Name of Patient : R.T. Diagnosis: Congestive Heart Failure secondary to CAD, HCVD
Age: 61 years old Chief Complaint: Cough, Difficulty of Breathing
Sex: Male Attending Physician: A.T.
Nursing Care Plan
General Objective: Facilitate the maintenance of a supply of oxygen to all body cells.
|Cues |Nursing Diagnosis |Rationale |Specific Objective |Interventions |Rationale |Evaluation |
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” | | |sounds and respiratory rate |2.Note respiratory rate, depth;|2.To assess for the extent of |evidenced by decreased |
| | |Due to increased pressure in |and absence of cyanosis. |use of accessory muscles; note |oxygen inadequacy. |crackles and RR of 21 cpm. |
|Objective Cues: | |the pulmonary circulation, | |areas of pallor/cyanosis; for | | |
| | |fluid component of the blood | |example, | | |
|Crackles | |will be forced to seep out into| |peripheral (nailbeds) versus | | |
|RR- 28 cpm | |the alveoli. Fluid accumulation| |central (circumoral) or general| | |
|O2 at 4 L/min. | |in the alveoli will interfere | |duskiness. | | |
|Orthopnea | |in the diffusion process where | | | | |
|Productive cough | |in carbon dioxide from the | |3. Auscultate breath sounds. | | |
|Friction Rub | |blood will move out into the | | | | |
|Bilateral Pleural Effusion (CXR-| |alveoli and oxygen in the | | | | |
|Feb. 4) | |alveoli will move into the | |4. Assess level of |3. To note areas of | |
|Pallor | |blood. Further fluid | |consciousness and mentation |decreased/adventitious | |
|Delayed capillary refill | |accumulation will also destruct|...