Nursing Care Plan

Cues
Subjective Data:
Patient complains
of shortness of
breath on any
type of activity,
non-radiating
chest pain,
increase cough,
and the inability
to sleep laying
down at night,
gained 7 pounds
since last weight
on Tuesday, takes
Lasix 60mg PO
BID but has not
taken any since
Monday because
he wasnt able to
go to the
pharmacy due to
the snowstorm
last week.

Nursing
Diagnosis
Fluid volume
overload related to
decreased cardiac
output as evidence
by ejection fraction
of 35%, edema in
lower extremities,
jugular distention,
bilateral crackles,
weight gain, BNAT
1824, and pleural
effusions noted in
lungs bilaterally.

Background
Knowledge

Goals/
Desired
Outcomes

Fluid volume
overload is the
increase of isotonic
fluid retention.

During the 8 hour

shift, client will
experience
resolution of fluid
imbalance as
evidenced by:

It is an excessive
fluid intake

Nursing
Interventions

Rationale

Evaluation

The goal was met

Auscultate apical
Tachycardia is
as manifested by
pulse, assess heart
usually present
stabilized fluid
rate, rhythm.
(even at rest) to
volume as
Document
compensate for
evidenced by:
dysrhythmia if
decreased
telemetry is
ventricular
The patient shall
available.
contractility.
Decline in weight
Premature atrial
have
toward client's
contractions
demonstrated
normal
(PACs), paroxysmal
behaviors that
B/P and pulse
atrial tachycardia
indicates the
within normal
(PAT), PVCs,
decrease fluid
range for client
multifocal atrial
volume
and stable with
tachycardia (MAT),
position change
and atrial
Edema decreased
Absence or
fibrillation (AF) are
from 3+ to 2+
resolution of S3
common
Vital signs is within
heart sound
dysrhythmias
balanced intake
normal range
associated with
and output
HF, although
Clear lung sounds
usual mental
others may also
on the left lower
status
occur. Note:
lung upon
Intractable
auscultation.
ventricular
dysrhythmias
unresponsive to

medication
suggest ventricular
aneurysm.

A 74 year old male presents to the ER with complaints of swelling in legs and feet, shortness of breath with any type of activity, non-radiating chest pain,
increase cough, and the inability to sleep laying down at night. Patient states he has felt bad since Tuesday and today is Friday. He also states he has gained 7 pounds
since he last weight on Tuesday.

Cues

Nursing
Diagnosis

Background
Knowledge

Goals/
Desired
Outcomes

Nursing
Interventions

Rationale

Evaluation


Objective Data:
Lisinopril 2.5 mg PO
BID
Coreg 6.25mg PO
Daily
Coumadin 5mg PO
Daily (has a history
of Atrial fibrillation)
Potassium PO
20meq BID
Multivitamin 1 Tab
PO Daily

decreased
Note heart sounds.
dyspnea,
peripheral
edema, and neck
vein distention
improved
breathing and
breath sounds
resolution of
ascites.
Administer
supplemental
oxygen as
indicated.

Vital Signs:
BP 155/93mmHg
HR 95, O2 Sat 90%
on 4L nasal cannula
Temp. 98.6
3+ pitting edema
noted in lower
extremites
Bilateral crackles
noted throughout
lung fields Hands
and abdomen are
swollen,
Jugular distention
noted.

Record Intake and

output

S1 and S2 may be

Knowledge on the
weak because of
measures to
diminished pumping
prevent and lessen
action. Gallop
fluid volume
rhythms are
excess
common (S3and S4),
produced as blood
flows into
noncompliant
chambers. Murmurs
may reflect valvular
incompetence

Increases available
oxygen for
myocardial uptake to
combat effects of
hypoxia.
Accurate I and O
isnecessary for
determining
renalfunction and
fluidreplacement
needsand reducing
risk of fluid
overload(Do note that

hypervolemia usually
occurs in anuric phase
Weigh patient daily at
the same time each
day

of ARF and may mask

the symptoms.)
Daily body weight is
best monitor of fluid
status and

degrading edema

Cues

Nursing
Diagnosis

Background
Knowledge

Goals/
Desired
Outcomes

Nursing
Interventio
ns

Rationale

Evaluation

Diagnostic Data:

BNAT 1824
K+5.0
Creatinine 1.8
BUN 21
Chest x-ray
preliminary
results show
possible
bilateral
pleural
effusions
Echocardiogram
results show
ejection
fraction of
35%.

Group 3
Mary Mae B. Buella
JM P. Cabarle
Jeanela R. Brijuega

Record occurrence of To determine fluid

dyspnea
retention
Avoid constrictive
clothing.

To prevent skin
irritation and
immobility