Nursing Care Plan

 


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Medical Diagnosis:Congestive Heart Failure, Fluid Volume Excess

        

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

“I was feeling short of breath.  It didn’t get better when I sat down.  I had a pressure-pain in the middle of my chest and I got scared.”

 

 

 

 

Objective:

BNP:  585

Troponin:  0.12

Bilateral 3+ pitting edema

Diminished pedal pulses 1+ bilaterally

Crackles heard bilaterally in lung bases, elevated BP, oliguria, hyperventilation, PaO2 86%


  

Problem:

Fluid volume excess

        

        

        

 

Long Term:

Client will remain free of edema, effusion, and anasarca by [Date] at 16:00.


   

-Monitor intake and output throughout shift on [date], note trends reflecting decreasing urine output in relation to overload.  Accurately measuring intake and output is vital for the client with fluid volume overload (Ackley et al., 2008). 

-Provide a restricted sodium diet as appropriate on [date].  Restricting sodium in the diet will favor the renal excretion of excess fluid (Kasper et. al, 2005)

        

Evaluation of this goal is set for 16:00, [date].  Client has bilateral pitting edema and adventitious breath sounds.  No progress towards goal made.  Continued intervention and evaluation required.

Monitored intake and output.  Provided a sodium restricted diet.  No progress towards goal.  Continuance of the interventions warranted along with further evaluation.

R/T:  compromised regulatory mechanism secondary to congestive heart failure

        

        

        

        

        

        

        

Short Term:

Client will explain measures that can be taken to treat or prevent excess fluid volume, especially dietary restrictions and medication schedules.

By shift’s end on [date]:

-Assess client’s current level of knowledge r/t excess fluid volume treatments and s/s

-Seek teachable moments to encourage health promotion.  The provision of information should not be restricted to just treatment information but also any information that prepares the client to manage health-related issues (Timmons, et. al 2006)

- Teach the importance of fluid and sodium restrictions.   Education programs based on empowerment, client participation, and adult learning principles have demonstrated effectiveness (Kennedy, et. al, 2003).

        

        

Client explained measures to prevent and treat excess fluid volume including dietary restrictions and medication regimen at 13:03 on [date].  Goal achieved.

At 11:00 on [date] assessed client’s current level of knowledge related to dietary measures and medications to prevent excess fluid volume and s/s of fluid volume excess.

Sought teachable moments to encourage health promotion, provided education on nutrition and easy meals to freeze and make at home.

Taught client the generalized and localized signs and symptoms of fluid volume excess to monitor for both within the hospital and at home.

Goal achieved.

AEB:  crackles in bases bilaterally, peripheral edema 3+ bilaterally, oliguria, 3 lb. weight gain in 2 days.

        

        

        

        

        

        

        

 

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References

Ackley, B. J., & Ladwig, G. B. (2008). Nursing Diagnosis Handbook. St. Louis: Elsevier.

 

Kennedy A, Nelson E, Reeves D et al: A randomised controlled trial to assess the impact of a package comprising a patient-orientated, evidence-based self-help guidebook and patient-centered consultations on disease management and satisfaction in inflammatory bowel disease, Health Technol Assess 7(28):3, 1113, 2003.

Timmins F: Exploring the concept of information need, Int J Nurs Pract 12(6):375381, 2006.

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