A 67yo male is admitted to the unit with a dx of CHF. Pt states, “I get short of

Question

A 67yo male is admitted to the unit with a dx of CHF. Pt states, “I get short of breath before I’m able to make it up one flight of stairs to my room.” He also reports having to take frequent breaks while doing everyday activities. During your assessment you observe his skin to be pale pink, with swelling in his hand and feet. You also notice pt leaning forward in the bed to breathe with labored breath sounds.

Please develop a nursing diagnosis and work through the table using the above information

Assess

Diagnose

Plan/Outcome

Intervention/

Implementation   

Evaluation/ Goal Achieved

Subjective

Objective

Short-term

Long-term

Short-term

Long-term

Subjective

Objective

Short-term

Long-term

Short-term

Long Term

Assess

Diagnose

Plan/Outcome

Intervention/

Implementation   

Evaluation/ Goal Achieved

Subjective

Objective

Short-term

Long-term

Short-term

Long-term

Subjective

Objective

Short-term

Long-term

Short-term

Long Term

Explanation / Answer

Subjective:

The patient says that he is having shortness of breath while climbing stairs.

Objective:

Patient is leaning forward on the bed to breath.

Short term:

Patient will maintain normal breathing pattern.

Long term:

Patient will perform purse lipped breathing

Place patient in upright sitting position for maximum lung expansion.

Provide respiratory medications and oxygen as per orders.

Maintain a clear airway by encouraging the patient to cough.

Encourage the patient to rest and pace activities.

Teach the patient purse lipped breathing and relaxation techniques.

Short term:

Patient maintained normal breathing pattern of 18 to 20 breaths per min

Long term:

Patient learnt and demonstrated purse lipped breathing.

Subjective:

Patient says that he is taking frequent breaks between activities.

Objective:

Swelling present in his hands and legs

Short term:

Patient will have clear lung sounds and normovolemic.

Long term:

Patient will explain measures to prevent fluid overload.

Monitor fluid intake.

Restrict sodium intake.

Take diuretics if prescribed.

Elevate extremities if edema present.

Place patient in semi fowlers position.

Educate patient and family regarding the importance of following strict dietary measures and fluid restrictions.

Short term:

Patient has clear lung sounds and edema is reduced.

Long term:

Patient explains measures to prevent fluid overload.

Assess Diagnosis Outcome Implementation Evaluation

Subjective:

The patient says that he is having shortness of breath while climbing stairs.

Objective:

Patient is leaning forward on the bed to breath.

Ineffective breathing pattern related to hypoxia as evidenced by shortness of breath on activity.

Short term:

Patient will maintain normal breathing pattern.

Long term:

Patient will perform purse lipped breathing

Place patient in upright sitting position for maximum lung expansion.

Provide respiratory medications and oxygen as per orders.

Maintain a clear airway by encouraging the patient to cough.

Encourage the patient to rest and pace activities.

Teach the patient purse lipped breathing and relaxation techniques.

Short term:

Patient maintained normal breathing pattern of 18 to 20 breaths per min

Long term:

Patient learnt and demonstrated purse lipped breathing.

Subjective:

Patient says that he is taking frequent breaks between activities.

Objective:

Swelling present in his hands and legs

Fluid volume overload related to decreased cardiac output as evidenced by edema of extremities.

Short term:

Patient will have clear lung sounds and normovolemic.

Long term:

Patient will explain measures to prevent fluid overload.

Monitor fluid intake.

Restrict sodium intake.

Take diuretics if prescribed.

Elevate extremities if edema present.

Place patient in semi fowlers position.

Educate patient and family regarding the importance of following strict dietary measures and fluid restrictions.

Short term:

Patient has clear lung sounds and edema is reduced.

Long term:

Patient explains measures to prevent fluid overload.

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