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    CHF Cardiomegaly Volume Overload

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    nursing concept maps
    The client was admitted with respiratory failure, fluid overload, and sepsis. They have a history of lung transplant, hypertension, kidney disease, and cancer. During this admission, the client was intubated, started on antibiotics for sepsis, and given diuretics to treat fluid overload. Goals include improving the client's respiratory status, managing their electrolytes and fluid balance, and preventing infections.

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    CHF Cardiomegaly Volume Overload

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    nursing concept maps
    285 views1 page
    The client was admitted with respiratory failure, fluid overload, and sepsis. They have a history of lung transplant, hypertension, kidney disease, and cancer. During this admission, the client was intubated, started on antibiotics for sepsis, and given diuretics to treat fluid overload. Goals include improving the client's respiratory status, managing their electrolytes and fluid balance, and preventing infections.

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    CONCEPT MAP

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    The client was admitted with respiratory failure, fluid overload, and sepsis. They have a history of lung transplant, hypertension, kidney disease, and cancer. During this admission, the client was intubated, started on antibiotics for sepsis, and given diuretics to treat fluid overload. Goals include improving the client's respiratory status, managing their electrolytes and fluid balance, and preventing infections.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    285 views1 page

    CHF Cardiomegaly Volume Overload

    Uploaded by

    nursing concept maps
    The client was admitted with respiratory failure, fluid overload, and sepsis. They have a history of lung transplant, hypertension, kidney disease, and cancer. During this admission, the client was intubated, started on antibiotics for sepsis, and given diuretics to treat fluid overload. Goals include improving the client's respiratory status, managing their electrolytes and fluid balance, and preventing infections.

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    TCC Nursing Program

    NUR 2564 Advanced Medical Surgical

    Key Problem Concept Map Key Problem


    Risk for Infection
    6 Fluid Volume Excess
    3
    Why was the client admitted?
    Supporting Data Pt. Was life-flighted from Supporting Data: CXR indicating
    WBC count 15.33: Central line outlying hospital where he was cardiomegaly with evidence of fluid
    placed: currently septic: surgery evaluated pH 7.2 & pCO2 of volume overload, right mid lung
    yesterday to remove squamous cell 60, CXR showing CHF, edema; Lung sounds diminished
    carcinoma on chest wall: Currently cardiomegaly, volume bilaterally at the bases, edema
    Intubated: has indwelling Foley overload. Outlying hospital was present and patient looks generally
    catheter not equipped to care for the pt. puffy. BNP of 2547.5; Input
    exceeded output with a negative
    Client Goal: Client will not acquire 1583ml
    any further infections; WBC count
    will begin to normalize as patient What is clients significant Client Goal: Remain free of jugular
    responds to antibiotic therapy history and/or co-morbidities? vein distention, positive
    HTN, CKD, bilat lung transplant 2004, hepatojugular reflex, and gallop
    hx of rejection & chronic host vs graft heart rhythm
    rejection. Hx of A-fib, CAD, stent
    placed in 2003, single vessel disease,
    squamous cell carcinoma on chest
    Key Problem 5 wall. Key Problem 1
    Risk for Aspiration Has the client had any Decreased cardiac output
    significant procedures/surgies
    Supporting Data: Patient is during this admission? Supporting Data: Patient converted
    Pt. was intubated on arrival
    currently intubated with from a normal sinus rhythm to atrial
    Does the client have family? wife
    endotracheal tube and is receiving has stayed at the bedside.
    fibrillation with RVR spontaneously
    supplemental nutrition via Other significant data: Patient in the night.
    nasogastric tube converted from NSR in the 70-80bpm
    range to atrial fibrillation with RVR. Pt.
    was started on an IV drip of Heparin Client Goal: Remain free of side
    Client Goal: Swallow and digest @ 30mL/hr. The pt. is effects from the medications used to
    nasogastric feeding without immunosuppressed, currently septic, achieve adequate cardiac output
    aspiration has fluid volume overload. My
    interpretation of the ABGs indicating
    partially compensated metabolic
    acidosis.

    Key Problem: 2 Key Problem 4


    Impaired Gas Exchange Risk for Electrolyte Imbalance
    Supporting Data: Abnormal blood gasses; pCO2-
    31mm/Hg; pH 7.28; pO2 125 mm Hg; CO2 21; Supporting Data: evidence of fluid volume overload
    Lower extremities were blue-purple in color and the patient also has kidney disease; BUN 54;
    indicating poor perfusion; CXR indicating fluid Creatinine 2.80; CA 7.9; Na 134; K 4.5; Phos 4.2; mag
    volume overload and small bilateral pleural effusions. 2.4; Input exceeded output with a negative 1583mls

    Client Goal: Demonstrate improved ventilation and Client Goal: Patient will attain normal serum
    adequate oxygenation as evidenced by blood gas potassium, sodium, calcium, and phosphorus
    levels within normal parameters for that client

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