J. H., a 67 year old female

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J. H., a 67 year old female by Mind Map: J. H., a 67 year old female

1. Nursing Diagnosis

1.1. Impaired gas exchange related to increased preload and alveolar-capillary membrane changes as evidenced by abnormal oxygen saturation, hypoxemia, tachypnea, restlessness, and patient's statement, “I am so short of breath” (Lewis et al., 2014).

1.1.1. Interventions

1.1.1.1. Monitor oxygen saturation, breath sounds, increased restlessness, tachypnea

1.1.1.2. Monitor oxygen saturation, breath sounds, increased restlessness, tachypnea

1.1.1.3. Position in semi or high Fowler's

1.1.2. J. H. Perspective Outcomes

1.1.2.1. Increased energy level to perform walking and cooking and spending time with her family

1.1.3. Nurse Perspective Outcomes

1.1.3.1. J. H.'s O2 will increase to above 95% on room air.

1.1.3.2. J. H.'s respiratory rate will be below 20 per minute.

1.1.3.3. J.H.'s sleep will be more restful due to ease of breathing and reduced anxiety.

1.2. Activity intolerance related to imbalance between O2 supply and demand secondary to cardiac insufficiency and pulmonary congestion as evidenced by dyspnea, shortness of breath, weakness, increase in heart rate on exertion, and patient's statement, “I am too tired to get out of bed; I have no energy” (Lewis et al., 2014).

1.2.1. Interventions

1.2.1.1. Teach active/rest cycles throughout the day to conserve energy

1.2.1.2. Collaborate with occupational/physical therapists to start an acceptable and tolerable exercise program/walking schedule

1.2.2. J. H. Perspective Outcomes

1.2.2.1. Increased restful sleep to increase energy level for activity tolerance to begin walking and cooking again

1.2.2.2. Increase energy level to spend more time with family

1.2.3. Nurse Perspective Outcomes

1.2.3.1. Increase restful sleep each night for increased energy level

1.2.3.2. Increased activities to reduce feelings of depression

1.3. Excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to heart failure as evidenced by edema, adventitious breath sounds, and patient statement, "I often forget to take my medications" (Lewis et al., 2014).

1.3.1. Interventions

1.3.1.1. Administer medications: Flurosemide 30 mg q24h and Metoprolo 50 mg q24h

1.3.1.2. Teach J. H. side effects of medications and collaborate with her for ideas to reduce forgetfulness

1.3.2. J. H. Perspective Outcomes

1.3.2.1. Decrease heart failure symptoms to increase quality of life through time with family and desired activities

1.3.3. Nurse Perspective Outcomes

1.3.3.1. Increase medication compliance to decrease modifiable risk factors of HF related to obesity and hypertension

2. Clinical Assessment Data

2.1. Subjective: fatigue with minimal exertion, SOB, dry cough, sleeps with 3 pillows, decreased level of activity, restlessness, forgets to take medications.

2.2. Objective: vitals are BP 156/78, HR 87, RR 31, T 36.1, O2 89% on room air, bilateral lung crackles, accessory muscles used, skin cool and clammy. alternating strong/weak pulses, S3 heart sounds.

2.2.1. Nurse Perspective Goals

2.2.1.1. Increase oxygen saturation

2.2.1.2. Lower respiratory rate

2.2.1.3. Management of weight and hypertension

2.2.1.4. Increase activity level

2.2.1.5. Increase restful sleep

2.2.1.6. Decrease feelings of depression

2.3. Medical History: MI 6 months ago, coronary artery disease (CAD), obesity, hypertension.

2.3.1. Furosemide (Lasix) 30 mg q24h

2.3.2. Metoprolol 50 mg q24h

3. Psychosocial Data

3.1. Husband passed away last year

3.2. Daughter and 3 grandchildren live in town that she has not seen since school started 3 months ago.

3.2.1. J. H. Perspective Goals

3.2.1.1. Increase energy level

3.2.1.2. Increase time with daughter/grandchildren

3.2.1.3. Resume walks and cooking

3.2.1.4. Increase restful sleep

3.3. Stopped going outside to take walks.

3.4. Stopped making herself dinners in the last year resulting in eating can soups.

4. Pathophysiology of Medical Diagnosis: Acute Left-Sided Heart Failure

4.1. Decreased cardiac output

4.1.1. Decreased filling or pumping of left ventricle

4.1.1.1. Decreased forward movement of blood, causing back up into left atria and pulmonary veins leading to pulmonary edema and congestion.

4.1.2. Compensatory mechanisms

4.1.2.1. Sympathetic nervous system releases catecholamines: increases heart rate, contractility, vasoconstriction

4.1.2.2. Kidneys activate renin-angiotensin-aldosterone system (RAAS): fluid retention

4.1.2.3. Heart releases cytokines: ventricle remodeling

4.1.3. Risk factors

4.1.3.1. MI

4.1.3.2. Obesity

4.1.3.3. Hypertension

4.1.3.4. Coronary artery disease (CAD)

4.1.3.5. Advanced age

4.2. Diagnostic findings

4.2.1. Increased sodium, potassium, blood urea nitrogen, N-termianl pro hormone of BPN

4.2.2. Chest x-ray reveals pulmonary congestion and edema

4.2.3. Electrocadiogram shows decreased ejection fraction, wall motion, and ventricular enlargement