Student - first Nursing Care plan

[Jules1982]

I am writing my first nursing care plan for school and I just want to run this by all you experienced nurses out there to make sure I am on the right track. I'm going to post the scenario I was given:

Mr. Ortiz is a 78-year-old male patient who was admitted to the medical unit two days ago with congestive heart failure (CHF). Mr. Ortiz presented to the hospital with a two day history of weakness, shortness of breath, and difficulty ambulating distances of more than 5 metres. He reports that he has been unable to get out of bed for the past two days. A comparison of Mr. Ortiz's weight from two days ago indicated a 4 kilogram weight increase. Mr. Ortiz tells you; "I rarely need my oxygen but now I need it all the time these past two days." The practical nurse reports that his respirations were 38 breaths per minute with ambulation to the bathroom. His last set of vital signs at 0530 was: 26 respirations/minute at rest; apical pulse 92 beats/minute; blood pressure 118/70; tympanic temperature 36.5°C; and oxygen saturation 91% on 2 liters of oxygen per nasal cannula. Bilateral course crackles are auscultated by the practical nurse. Mr. Ortiz has a frequent productive cough of clear sputum, 2+ pitting edema bilaterally in his ankles and feet.

Is the nursing diagnosis for this: Activity Intolerance Or Excess Fluid Volume. I can only have one and I thought Activity Intolerance.

Thank you so much!

Jules

[Jules1982]

Can someone move this to the student thread, I don;t know how it ended up in the CRNE thread, that was not my intention.

Jules

[Silverdragon102, BSN]

Moved across to student section

[flyingchange]

Hi Jules,

Welcome to nursing, where 4 answers on a multiple choice question are right but there is only one that's the most right.

If you think about this case as an acute disease exacerbation, activity intolerance is actually secondary to excess fluid volume. It sounds like he was getting around just fine but for the last 2 days he has been fluid overloaded.

So in the interest of best preparing him for discharge, what would the priority be?

[petethecanuck]

When doing your assessments/care plans always use your ABC's as a starting point and then go from there.

Good luck!

As a side point, what was your rationale for choosing activity intolerance? It's always helpful to reflect upon our decisoin making process. :)