Room: McClure 517-1 Allergy: Penicillin 1605 Assessment M.J. is a 67 y/o male wi
ID: 242663 • Letter: R
Question
Room: McClure 517-1 Allergy: Penicillin
1605 Assessment
M.J. is a 67 y/o male with a dx of CHF. Pt states, “I get short of breath before I’m able to make it from the bed to the bathroom.” You also notice the pt leaning forward in the bed to breathe.
Vital Signs:
Pulse: 92 BPM and Regular
Respiratory Rate: 28 BPM
SpO2 Right Index Finger: 95% on 4 L by NC
Blood Pressure: 146/92 Right Upper Extremity
Temperature: 37.1oC
IV: 20g PIV placed in the left wrist. IV was placed yesterday by EMS and flushes well. The dressing is clean, dry, and intact.
I&O:
Intake: 125 mL/hr of IV 0.45% Saline
Output:
1 Large Dark Brown Stool
450 mL of Straw Colored Urine
Respiratory Assessment
Accessory muscle use noted. Breathing is labored. Coarse crackles present bilaterally in the lower posterior lung fields. Productive cough with pink frothy sputum.
Safety and Management
Mental status is alert and oriented x 4.
Please develop a nursing diagnosis and plan for a patient using the above information. Write what parts of the information provided go in subjective or objective section.
Explanation / Answer
Congestive Heart failure
Subjective Data : Shortness of breath, Inability to walk from the bed to the bathroom
Objective Data : Difficulty in breathing as seen by patient leaning forward to breathe and as evidenced by accessory muscle use and coarse crackles present on auscultation. Productive Cough with pink frothy sputum
Nursing Diagnosis
1. Decreased cardiac output related to changes in myocardial contractility as evidenced by laboured breathing, use of accessory muscles and coarse crackles during auscultation.
Nursing Goal: The patient should show signs of normal Vital signs and decreased dsypnea episodes
S.No
Nursing Interventions
Rationale
1
Auscultate apical pulse, assess heart rate, rhythm. Inform any changes
Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility.
2
Assess heart sounds
S1 and S2 may be weak because of diminished pumping action.
Gallop rhythms are common (S3and S4),as blood flows into noncompliant chambers.
Murmurs may reflect valvular incompetence.
3
Palpate peripheral pulses
It helps identify decreased cardiac output as the pulses reflect weak
4
Monitor Blood pressure
It helps identify any rise in blood pressure due to increased systemic vascular resistance
5
Assess the skin of cyanosis and pallor
Cyanosis can occur due to decreased oxygen saturation. And Pallor is caused due to decreased peripheral perfusion, vasoconstriction and anaemia
6
Monitor urine output, noting decreasing output and concentrated urine.
Kidneys retain fluids due to cardiac overload
7
Note changes in sensorium: lethargy, confusion, disorientation, anxiety and depression
Indicates deceased cerebral perfusion
8
Provide a Psychological reassurance and calm environment
Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate.
2. Fluid Volume excess related to decreased cardiac output,Glomerular filtration rate as evidenced by decreased urinary output
Nursing Goal: Patient will demonstrate steady fluid volume and clear breath sounds
S.No
Nursing Interventions
Rationale
1
Monitor Urine Output, colour
Urine output can be scanty due to reduced renal perfusion
2
Monitor / calculate the balance of income and output 24 hours.
Diuretics may result in increase in loss of fluids
3
Provide Fowlers/ Semi fowlers position
Increases Glomerular filtration rate
4
Assess breath sounds and note any change
Excess fluid volume leads to Pulmonary congestion as results in cough
5
Monitor blood pressure
It helps identify any rise in blood pressure due to increased systemic vascular resistance, hypertension suggests fluid volume excess
6
Assess bowel sounds
Visceral congestion leads to constipation
7
Provide small frequent meals
Enhances digestion
3. Activity intolerance related to imbalance between supply oxygenation needs as evidenced by shortness of breath.
Nursing Goal : The patient should be able to meet his activities of daily living with minimal support
S.No
Nursing Interventions
Rationale
1
Identify stressors for decreased activity. Check vital signs before and after the activity, particularly when patients using vasodilator, diuretic.
Decrease in stressors helps improve cardiac function. Orthostatic hypotension can occur due to vasodilators
2
Encourage activity with periods of rest
It improves cardiac efficacy and reduces episodes of shortness of breath. Orthostatic hypotension can occur due to increased activities
3
Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase activity as tolerated.
Decreases venous stasis, and may reduce incidence of thrombus or emboli formation
4
Provide bedpan.
Note for straining during defecation, holding breath during position changes.
Bedpan use decreases work of getting to bathroom. Vasovagal manoeuvre causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function.
5
Encourage rest, semi recumbent in bed or chair. Assist with physical care as indicated.
Physical rest should be maintained during acute or refractory HF to improve efficiency of cardiac contraction and to decrease myocardial oxygen demand/ consumption and workload.
6
Check for calf tenderness, diminished pedal pulses, swelling, local redness, or pallor of extremity.
Reduced cardiac output, venous pooling, and enforced bed rest increases risk of thrombophlebitis.
4. Ineffective airway Clearance related to retained secretions as evidenced by pink frothy sputum
Nursing Goal:Achieve airway cleaaarance
S.No
Nursing Interventions
Rationale
1
Identify signs and symptoms of airway blockage
Helps reduce formation of mucus production and bronchial infection
2
Give the patient 6 to 8 glasses of fluid / day
It helps thin (liquidify) the mucus present
3
Teach and give encouragement use of diaphragmatic breathing and coughing techniques.
It reduces laboured breathing.
Example Breathing technique: Ask him to breathe in as he would smell a rose and breathe out as he would blow a candle
4
Encourage rest, semi recumbent in bed or chair. Assist with physical care as indicated.
It decreases in cardiac overload
5
Assist in the provision of action nebulizer, metered dose inhalers.
It helps to thin the mucus production
6
Perform postural drainage with percussion and vibration in the morning and evening according to the required.
It encourages the mucus to become thin and removes excess mucus through cough
7
Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
It can help manage effective breathing
S.No
Nursing Interventions
Rationale
1
Auscultate apical pulse, assess heart rate, rhythm. Inform any changes
Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility.
2
Assess heart sounds
S1 and S2 may be weak because of diminished pumping action.
Gallop rhythms are common (S3and S4),as blood flows into noncompliant chambers.
Murmurs may reflect valvular incompetence.
3
Palpate peripheral pulses
It helps identify decreased cardiac output as the pulses reflect weak
4
Monitor Blood pressure
It helps identify any rise in blood pressure due to increased systemic vascular resistance
5
Assess the skin of cyanosis and pallor
Cyanosis can occur due to decreased oxygen saturation. And Pallor is caused due to decreased peripheral perfusion, vasoconstriction and anaemia
6
Monitor urine output, noting decreasing output and concentrated urine.
Kidneys retain fluids due to cardiac overload
7
Note changes in sensorium: lethargy, confusion, disorientation, anxiety and depression
Indicates deceased cerebral perfusion
8
Provide a Psychological reassurance and calm environment
Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate.
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