Download Planning/Implementation/Evaluation Med/Surg Nursing Diagnosis

Planning/Implementation/Evaluation
Med/Surg Nursing Diagnosis: Fluid Volume Excess R/T decreased cardiac output AEB 15+ pound weight gain, B/L LE +3 pitting edema, and BNP 2510
Long-Term Goal: Patient maintain optimal fluid balance
Outcome Criteria
Interventions
One outcome criteria for
each intervention.
Number each one.
Label each as
assess/monitor/independent/
dependent/teaching/collaboration
1.
1. Dependent: Administer Lasix
tab 40mg BID
2. Patient will have
less than 100cc of
output each hour
2. Independent: Monitor urine
output in response to diuretic q 1
hr
3. Patient lungs
sounds will be clear
when assessed
3. Independent: Assess lung sound
q 4 hrs
4. Patients BNP will
trend towards less
than 99 when
monitored
4.Dependent: Monitor BNP when
obtained
Rationale
Evaluation
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.
Evaluate the patient outcome,
NOT the intervention
1. The patient came into the hospital with C/O 10+ pound weight gain in 10
days and 3+ B/L LE pitting edema. It is important to lower the amount of
excess fluids he has gained to decrease his preload which will help increase
he cardiac output. Lasix increases the renal excretion of fluids. Reducing the
preload will allow the heart to work more efficiently by improving stroke
volume and increasing cardiac output.
2. It is important to monitor the response to diuretic therapy because an
increase response could shift the patient into fluid volume deficit and
electrolyte imbalances. This could cause the patient to be hypotensive,
experience increased weakness, and increase their BUN. The patient BUN
was already high at 39, his blood was low at 100/58, and he was already
weak. While it is important to reduce the fluid volume excess, you don’t
want to do too fast, because excess fluid loss can stimulate the aldosterone
system and lead to increased fluid volume again.
3. The patients lungs sound were diminished but clear. When a person has
left ventricular dysfunctions blood and fluids back up in the lungs and
causes fine crackles at the base of the lungs. If he were to develop crackles
in his lungs in would be a sign of excess fluid accumulation in the lungs.
Because he had clear lung sounds his fluid volume excess has not worsen
and the diuretic therapy was helping him.
4. When the patient was admitted on 10/6/14 his BNP was 2510. On
10/9/14 his BNP was 825. B-Type natriuretic peptide (BNP) are hormones
that are secreted in the left ventricle of the heart. The level increase when
the ventricles are working harder to pump the blood through the body,
which is known as left ventricular dysfunction. It also helps determine if
dyspnea is related to cardiac problems. The higher the levels increase the
more severe the heart failure is. When a patient’s BNP are above 900 heart
failure is diagnosed as severe. Monitoring BNP will help determine if the
left ventricle dysfunction is improving or getting worst. Since his BNP was
decreasing it shows that his left ventricle was working more efficiently.
1. unmet: They patient still
had B/L 2+ pitting edema
2. Unmet: Patient had 825
output for the 8 hour night
shift. MD switched his Lasix
from IV to PO
3.Met: Patients lung sounds
were clear
4. Met: On 10/9/14 his BNP
was trending down and
were 825
5. Patients Na+ 135145, Mg2+ 1.6-2.6
mg/dl, Ca 9-10.5
mg/dl, and K+ 3.5-5
mg/dl by 10/11/2014
5.Dependent: Monitor
electrolytes daily
5. Proper electrolyte balance of Na+, Ca, K+ and Mg are important for
6. Patient will have
no B/L LE pitting
edema by 10/11/14
6.Dependent: Administer Digoxin
0.125 mg before lunch
6. Digoxin increases the force of myocardial contraction, prolongs
7. Patient will have
decreased SOB and
edema by 10/11/14
7. Dependent: Administer
Lisinopril 5mg QD
8. Patient edema will
be trending down by
10/11/14
8. Independent: monitor edema q
shift
9.
9. Dependent: Assess
Echocardiogram when obtained
cardiac output. A change in electrolyte levels could cause dysrhythmias
which could further decrease the patients cardiac output. The cardiologist
place the patient on 40mg IV push to decrease his fluid volume excess.
Since this is a large dose of Lasix, it is important to monitor for excessive
loss of his electrolytes.
refractory period of the AV node, and decreases conduction through the SA
and AV nodes. The therapeutic effects are and increase in cardiac output
and slowing of the heart rate. The patient had fluid volume excess because
of his decreased cardiac output. By increasing his cardiac output with
digoxin it will lower his fluid volume.
7. Ace inhibitors are one of the core measurement for heart failure
patients. They block the conversion of angiotensin I to the vasoconstrictor
angiotensin II, prevent the degradation of bradykinin and prostaglandins,
and also increase plasma renin levels and decrease aldosterone levels. The
effect will be vasodilation which will decrease BP, improve cardiac output,
and help with diuresis through decreasing the aldosterone levels. The
patient was experiencing fluid volume excess. Administering an ace
inhibitor will improve his quality of life by decreasing the symptoms of
excess fluids.
8. Decreased cardiac output causes a backup of blood on the right side of
the heart which causes the blood to stay in the veins. The outcome is
peripheral edema. The patient was admitted to the hospital with
complaints of 15+ weight gain and 3+ B/L pitting edema. By monitoring the
patient’s edema you can assess if the treatment for fluid volume excess is
working and the patients cardiac output is improving.
9. An echocardiogram measures abnormalities of the valves, ejection
fractions, and cardiac functions. An ejection fraction is the percentage of
end-diastolic blood volume that is ejected during systole. The normal
ejection fraction is 50-70%. The measurement of ejection fraction is
important in heart failure patients as the decrease in it is the hallmark of
left sided heart failure. An ejection fraction less than normal would cause
symptoms of fluid volume excess because the heart is not pumping enough
blood through the body and the fluids are getting backed up. The patient
was experiencing fluid volume excess which could be due to having a
decreased ejection fraction.
5. partially met: Patients K+
was 3.5, Na+ 137, Ca 8.9,
Mg2+ 1.3
6. partially met: Patients
edema was decreasing but
he still had B/L LE 2+ pitting
edema
7. partially met: Patients
edema was decreasing but
he still had B/L LE 2+ pitting
edema and was still SOB
8. partially met: Patients
edema was decreasing but
he still had B/L LE 2+ pitting
edema
9.
10. Patient will not
need more than 2
pillows when laying
down
10. Independent: Assess for
orthopnea q shift
10. Orthopnea is the shortness of breath that occurs when a patient is in a
11. Patient BUN will
be trending towards
21 mg/dl by 10/11/14
11.Dependent: Assess BUN level
qD
11. An increase in BUN could mean that there is a decrease in the perfusion
12. Patient will not be 12.Independent: assess for SOB q
SOB by 10/11/14
shift
13. Patient K+ levels
will be 3.5-5 mEq/l by
10/11/14
13. administer potassium chloride
20 mEq BID
14. Patient will
verbalize importance
of weighing himself
by 10/11/14
14. Teach to weigh self QD
15. Patient will eat a
2 gram sodium diet
now
15. Collaborate with nutritionist as
needed
recumbent position which is relieved by sitting or standing. It is caused by
pulmonary congestion that makes the person SOB. It is usually counted as
how many pillows are person needs so that they don’t feel short of breath
when they are laying down. The patient was already in fluid volume excess,
so he was at a risk or orthopnea. An increase in the number of pillows used
will help determine if there is a shift in his fluid volume.
to the kidneys. The decreased perfusion is due to left ventricular
dysfunction and a decrease in cardiac output. The patient was in had fluid
volume excess so the BUN should be low. His BUN was trending up and was
39 on 10/9/14. Monitoring BUN would tell you if his cardiac output was
increasing or decreasing.
12. The patient had fluid volume excess and was experiencing
shortness of breath. The shortness of breath is caused increase
pulmonary pressures which is due to pulmonary interstitial and
alveolar edema. If there is an increase in SOB the fluid volume could
still be high and if there is a decrease in fluid volume. Assessing for
SOB will help determine which way the fluid is shifting.
13. The patient is in fluid volume excess and was prescribed Lasix to
decease his fluids. Lasix therapy increases renal excretion of
potassium causing the patient level to go dangerously low. The
patient’s potassium levels were trending down and at 3.5 mEq/l on
10/14/14. This could cause the patient to have dysthymias.
Administering potassium chloride will increase his levels to normal.
14. It is important to teach the patient to weigh themselves at the
same time on the same scale in the same clothing every day.
Increase body weight is an indicator of increased fluid retention. The
reason the patient was hospitalized was his increase in weight. It is
important to stress documenting weight changes when he is
discharge so his fluid volume can be managed correctly.
15. Poor adherence to a low sodium diet is one of the most common
reason a patient with heart failure is readmitted. The patient was
admitted due to fluid volume excess. A reduction in the sodium
intake will reduce preload with will increase cardiac output and
decrease fluid retention. A nutritionist will help the patient learn
what foods to stay away from to help decrease his sodium levels.
10. Met: patient was using
only two pillows on 10/9/14
11.not met: the patients
BUN went up to 41 on
10/9/14
12. partially met: patient
still was SOB but it was
decreasing
13. Met: Patients K+ levels
were 3.5 mEq/l on 10/9/14
14. Partially met: I discussed
the importance to daily
weight, but he didn’t
verbalize it back to me.
15. Met: patient is eating a 2
gram sodium diet
Psychosocial Need
Prioritized Psychosocial Nursing Diagnosis: Death anxiety R/T a failing heart AEB expressing his anxiety during admission
Long-Term Goal: Patient will manage death anxiety
Outcome Criteria
Interventions
One outcome criteria for
each intervention.
Number each one.
Label each as
assess/monitor/independent/
dependent/teaching/collaboration
Rationale
Evaluation
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.
Evaluate the patient outcome,
NOT the intervention
1. Patient will
verbalize feelings
during interactions
1. Independent: Encourage patient 1. The cardiologist had just spoken with the patient and explained
to discuss his feeling during
how his heart is failing. He said the patient may die at any time. This
interactions.
may give the patient death anxiety. Encourage the patient to discuss
he is feelings. Keep statements value-free, advice free, and
reassurance free. Ask the patient what they are feeling about what
the cardiologist had to say.
2. Patient have no
anxiety during
interactions
2. Independent: Practice active
listening during patient
interactions.
3. Patient will have
no anxiety after
taking a
benzodiazepine
3. Dependent: obtain a
prescription for a benzodiazepine
PRN now
4. Patient will have
no anxiety when
discussing self-care
measures
4. Independent: Keep language
simple when discussing self-care
measures
2. A very important part of the nurse- patient therapeutic
relationship is active listening. The patient is hospitalized, not feeling
well, and has chosen to turn off his ICD which was helping him stay
alive. This can all be very overwhelming and could cause death
anxiety. Just being there and focusing your attention on the patient
will help decrease his anxiety.
3. A benzodiazepine depresses the CNS by potentiating GABA, an
inhibitory neurotransmitter. By increasing the GABA levels you
decrease a person’s anxiety level. Even though the patient stated his
anxiety level was getting better, now that he has decided to turn off
his ICD the anxiety may increase again. Having the benzodiazepine
available will allow you to help manage his anxiety if it became
severe.
4. When a patient is experiencing moderate to severe anxiety their
ability to comprehend what you are telling them is decreased. The
patient has just been told he may die soon. This could increase his
anxiety due to the fear of the unknown and what’s to come for him.
Keeping your language simple and easy for him to understand can
help decrease his anxiety.
1. Partially met: The patient
discussed how he was tired
and knew he could die at
any time. I’m not sure I
asked him enough questions
to allow him to verbalize
what he was really feeling to
me.
2. Met: when he was
verbalizing his feelings, I
stopped what I was doing to
listen to him.
3. Unmet: He didn’t need a
benzodiazepine
4. Met: When talking to him,
I kept the language simple.