1.

Nursing Diagnosis:
Decreased cardiac output
a. Assessment: Concept Map
Patient had edema in lower extremities (+1 2. Nursing Diagnosis:
edema), patient felt fatigued and took a lot of Excess fluid volume
naps (patient was able to walk long distance a. Assessment:
with walker and now cannot take more than a Patient had new onset of a heart murmur,
few steps), patient had heart murmur, patient’s respirations were shallow, patient’s
peripheral pulses were weak, alteration in chest x-ray showed small bilateral pleural
blood pressure (from 190/96 in dialysis to effusions, patient had end stage renal disease,
105/74 an hour later when he returned to the patient was on daily weights (gained 5 pounds
Medical Diagnosis:
unit), patient had crackles in all lung lobes, in two days), patient had free floating fluid in
NSTEMI, ESRD, abdomen, patient had alteration in blood
patient had a cough (sputum color was tan),
respirations were shallow, renal status: end thrombocytopenia. pressure (190/96 to 105/74).
stage renal disease (patient is on
hemodialysis). Priority Assessment: b. Medication & Treatments:
Troponin- 5.41 (normal is Anti-infective for pleural effusions
b. Medication & Treatments: 0.00-0.04), chest pain, Antihypertensives for blood pressure
Vasodilator- hydralazine 25mg tablet blood pressure, LOC,
Ace inhibitor- lisinopril 10mg tablet c. Lab Values:
mental status.
Fluid balance- 1200ml/day fluid restriction Hemoglobin-8.9 (normal is 13.5-17.7)
Hematocrit- 29.2 (normal is 39.8-52.3)
c. Lab Values: BUN- 96 (normal is 7-22)
BUN-96 (normal is 7-22) Creatinine- 5 (normal is 0.5-1.5)
Creatinine- 5 (normal is 0.5-1.5)

3. Nursing Diagnosis:
Activity intolerance
a. Assessment: Additional Key Data:
Patient has COPD and chronic cough, Patient did not complain of
respirations are shallow, breath sounds are constipation during my shift.
diminished, and crackle in lungs upon Other Nursing
auscultation, feels fatigued with activity.
Diagnoses:
b. Medication & Treatments:  Anxiety
Works with physical therapy daily, breathing  Impaired urinary
treatments as needed, getting up in the chair for elimination
all meals.  Ineffective tissue
perfusion
c. Lab Values:  Risk for
WBC- 20.61 (normal is 4.5-11) constipation
RBC- 3.31 (normal is 4.7-6.1)
Hemoglobin-8.9 (normal is 13.5-17.7)
Hematocrit- 29.2 (normal is 39.8-52.3)
CO2- 15 (normal is 24-30)
 Goals and Interventions

1. Nursing Diagnosis: Decreased cardiac output related to reduced myocardial perfusion

secondary to NSTEMI as evidence by heart murmur, edema in lower extremities, fatigue,
dyspnea, and crackles in lungs.

Goals/outcomes: Patient will show decreased signs of heart failure, such as fewer crackles in
lungs upon auscultation, decreased edema (+1), and increased peripheral pulses, by 3/14/18
(Phelps, Ralph, & Taylor, 2017). Goal was met.

Interventions:
1. Intervention: Auscultate patient’s lungs at least every 4 hours for adventitious
lung sounds such as crackles (Phelps, et al., 2017).
Rationale: Crackles may indicate fluid build up in the lungs, which is a sign of
cardiac failure (Phelps, et al., 2017).

2. Intervention: Palpate peripheral pulses every 4 hours to monitor for a change in

pulses, such as an increase or decrease (Phelps, et al., 2017).
Rationale: Decreased peripheral pulses indicate low blood pressure and not
enough blood flow to the lower extremities, which is a sign of cardiac failure
(Phelps, et al., 2017).

3. Intervention: Monitor for an increase or decrease in edema (Phelps, et al.,

2017).
Rationale: Increase in edema indicates impending cardiac failure and build up of
fluid (Phelps, et al., 2017).

4. Intervention: Monitor patient for dyspnea every 2 to 4 hours (Phelps, et al.,

2017).
Rationale: Older patients with a previous myocardial infarction frequently
develop dyspnea related to left sided heart failure (Phelps, et al., 2017).

2. Nursing Diagnosis: Excess fluid volume related to compromised regulatory mechanism as

evidence by heart murmur, pleural effusions, and weight gain of 5 pounds in two days (Phelps,
et al., 2017).

Goals/outcomes: Patient will explain ways to reduce excess fluid volume, such as monitoring
fluid intake and output, by end of shift (Phelps, et al., 2017). Goal was met.

Interventions:
 1. Intervention: Explain reasons for fluid restrictions. For this patient, I would
explain that since he has end stage renal disease, he should restrict his fluid
intake to 1200mL/day as protocol for end stage renal disease (Phelps, et al.,
2017).
Rationale: Explaining the reason for fluid restriction will enhance the patient’s
knowledge to preventing excess fluid volume when he returns home (Phelps, et
al., 2017).

2. Intervention: Explain to patient the reason to perform daily weights. For this
patient, I would explain that excessive weight gain over a short period of time
adds to excessive fluid overload. I would also explain that daily weights should
be performed before breakfast to get a true weight. After explaining this to the
patient, I would listen to patient feedback to know that the patient understands
the need for daily weights (Phelps, et al., 2017).
Rationale: Explaining the reason for performing daily weights will enhance the
patient’s readiness for preventing fluid volume when after being discharged
from the hospital. Patient teachback shows that the patient understands why
daily weights need to be performed (Phelps, et al., 2017).

3. Intervention: Monitor intake and output at least every 4 hours (Phelps, et al.,
2017).
Rationale: Intake greater than output indicates fluid retention, which is common
in this patient regarding that fact that he has end stage renal failure. Also,
performing this in front of the patient will help the patient understand the need
to do this at home (Phelps, et al., 2017).

4. Intervention: Place patient on a sodium restriction of 1500mg/day (National

Kidney Foundation, 2017).
Rationale: Restricting sodium intake will help decrease fluid retention (Phelps, et
al., 2017).

3. Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and
demand as evidence by fatigue, exertional dyspnea, and crackles in lungs (Phelps, et al., 2017).

Goals/outcomes: Patient will be able to walk from the bed to the door without dyspnea, by
3/14/18 (Phelps, et al., 2017). Goal was not met.

Interventions:

1. Intervention: Explain to patient the need for activity. One way to do this is by
saying that a lack of activity may have a negative impact on psychological well-
being (Phelps, et al., 2017).
 Rationale: Explaining the need of activity will improve the patient’s readiness to
reach the goal of walking to and from the door without dyspnea (Phelps, et al.,
2017).

2. Intervention: Walk with patient at least 3 times per shift, to and from the door
(Phelps, et al., 2017).
Rationale: Alternating periods of activity and rest will help build patient’s activity
tolerance (Phelps, et al., 2017).

3. Intervention: Teach patient ways to conserve energy while performing activities

of daily living, such as sitting down while brushing his teeth (Phelps, et al., 2017).
Rationale: Conserving energy will reduce cellular metabolism and oxygen
demand (Phelps, et al., 2017).

4. Intervention: Teach patient exercises for increasing strength and endurance,

such as raising and lowering legs in the bed at least two times an hour (Phelps, et
al., 2017).
Rationale: These exercises will improve breathing and promote physical
reconditioning, which makes it easier to reach the patient’s goal (Phelps, et al.,
2017).
 Reference

National Kidney Foundation (2017). Sodium and your CKD diet: How to spice up your

cooking. Retrieved from https://www.kidney.org/atoz/content/sodiumckd

Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Sparks & Taylors nursing diagnosis

reference manual. Philadelphia: Wolters Kluwer.