Question

Client Profile: Ahmed is a 65-year-old man. He lives alone and is able to manage himself independently. Ahmed was admitted to the hospital two months ago with heart failure. Since his discharge, a visiting nurse visits every other week to assess for symptoms of heart failure and see that Ahmed is continuing to manage well on his own.. Case Study: The visiting nurse stops in to see Ahmed today. The nurse immediately notices that Ahmed’s legs are very swollen. Ahmed states, “I noticed they were getting a bit bigger. They are achy, too.” The nurse asks Ahmed if he has been weighing himself daily to which Ahmed replies, “I got on that scale the last time you were here, remember?” The nurse weighs Ahmed and he has gained 10 kilo grams. Additional assessment findings indicate that Ahmed gets short of breath when ambulating from one room to the other (approximately 20 feet) and must sit down to catch his breath. His oxygen saturation is 95% on room air. Bibasilar crackles are heard when auscultating his lung sounds. The nurse asks Ahmed if He is currently or has in the past few days experienced any chest, arm, or jaw pain or become nauseous or sweaty. Ahmed states, “No, I didn’t have any of that. The nurse asks about any back pain, stomach pain, confusion, dizziness, or a feeling that Ahmed might faint. Ahmed denies these symptoms stating, “No. None of that. Just a little more tired than usual lately.” His vital signs are temperature 36.4oC, blood pressure 140/70, pulse 93, and respirations 22. The nurse reviews Ahmed’s list of current medications. Ahmed is taking aspirin, clopidogrel, lisinopril, and carvedilol. The nurse calls the health care provider who asks the nurse to draw blood for a complete blood count (CBC), Kidney Function test (KFT), troponin, creatine kinase (CPK), creatine kinase-MB (CKMB), and albumin. The health care provider also prescribes oral (PO) furosemide and asks the nurse to arrange an outpatient electrocardiogram (ECG), chest X-ray, and echocardiogram

4- Formulate nursing care plan, prioritizing THREE nursing diagnosis according to Ahmed's Case following the table below.

Assessment, Nursing Diagnosis, Planning Implementation, Scientific Rationale, Evaluation Expected Outcome

Answer 1

Nursing care plan:
Assessment:
-Assess patient body mass index for weight gain.
-assess patient BP and pulse rate
-assess patient heart sound and murmur.
-assess patient pulmonary status for breath sound, crackles, pleural effusion
Priority nursing diagnosis:
-risk for impaired gas exchange
-excess fluid volume
-Fatigue
Planning:
-improve patient functional ability and wellbeing
-lifestyle modification
-treatment adherence
Implementation:
-auscultate patient breath sounds, crackles, and wheezed to find pulmonary congestion.
-teach patient deep breathing and coughing exercise to clear airway and promote o2 exchange
-place the patient in fowlers position to increase lung capacity
-monitor patient ABG, o2 saturation for hypoxemia
-Administer oxygen saturation as per doctor instruction to improve 02 concentration and reduce tissue hypoxemia
-Administer diuretics to reduce lung congestion and promote gas exchange
-monitor patient intake and output chart to access renal function and fluid loss and fluid restriction.
-check patient weight daily due to more fluid shift and retention.
-assess the patient for dyspnea due to any pulmonary complication
-sodium and fluid restriction should be followed to prevent peripheral edema.
-assess patient sleep disturbance
-involve patients in mild activity and exercise to promote optimal outcomes.
-provide adequate rest and assist the patient with self-care needs.
-include patient with coping behavior to promote a sense of control and improve self-esteem
evaluation:
evaluate patient family knowledge about the level of care, symptoms identification, medication, and diet followup, activity and ability level, and weight management, etc.
outcome:
patient benefit from heart failure management and improvement in survival provides positive outcomes. patient clinical visits and home care interventions improve patient health outcomes.