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Cluster One:

Subjective: Fatigue, weakness, and dyspnea. Patient states: “I can’t stand on my own” and “I keep
falling asleep.”
Objective: +1 pitting edema on lower extremities bilaterally, weight gain of 10 pounds in past
week, decreased peripheral pulses, presence of S3 heart sound, distant heart sounds, BNP of 910 and
Echocardiogram showing ejection fraction on 38%.

Nursing DX: Decreased cardiac output R/T pump failure AEB BNP of 910 and echocardiogram
showing ejection fraction of 38%.

Cluster Two:
Subjective: “I feel so short of breath just from standing.”
Objective: Respirations 24, diminished breath sounds at left base, hemoglobin 9.8, RBC 3.64, CO2
level 23, confusion noted as patients keeps thinking her granddaughter is her daughter.

Nursing DX: Impaired gas exchange R/T ventilation-perfusion imbalance AEB SOB, RR 24, and
CO2 level of 23.
Cluster Three:
Subjective: “my socks feel so tight”
Objective: +1 pitting edema on lower extremities bilaterally, 10 pound weight gain in one week,
hepatomegaly- liver enlarged upon palpation, Diminished breath sounds at left lung base, presence
of S3 heart sound, HGB 9.8, HCT 30.3

Nursing DX: Excess fluid volume R/T compromised regulatory mechanism AEB +1 pitting edema
in lower extremities bilaterally, and presence of S3 heart sounds.
Admitting DX:

Congestive Heart
Failure
Interventions Rationale
Assess for a change in mental status. (I) Confusion, agitation, decreased cognition,
may occur due to decreased brain perfusion
(Doenges, Moorhouse, & Murr, 2016).
Monitor all vital sings (I) The nurse is to monitor vital signs, note any
change in status, record, adjust the nursing
care plan and report abnormal changes to the
physician to prevent further complications
(Amakali, 2015).
Assess for changes in heart rate or rhythm (I) Heart irritability is common, reflecting
conduction defects and or ischemia (Doenges,
Moorhouse, & Murr, 2016).
Auscultate heart sounds (I) S3, S4 is noted when heart failure is present
and may indicate cardiac decompensation
(Doenges, Moorhouse, & Murr, 2016).
Assess peripheral pulses (I) The volume (pressure of the pulse) is likely to
be shallow, and can indicate low cardiac
output (Amakali, 2015).
Administer medications as indicated. (D) Contractility of the heart can also be enhanced
with drug therapy (Ignatavicius & Workman,
2010).
Review laboratory and diagnostic tests Gives clues to complications arising from HF
(Electrolytes, BNP, ABG, Chest x-rays & and confirms diagnosis (Ignavicius &
ECG). (C) Workman, 2010).

Goal/Outcomes: Patient will demonstrate cardiac pump effectiveness AEB hemodynamic stability
measured by blood pressure, cardiac output, urinary output, and peripheral pulses being within
normal limits for the patient by the end of shift. Patient will report or demonstrate decreased
episodes of dyspnea by end of shift. Patient will demonstrate an increase in activity tolerance by end
of shift. Patient will participate in activities that reduce the workload of the heart by complying with
therapeutic medication regimen program on the day of care.
Evaluation: By the end of shift the patient’s goals were partially met. The patient did show signs of
hemodynamic stability with BP of 130/62, and adequate urinary output of >30mL/hr. However,
updated cardiac output diagnostics were not available to determine amount of cardiac output, and
patient’s peripheral pulses remained reduced, but may be due to edema. Patient did demonstrate
decreased episodes of dyspnea and an increase in activity tolerance by balancing activity with rest.
Patient was able to walk to the bathroom three times during shift with assistance, with minimal SOB.
Patient also ambulated 75ft in the hall for the first time during hospital stay, tolerating well and
demonstrated minimal SOB. Patient also remained completely compliant with medication regimen
on the day of care. Patient’s mental status and heart sounds remained stable and within patient’s
normal limits.
Interventions Rationale
Evaluate skin and mucous membrane color Duskiness and central cyanosis are late signs
noting areas of pallor or cyanosis. (I) of hypoxemia (Doenges, Moorhouse, & Murr,
2016).
Observe rate, rhythm, and depth of Provides insight into the work of breathing
inspirations. (I) and adequacy of alveolar ventilation
(Doenges, Moorhouse, & Murr, 2016).
Auscultate breath sounds q4 to 8 hours. (I) The oxygen content of the blood is often
decreased in patients who have pulmonary
congestion (Ignatavicius & Workman, 2010).
Review pertinent diagnostic data (ABGs, To evaluate lung mechanics, capacities and
hemoglobin, RBCs and electrolytes) and functions. Blood studies are useful in
pulmonary function studies. (C) revealing systemic reasons for problems with
oxygenation and the results of hypoxemia and
acid-base imbalances (Doenges, Moorhouse,
& Murr, 2016).
Provide supplemental oxygen if ordered and Dictated by pulse oximetry, ABG’s and client
necessary. (In emergency situation this would symptoms (Doenges, Moorhouse, & Murr,
be first) (C) 2016).
Place in high fowler’s position with pillows To maximize chest expansion and improve
under each arm. (I) oxygenation (Ignatavicius & Workman,
2010).
Perform deep-breathing exercises To help improve oxygenation and prevent
(spirometer) q2 hrs. (I) atelectasis (Ignatavicius & Workman, 2010).

Evaluation: Patient’s goals were met on the day of care. Although there was not updated labs to
determine patient’s CO2 and blood PH levels, her O2 stats remained at 97% on room air. Patient was
free from cyanosis and pallor and vitals remained stable at BP 130/62, T 99, HR 72, and RR 20.
Patient also participated in active use of spirometry, and was able to successfully reach her goal.
However, the patient’s breath sounds remained diminished at left base. Patient remained in high
fowler’s position throughout the day, tolerating well.
Goal/Outcome: Patient will demonstrate improved ventilation and adequate oxygenation of tissues
by AEB ABGs within patient’s normal parameters and absence of symptoms of respiratory distress
by end of shift. Patient will also participate in treatment regimen: use of spirometer within level of
ability and situation on the day of care.
Interventions Rationale
Auscultate breath sounds for presence of Indication of pulmonary congestion and
crackles or congestion. (I) potential of developing pulmonary edema that
can interfere with oxygen-carbon dioxide
exchange at capillary level (Doenges,
Moorhouse, & Murr, 2016).
Auscultate heart tones for S3, ventricular Signs suggestive of heart failure, which
gallop. (I) results in decreased cardiac output and tissue
hypoxia (Doenges, Moorhouse, & Murr,
2016).
Assess for presence of neck vein distention. Sign of increased intravascular volume
(I) (Doenges, Moorhouse, & Murr, 2016).
Note presence and location of edema. (I) Heart failure is associated with dependent
edema because of hydrostatic pressures, with
dependent edema being a defining
characteristic for excess fluid (Doenges,
Moorhouse, & Murr, 2016).
Daily weights. (I) Accurate daily weights are needed to
document fluid retention, weight is the most
reliable indicator of fluid loss (Ignatavicius &
Workman, 2010).
I & O (I) Urine output must be serially assessed so that
the dosage of a diuretic can be titrated to a
patient’s need (Albert, 2012) and to assess
fluid balance (Doenges, Moorhouse, & Murr,
2016).
Administer loop diuretics as prescribed. (D) Loop diuretics are the hallmark
pharmacological treatment for hypervolemia.
Loop diuretics rapidly relieve signs and
symptoms of pulmonary congestion by
lowering left ventricular filling pressure
(Albert, 2012).
Follow low-sodium/cardiac diet as ordered by Low salt diet minimizes the risk of fluid
physician. (C) retention which places a load on the ailing
heart. Reduced fat diet minimizes the risk for
ischemic HD (Ignatavicius & Workmas,
2010).
Goal/Outcome: Patient will stabilize fluid volume AEB balanced I&O, vital signs within patient’s
normal limits, stable weight, and be free of signs of edema by end of shift.
Evaluation: Patient’s goals were partially met. Patient’s I&O remained balanced with an output >
30mL/hr, vitals remained stable at T 99, BP 130/62, HR 72, and RR 20. Patient did not gain any
weight compared to the day before and remained 192 lbs. Patient’s breath sounds remained
diminished in left base, but were clear in all other lung fields. Patient continued with low-
sodium/cardiac diet and diuretics on day of care. Patient was absent from JVD, however edema in
lower extremities remained as +1 bilaterally.

Intrapersonal Stressor: Multiple co-morbidities and advanced age.


As the patient has chronic kidney disease, atrial fibrillation, HTN, Coronary artery disease and is 92
y.o. it will be harder for her to recover from acute exacerbation of HF.

Interpersonal Stressor: Patient and her mother explained that they are unable to find good home care
for the patient. Patient worries about being taken care of when she goes home.

Extrapersonal Stressor: Patient lives alone.


As the patient is 92 y.o. and has multiple chronic conditions she worries about being home alone.
She states “what is something happens to me when nobody is home.”
Patient: 92 y.o. Female
HPI: Patient presented to ER with generalized weakness and fatigue, a weight gain of 10 pounds in the past week and feeling SOB.
Patient is unable to tolerate usual activities and family noticed a change in patient’s orientation. Patient was diagnosed with heart
failure.
PMH: Chronic kidney disease, atrial fibrillation, HTN, coronary artery disease, Urinary tract infection, and pulmonary hypertension.
References

Albert, N. (2012). Fluid management strategies in heart failure. Critical Care Nurse,32(2).

Amakali, K. (2015). Clinical care for the patient with heart failure: A nursing care perspective. Cardiovascular Pharmacology, 4(2),

doi: 10.4172/2329-6607.1000142

Doenges, M., Moorhouse, M., & Murr, A. (2016). Nursing Diagnosis Manual (5th ed.). Philadelphia, PA: F. A. Davis Company.

Ignatavicius, D., & Workman, M. (2010). Medical-Surgical Nursing Patient-Centered Collaborative Care (6th ed., Vol. 2). St. Louis,

MI: Saunders Elsevier.

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