NURSING CARE PLAN
Name of Patient : SUPERMAN
Age & Sex: 63/ M
Chief Complaint : Dyspnea
Diagnosis: Coronary Artery Disease; Congestive Heart Failure II with passive liver congestion
CUES
Subjective:
Verbalized that, Nagkukuri
ako pag hinga pag nagios ako.
Han ak pag kadi duro duro na
gud adto.
Verbalized that,
Objective:
Grade 1 Bipedal Pitting
edema
Client weighed 55 kg
before admission and 62
kg during admission
Dyspnea noted.
Productive cough noted
with yellow sputum
NURSING DIAGNOSIS
Excess fluid volume related to
compromised regulatory
mechanism evidenced by
edema, weight gain, dyspnea
SCIENTIFIC RATIONALE
Heart failure is the result of
poor cardiac function and is
reflected by a decreased
volume of blood pumped out
by the heart, called cardiac
output. Heart failure can be
caused by weakness of the
heart muscle, which pumps
blood out through the arteries
to the entire body, or by
dysfunction of the heart valves,
which regulate the flow of
blood between the chambers
of the heart. The diminished
volume of blood pumped out
by the heart (decreased
cardiac output) is responsible
for a decreased flow of blood
to the kidneys. As a result, the
kidneys sense that there is a
reduction of the blood volume
in the body. To counter the
seeming loss of fluid, the
kidneys retain salt and water.
In this instance, the kidneys
are fooled into thinking that the
body needs to retain more fluid
volume when, in fact, the body
already is holding too much
fluid.
This fluid increase ultimately
results in the buildup of fluid
within the lungs, which causes
shortness of breath. Because
GOALS
After proper nursing
interventions the patient will be
able to :
1. Demonstrate stabilized fluid
volume, with balanced intake
and output (I&O), stable
weight, vital signs within
clients normal range, and
absence of edema.
NURSING INTERVENTIONS
Independent
1. Measure I&O, noting
positive balanceintake in
excess of
output. Weigh daily, and note
gain more than 0.5 kg/day.
2. Monitor BP and CVP, if
available. Note JVD and
abdominal vein distention.
3. Assess respiratory status,
noting increased respiratory
rate and dyspnea.
4. Auscultate lungs, noting
diminished or absent breath
sounds and developing
adventitious soundscrackles.
RATIONALE EVALUATION
1. Reflects circulating volume Client reported having no
status, developing or resolving difficulty in urination and
fluid shifts, and response to elimination. He was ordered to
therapy. Positive fluid balance limit oral intake of fluid to 800
and weight gain often reflects cc per day. There was no
continuing fluid retention. Note: vomiting or diarrhea noted.
Decreased circulating volume Client weighed 55 kg before
and fluid shifts can directly admission and 62 kg during
affect renal function and urine admission.
output, resulting in hepatorenal
syndrome.
2. BP elevations are usually
associated with fluid volume
excess but may not occur
because of fluid shifts out of
the vascu- lar space. JVD and
presence of distended
abdominal veins are
associated with vascular
congestion.
3. Indicative of pulmonary Verbalized that, oo mayubo
congestion or edema. ko, yellow na it plema.
4. Increasing pulmonary Auscultated lungs and crackles
congestion may result in bibasal left noted.
consolidation, impaired gas
exchange, and complications,
such as pulmonary edema.
of the decreased volume of
blood pumped out by the heart
(decreased cardiac output), the
volume of blood in the arteries
is also decreased, despite the
actual increase in the body's
total fluid volume. An
associated increase in the
amount of fluid in the blood
vessels of the lungs causes
shortness of breath because
the excess fluid from the lungs'
blood vessels leaks into the
airspaces (alveoli) and
interstitium in the lungs. This
accumulation of fluid in the
lung is called pulmonary
edema. At the same time,
accumulation of fluid in the
legs causes pitting edema.
This edema occurs because
the build-up of blood in the
veins of the legs causes
leakage of fluid from the legs'
capillaries (tiny blood vessels)
into the interstitial spaces.
Reference:
http://answers.webmd.com
/answers/1175849/why-does-a-
patient-with-heart
5. Monitor for cardiac
dysrhythmias. Auscultate heart
sounds, noting development of
S3/S4 gallop rhythm.
6. Assess degree of peripheral
and dependent edema.
7. Measure abdominal girth.
8. Encourage bedrest when
ascites is present.
9. Provide frequent mouth care
and occasional ice chips,
particularly if NPO; schedule
fluid intake around the clock.
Collaborative
1. Monitor serum albumin and
electrolytes, particularly
potassium and sodium.
5. May be caused by HF,
decreased coronary arterial
perfusion, or electrolyte
imbalance.
6. Fluids shift into tissues as a
result of sodium and water
retention, decreased albumin,
and increased antidiuretic
hormone (ADH).
7. Reflects accumulation of
fluid or ascites resulting from
loss of plasma proteins and
fluid into peritoneal space.
Note: Excessive fluid
accumulation can reduce
circulating volume, resulting in
hypotension and dehydration.
8.May promote recumbency-
induced diuresis.
9. Decreases sensation of
thirst, especially when fluid
intake is
restricted.
1. Decreased serum albumin
affects plasma colloid osmotic
pres- sure, resulting in edema
formation. Reduced renal
blood flow, accompanied by
elevated ADH and aldosterone
levels and the use of diuretics
to reduce total body water,
may cause various electrolyte
shifts and imbalances.
ECG of 04-16-17 at 3:00 pm
revealed Sinus rhythm,normal
axis, left atrial enlargement by
Dr. Yvette Marie Eder.
Grade 1 pitting bipedal edema.
Verbalized that, Han una
28inches la iton akon hawak
nag tikang pag dako January.
Measured abdominal girth last
05-06-17 resulted to 39 inches.
Noted ascites. Patient was
ordered to have complete bed
rest without toilet privileges last
04-16-17.
Oral fluid intake was limited to
800 cc/ day. Wife assisted on
self care needs of husband.
Lab Results as follows :
Serum Albumin- 31 g/L
NORMAL
Sodium 137.1 mmol/L
NORMAL
Potassium- 3.16 mmol/L
DECREASED
Chloride 104 mmol/L
NORMAL
2. Monitor serial chest x-rays.
3. Restrict sodium and fluids,
as indicated.
Administer salt-free albumin
and plasma expanders, as
indicated.
4. Administer medications, as
indicated, for example:
Diuretics, such as
spironolactone
(Aldactone) and
furosemide (Lasix)
Potassium
Positive inotropic drugs
and arterial vasodilators
Reference :
Nursing Care Plans, 8th ed. By
Alice Murr
2.Vascular congestion, Crackles Bibasal Left ,
pulmonary edema, and pleural Dyspnea was noted.
effusions frequently occur.
3. Sodium may be restricted to Ordered to have Low salt, Low
minimize fluid retention in fat diet since admission.
extravascular spaces. Fluid
restriction may be necessary to
correct dilutional
hyponatremia.
4.Albumin may be given to
increase the colloid osmotic
pressure in the vascular
compartment, thereby
increasing effective circulating
volume and decreasing
formation of ascites.
Used with caution to
control edema and
ascites, block effect of
aldosterone, and increase
water excretion while
sparing potassium when
conservative therapy with
bedrest and sodium
restriction do not alleviate
problem. Diuretic given in
coordination with albumin
administration may
enhance fluid removal.
Serum and cellular
potassium are usually
depleted because of liver
disease and urinary
losses.
Given to increase cardiac
output and improve renal
blood flow and function,
thereby reducing excess
fluid.
Reference :
Nursing Care Plans, 8th ed. By
Alice Murr