Martinez, L. G. & Bucher, L. (2010). Nursing management: Coronary artery disease and acute coronary syndrome. In Lewis, S., Heitkemper, M., Dirksen, S. R., O'Brien, P. G., Barry, M., Goldsworthy, S., & Goodridge, D. (Eds.). Medical-surgical nursing in Canada (2nd ed. pp. 846-882). Toronto, ON: Mosby Elsevier 2/2 Stenberg College RDPN Program Nursing Care Plan Nursing Diagnosis Desired Outcomes Interventions (C) - Collaborative Rationale & APA “Reference Evaluation of Interventions NDX: (Problem) Risk for excess fluid volume R/T: Cardiac failure Pulmonary Edema Right and Left Ventricular Hypertrophy AEB: In respiratory distress, use of accessory Goal (Reversal of Problem) Decrease intravascular volume (p. 934). Client will list measurable outcomes; reverse and symptoms Restrict sodium to 2-g per day Restrict fluids to 100 mL per day Take medications as prescribed – Enalapril N1-(I) (C) Position to alleviate dyspnea (e.g., position with legs dangling Assess ABC’S and supplement patient’s oxygen by mask or nasal catheter 6 L-min Auscultate lungs for presence of normal or adventitious sounds R1- To improve ventilation by decreasing venous return to the heart and increasing thoracic capacity and facilitating breathing(p. 943). Patient is in respiratory distress and has an increased respiratory rate. Oxygen will increase CO and help relax the pt (p. 935). Crackles may indicate failure which can contribute to decreased cardiac output (p. 622). E1- Patient has regular, non-labored respirations Patient has regular, non-labored respirations Patients lung sounds are clear to auscultation in all lobes :
muscles, respiratory rate 36 breaths/min Moist crackles in both lungs The patient’s statement, “I’m of breath and my ankles, are so big and puffy!” Cyanotic lips and extremities Frequent coughing Has to sleep with head elevated on 3 pillows (Vasotec) 5mg PO daily Digoxin 0.25mg PO Furosemide (Lasix) 40 mg IV BID Potassium 40 mEq PO BID Daily Weight Measurements Evaluation of Outcomes (address each outcome) 1.restricted sodium intake will reduce fluid volume N2-(I) (C) Administer diuretic (Lasix) as per doctors’ orders Fluid and electrolyte management – Monitor serum electrolytes especially sodium and potassium R2- Diuretics mobilize edematous fluid, reduces pulmonary venous pressure, & reduces preload improving CO (p. 937). Serum Sodium levels will determine if therapeutic measures have been effective or not as volume imbalances are often associated with changes in serum sodium levels and serum potassium levels indicate secondary HTN E2- Left ventricular function has improved Pt’s serum electrolyte levels came back with normal results ensuring that her treatment plan has been effective Monitor respiratory pattern for symptoms of respiratory difficulty Monitor hemodynamic status, including CVP, MAP, and PAOP, if available Monitor renal function and intake and output Monitor for the therapeutic effect of a diuretic (↑ urine output,↑ CVP, improvement of breath sounds) Weigh the patient, same Enables early detection of pulmonary congestion (p. 943). Evaluates the effectiveness of therapy (p. 943). To monitor fluid balance (p. 943). To assess the patient’s response to treatment (p. 943). Ensures valid comparisons day to day Pt responded to treatment well and no longer displays symptoms associated with hypovolemia and edema Patient’s weight has been consistent
Increasing dyspnea on exertion during the last 2 years. 2. measuring weight and restricting fluid intake to 6-8 glasses fluid a day helps monitor fluid retention 3. Drug adherence is necessary to reduce and treat signs and symptoms of CHF. Evaluation of Goal: Goal met if patient adheres to care plan Continuation of plan: Continue plan and closely monitor patient. Will make adjustments accordingly N5- (I) (C) Nutritional Therapy obtain a diet history from patient and appraise their current knowledge regarding sodium restricted diet R5- To assess areas needing additional instruction and clarification (p. 944). R5- Pt will show collaboration of low sodium recipes and food journal documenting daily intake. 4.5/5 References Bouffard, L. (2014) Nursing Management: Heart Failure. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp. 928-949) Toronto, ON: Elsevier Canada 18.5/20