AC is a 45 year old male who has a history of heart failure, and mitral valve stenosis. He was admitted through the ED last night after having increased difficulty taking care of his own needs (he says it just makes him “to tired”), and falling. He stated he has “no energy”, and has had increased swelling in his lower extremities and feels bloated “all over”. He has a history of a mitral vale replacement 4 years ago, and his appendix removed last year. He states he had no complications from those surgeries.
He does not drink or smoke. He is on 4L of O2 sating at 98%. Skin intact, cyanosis noted around his mouth when he was off his oxygen. Skin is intact but he has pitting edema 3+ bilateral lower extremities. 18 g IV to his left wrist saline locked. Diet is cardiac, patient needs assistance eating (lack of energy), and has a fluid restriction of 1200mL/day. He is a fall risk, and currently has a bedrest order. We are waiting for a dopler cardia study to determine ejection fraction. Lung sound are clear. Vitals unremarkable. Full code.
1. Highlight all abnormal.
2. Write 3 NURSING diagnoses according to NANDA.
NANDA (please use ONLY nursing diagnoses according to the book, NOT medical!!!!)
R/T (what it’s related to)
AEB (As Evidenced By)
than write separately for each nursing diagnose:
3. Chose a goal
4. Objective measures
5. Appropriate interventions