to me with the secondary to list. I think I would just go with CHF and thromboangiitis obliterans.

As far as interventions: TEDS for edema, teach low salt diet to prevent further water retention, his legs should be kept elevated.

I would think he would want to do ROM exercises to promote circulation (passively or otherwise), stopping of course if the patient experiences any pain. The only time I would think not to do exercises would be if the patient had orthopedic surgery in which the joint needs to stay aligned. That's my thought as a fellow student anyways. Good luck.

Thank you so much!! Your input has definitely helped me!!!

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One things though, are compression stockings able to be used for PITTING edema??

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Hmm...I wouldn't think compression stockings would be as effective. When I think of lower extremity edema, I think of the whole foot and up half way the calf having edemous. The compression stockings only wrap around the calfs. I have also seen nurses use the elastic ace bandage to wrap tightly around the lower extremity. Ace bandage seems even better then TEDS to me!

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Hmm...I wouldn't think compression stockings would be as effective. When I think of lower extremity edema, I think of the whole foot and up half way the calf having edemous. The compression stockings only wrap around the calfs. I have also seen nurses use the elastic ace bandage to wrap tightly around the lower extremity. Ace bandage seems even better then TEDS to me!

I'm just not sure about the whole compression of the lower extremities thing now, because if my diagnosis is ineffective peripheral tissue perfusion, wouldn't some type of compression be making this worse because it's promoting venous blood flow back to the heart when blood needs to be getting to the lower extremities? Or does this just promote blood flow as a whole...so blood is able to circulate better to and from the heart??

I don't know why but I'm so confused!!!!

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My thinking is that if you have edema, third spacing. That means fluid from your veins have escaped into your tissues. If you can promote fluid to return to the venous blood flow, I would think it would be a good thing.

As far as promoting venous blood flow back to the heart, why do you think any blood needs to get to the heart in the first place? Or even, what in the blood do the lower exteremities need to be perfused with exactly? Blood flow to the heart is ___, and blood flow leaving the heart is ___ is one clue.

Part of the battle in nursing school is trying to think this way. I'm still working on it myself!

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My thinking is that if you have edema, third spacing. That means fluid from your veins have escaped into your tissues. If you can promote fluid to return to the venous blood flow, I would think it would be a good thing.

As far as promoting venous blood flow back to the heart, why do you think any blood needs to get to the heart in the first place? Or even, what in the blood do the lower exteremities need to be perfused with exactly? Blood flow to the heart is ___, and blood flow leaving the heart is ___ is one clue.

Part of the battle in nursing school is trying to think this way. I'm still working on it myself!

Oh Ok I get what you're saying now, blow flow to the heart is deoxygenated and blood flow leaving the heart is oxygenated. So this edematous blood in the lower extremities needs to get back to the heart so it can get oxygenated and then perfuse the lower extremities.

That does make a lot more sense. I don't know why I couldn't think of this before...

Thanks!!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

looking at some of the posts on https://allnurses.com/general-nursing-student/help-care-plans-286986.html- help with care plans which includes a lot of different information on care plan construction and diagnosis might be helpful for you. a care plan should be constructed using the steps of the nursing process to help you organize. the information you collect is used to build upon the next step of the process. the nursing process is the problem solving tool we use in our profession. a care plan is merely a collection of a patient's nursing problems along with strategies of how we are going to treat and solve those problems.

  1. assessment
  2. nursing diagnosis
  3. planning (writing goals and interventions)
  4. implementation
  5. evaluation

so, first thing i did was go back through what you posted and collect all your assessment data. i want you to notice, however, how i listed it:

  • medical history:
    • thromboangiitis obliterans (buerger's disease)
    • hypertension
    • smoker (quit 2 years ago)
    • chf
    • copd
    • kidney disease

    [*]abnormal physical data:

    • bilateral 2+ pitting edema in his lower extremities
    • cool hands and feet
    • diminished peripheral pulses.

one of the things that is important as a learner is to look up the pathophysiology, signs and symptoms and complications of the medical diseases and conditions that the patient has, especially if this hasn't been covered in class lectures yet. this information is important to the understanding of the cause (why) of the nursing problems you are attempting to identify. understanding the pathophysiology helps explain why a symptom is occurring. this is also part of the assessment process.

once assessment is completed we can move onto diagnosing. diagnosing is based upon the abnormal data gleaned from examining the situation and analyzing what we have. the diagnostic statement has 3 parts and assessment data has input into each part of that statement.

ineffective peripheral tissue perfusion r/t compromised blood flow secondary to congestive heart failure, chronic obstructive pulmonary disease, and thromboangiitis obliterans manifested by lower extremity edema, cool hands and feet, and diminished peripheral pulses.

  • problem: ineffective peripheral tissue perfusion.
    definition
    :
    decrease in blood circulation to the periphery that may compromise health.

    • in using this diagnosis you are referring to blood flow, specifically
      arterial
      blood, not getting to the cells of the patient's peripheral parts of his body. the medical problem going on is one of ischemia that produces the symptoms. [this long term ischemia process can also go on in the heart
      (a different medical diagnosis)
      producing chest pain, arrhythmias and eventually heart attacks except that we would diagnose as
      decreased cardiac output.
      ]

    [*]
    etiology:

    • compromised blood flow

      • secondary to:

        • congestive heart failure

        • chronic obstructive pulmonary disease

        • thromboangiitis obliterans

        • hypertension

        • (__ years of) smoking

          • you need to look up the pathophysiology of this disease:
            http://www.merck.com/mmpe/sec07/ch080/ch080h.html

          • although he no longer smokes, it is the smoking that brought about the problem, his hypertension contributed to it and thromboangiitis obliterans is the medical name for it. thromboangiitis obliterans is chronic, progressive and has complications. chf and copd have nothing to do with how this problem began or is continuing to evolve.

          • etiology:
            impaired arterial blood flow secondary to thromboangiitis obliterans, hypertension and __ years of smoking

    [*]
    symptoms:

    • lower extremity edema

      • "bilateral 2+ pitting edema in his lower extremities" which you listed in your post would be better

      [*]
      cool hands and feet

      [*]
      diminished peripheral pulses.

    [*]see

i am trying to come up with nursing interventions and i'm having a hard time

interventions are step #3 of the nursing process when care planning and follow step #1 (assessment) and step #2 (diagnosis). just as doctors most often treat the symptoms of a disease (diagnosis), so do we. look at the symptoms for your diagnosis. what can you, the nurse, do for that edema? what can you do for his cold hands and feet? what about those poor pulses? that may be a little trickier.

there are four types of nursing interventions (actions) that we nurses can perform:

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)

  • care/perform/provide/assist (performing actual patient care)

  • teach/educate/instruct/supervise (educating patient or caregiver)

  • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

read about the disease and how the doctor would treat it as well. follow some of their recommendations. think about how the patient's symptoms impact their ability to perform their adls. search the internet for information about the disease and home care. you will find a lot of information since there are thousands of older smokers in our society dealing with this disease.

i only need to come up with 2 interventions

challenge yourself. at minimum, you should be able to come up with at least 4 (an assessment, one item of care, a teaching intervention and one management intervention) for each symptom!

activity intolerance r/t compromised oxygen transport system secondary to congestive heart failure and chronic obstructive pulmonary disease manifested by weakness, and dyspnea with exertion

never diagnosis someone with something unless you understand what it is.
activity intolerance
.
definition
:
insufficient physiological or psychological energy to endure or complete required or desired daily activities
(page 134,
nanda international nursing diagnoses: definitions and classifications 2009-2011
). signs and symptoms include:

  • abnormal blood pressure response to activity

  • abnormal heart rate response to activity

  • ekg changes reflecting arrhythmias

  • ekg changes reflecting ischemia

  • exertional discomfort

  • exertional dyspnea

  • verbal report of fatigue (that is not your observation of fatigue--that would warrant considering a nursing diagnosis of
    fatigue
    or something else)

  • verbal report of weakness (that is not your observation of weakness--that would warrant considering a different nursing diagnosis)

but it is important to note that there is a strong circulation and respiratory system connection in the etiology of this problem. the cause of
activity intolerance
is:

  • bed rest

  • deconditioning

  • generalized weakness

  • imbalance between oxygen supply/demand (as occurs in many heart and lung diseases)

  • immobility

  • sedentary lifestyle

is this a good diagnosis for him?

look at your assessment data a little more closely now that i have given you more information and discussion about it. does it support using this diagnosis?

what type of interventions could i use??

again, interventions are going to depend upon what the patient's symptoms are. weakness and dyspnea with exertion are pretty vague symptoms to work with. you have to be more specific in your description of what the patient is experiencing so he can be helped. this is a common problem of copders (i worked with them for most of my clinical career) and if you search your books and the internet you are going to find a lot of information on how to help this patient.

this thread has many helpful weblinks that include sites where information can be found about diseases and treatments. a good site to start with when you just need to get going is: medline plus (use the search box) http://www.medlineplus.gov/ which will give you some direction and ideas.

Up Vote Up Vote ×
looking at some of the posts on https://allnurses.com/general-nursing-student/help-care-plans-286986.html- help with care plans which includes a lot of different information on care plan construction and diagnosis might be helpful for you. a care plan should be constructed using the steps of the nursing process to help you organize. the information you collect is used to build upon the next step of the process. the nursing process is the problem solving tool we use in our profession. a care plan is merely a collection of a patient's nursing problems along with strategies of how we are going to treat and solve those problems.
  1. assessment
  2. nursing diagnosis
  3. planning (writing goals and interventions)
  4. implementation
  5. evaluation

so, first thing i did was go back through what you posted and collect all your assessment data. i want you to notice, however, how i listed it:

  • medical history:
    • thromboangiitis obliterans (buerger's disease)
    • hypertension
    • smoker (quit 2 years ago)
    • chf
    • copd
    • kidney disease

    [*]abnormal physical data:

    • bilateral 2+ pitting edema in his lower extremities
    • cool hands and feet
    • diminished peripheral pulses.

one of the things that is important as a learner is to look up the pathophysiology, signs and symptoms and complications of the medical diseases and conditions that the patient has, especially if this hasn't been covered in class lectures yet. this information is important to the understanding of the cause (why) of the nursing problems you are attempting to identify. understanding the pathophysiology helps explain why a symptom is occurring. this is also part of the assessment process.

once assessment is completed we can move onto diagnosing. diagnosing is based upon the abnormal data gleaned from examining the situation and analyzing what we have. the diagnostic statement has 3 parts and assessment data has input into each part of that statement.

ineffective peripheral tissue perfusion r/t compromised blood flow secondary to congestive heart failure, chronic obstructive pulmonary disease, and thromboangiitis obliterans manifested by lower extremity edema, cool hands and feet, and diminished peripheral pulses.

  • problem: ineffective peripheral tissue perfusion.
    definition
    :
    decrease in blood circulation to the periphery that may compromise health.

    • in using this diagnosis you are referring to blood flow, specifically
      arterial
      blood, not getting to the cells of the patient's peripheral parts of his body. the medical problem going on is one of ischemia that produces the symptoms. [this long term ischemia process can also go on in the heart
      (a different medical diagnosis)
      producing chest pain, arrhythmias and eventually heart attacks except that we would diagnose as
      decreased cardiac output.
      ]

    [*]
    etiology:

    • compromised blood flow

      • secondary to:

        • congestive heart failure

        • chronic obstructive pulmonary disease

        • thromboangiitis obliterans

        • hypertension

        • (__ years of) smoking

          • you need to look up the pathophysiology of this disease:
            http://www.merck.com/mmpe/sec07/ch080/ch080h.html

          • although he no longer smokes, it is the smoking that brought about the problem, his hypertension contributed to it and thromboangiitis obliterans is the medical name for it. thromboangiitis obliterans is chronic, progressive and has complications. chf and copd have nothing to do with how this problem began or is continuing to evolve.

          • etiology:
            impaired arterial blood flow secondary to thromboangiitis obliterans, hypertension and __ years of smoking

    [*]
    symptoms:

    • lower extremity edema

      • "bilateral 2+ pitting edema in his lower extremities" which you listed in your post would be better

      [*]
      cool hands and feet

      [*]
      diminished peripheral pulses.

    [*]see

i am trying to come up with nursing interventions and i'm having a hard time

interventions are step #3 of the nursing process when care planning and follow step #1 (assessment) and step #2 (diagnosis). just as doctors most often treat the symptoms of a disease (diagnosis), so do we. look at the symptoms for your diagnosis. what can you, the nurse, do for that edema? what can you do for his cold hands and feet? what about those poor pulses? that may be a little trickier.

there are four types of nursing interventions (actions) that we nurses can perform:

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)

  • care/perform/provide/assist (performing actual patient care)

  • teach/educate/instruct/supervise (educating patient or caregiver)

  • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

read about the disease and how the doctor would treat it as well. follow some of their recommendations. think about how the patient's symptoms impact their ability to perform their adls. search the internet for information about the disease and home care. you will find a lot of information since there are thousands of older smokers in our society dealing with this disease.

i only need to come up with 2 interventions

challenge yourself. at minimum, you should be able to come up with at least 4 (an assessment, one item of care, a teaching intervention and one management intervention) for each symptom!

activity intolerance r/t compromised oxygen transport system secondary to congestive heart failure and chronic obstructive pulmonary disease manifested by weakness, and dyspnea with exertion

never diagnosis someone with something unless you understand what it is.
activity intolerance
.
definition
:
insufficient physiological or psychological energy to endure or complete required or desired daily activities
(page 134,
nanda international nursing diagnoses: definitions and classifications 2009-2011
). signs and symptoms include:

  • abnormal blood pressure response to activity

  • abnormal heart rate response to activity

  • ekg changes reflecting arrhythmias

  • ekg changes reflecting ischemia

  • exertional discomfort

  • exertional dyspnea

  • verbal report of fatigue (that is not your observation of fatigue--that would warrant considering a nursing diagnosis of
    fatigue
    or something else)

  • verbal report of weakness (that is not your observation of weakness--that would warrant considering a different nursing diagnosis)

but it is important to note that there is a strong circulation and respiratory system connection in the etiology of this problem. the cause of
activity intolerance
is:

  • bed rest

  • deconditioning

  • generalized weakness

  • imbalance between oxygen supply/demand (as occurs in many heart and lung diseases)

  • immobility

  • sedentary lifestyle

is this a good diagnosis for him?

look at your assessment data a little more closely now that i have given you more information and discussion about it. does it support using this diagnosis?

what type of interventions could i use??

again, interventions are going to depend upon what the patient's symptoms are. weakness and dyspnea with exertion are pretty vague symptoms to work with. you have to be more specific in your description of what the patient is experiencing so he can be helped. this is a common problem of copders (i worked with them for most of my clinical career) and if you search your books and the internet you are going to find a lot of information on how to help this patient.

this thread has many helpful weblinks that include sites where information can be found about diseases and treatments. a good site to start with when you just need to get going is: medline plus (use the search box) http://www.medlineplus.gov/ which will give you some direction and ideas.

wow, thank you so much for all of the help!! i will definitely look more into everything and make some changes! i really appreciate it :)

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