Concept Map for Patient with CHF Exacerbation

: Pathophysiology : Risk Factors ( Place * for patient ) *Hypertension *African American Coronary artery disease Sleep apnea Smoker “Heart failure occurs when the heart is unable to pump sufficient blood to meet the metabolic needs of the body” (Nursing Central, 2019). Due to reduced cardiac output the renin angiotensin system is stimulated which causes intravascular volume to increase which leads to increased blood pressure. When the blood pressure is increased it results to an increase of cardiac workload. According to Bauldoff (2020), “Heart failure progresses due to the very mechanisms that initially maintained circulatory stability” (p.1055). As this is an ongoing process the heart loses the ability to contract forcefully. While the heart is deteriorating less blood is being delivered to the heart and tissues. As the heart continues to decrease the patient will display symptoms of dyspnea, peripheral edema, and angina.\ : Diagnostics/Results CT scan: showed acute damage to kidneys as shown with fluid retention : Patient Story : Provider Orders Cardiac diet Take Medications as scheduled Administer Oxygen via NC Ambulate patient Initiate non pharmacological sleep measures Measure intake and output Measure VS Take patient precaution measures with pressure ulcers Check BUN levels every morning Check electrolyte panel every morning Name: R.W Age/Gender: 62 Male Race/Ethnicity: African American Admission Date: 3/5/2021 Primary Dx: SOB r/t CHF exacerbation : Physical Assessment Neuro: A&O x4. PERRL. Full consciousness with WDL cognitive. Speech is WDL. GCS total is 15. Integumentary: Skin color appropriate for ethnicity, it is warm and recoils immediately. Braden score of 22. Iv is patent and skin is intact. Cardiovascular: heart rate at 100 bpm. Pulse is palpable and strong. Capillary refill < 4 seconds. BP is 127/72 Pulmonary: RR is 20, dyspnea with exertion, vesicular breath sounds with few bronchi, productive cough, uses a nasal cannula with 7L.O2 sat at 100%. GI: Abdomen is flat, soft, non distended and contender. Active bowel sounds in 4 quadrants. Passing flatus continent of stool. Hematologic: WBC 11.7; low RBC 3.26; low HCT 30.6; Platelet 148; low hemoglobin 9.6; Troponin 0.02; GU: Patient continent of urine. Color was yellow and no odor present. Musculoskeletal: Full range of mobility in upper extremities. Patient is ambulatory but has pain lower left leg. R/L lower edema in legs and feet. Interventions with Rationales for each Assess vital signs and auscultate lungs to see abnormal finding . 1 such as wheezes or crackles which is present with fluid volume excesss Restrict fluid intake as instructed to reduce fluid volume and . 2 manage edema Weigh patient daily since diuretics is prescribed we want to . 3 manage the fluid volume excess but also monitor for weight gain or weight loss ( Evaluation (for each goal Goals met no crackles or wheezes present . 1 Goal met for fluid restricted . 2 Goal met no signs of sudden weight gain or loss . 3 : Signs/Symptoms ( Place * on current ) *shortness of breath *swollen legs * rapid or irregular heartbeat weakness *persistent cough wheezing ascites *chest pain rapid weight gain - : Medical History COPD Hypertension Cor pulmonale Atrial fibrillation Emphysema CKD stage 2 Alcohol use disorder : Current Medications Furosemide 20mg Lorazepam 0.5mg Lisinopril tab 20 mg Sertaline 100mg Duoneb 3ml Rivaroxaban tablet 15mg ( Nursing Diagnosis: (actual Excess fluid volume rate related to . 1 reduced glomerular filtration rate as evidenced by hypertension, edema of the ankles, and respiratory distress. (Gulanick ( 2016 : Measureable Goals Reduce demand of oxygen requirements . 1 Absence of edema . 2 Breath sounds clear . 3