‘Sublective data: Pt stated “There is a tightness in through here (gesturing to abdomen) where it hurts and | am short of breath”. Pt clo GI bloating for 1 month. Obiective data: 3+ pitting edema (above knees through feet bilaterally) HGB 8.9, HCT 27, BNP 897, BUN 23, GFR 63, Creatinine 1.5, weight gain, Ejection Fraction 35-40%, EKG indicates diastolic dysfunction, moderate mitral valve insufficiency, dry cough ‘Nursing Interventions: (Dependent) + Administer meds (Lasix and Zaroxolyn) as ordered for dioresis * Provide diabetic, low sodium jet with 120m! fluid restriction as ord (Independent) + Monitor extent and location of edema aah + Monitor intake and output aah ‘+ Monitor pt weight QAM 0700 * Reposition pt qzh elevating legs as tolerated + Encourage rest 2xq shift + Monitor vital signs q4h NUR 1726 Concept Map atient will demonstrate a decroaso in poriphoral ema AEB no greater than 1¢ pitting edema at the pedis by 11/9/10. 4. Ptintake 200ml and output 900m! at 1100, goal met and will continue. Qutcomes: By 11/3/10 1.Pt will have a greater fluid output than input 2.Pt will have decrease in fluid retention AEB weight loss 3, Pt will better tolerate physical activity during PT AEB. fannefalrstloniend (eects ce! 2. Ptwill be weighed in the AM goal likely ‘met and will continue. Dx: Fluid Volume Excess rit decreased kidney function secondary to ineffective cardiac pump and rate AEB SOB, pulmonary edema, peripheral edema, weight gain, Gl bloating, dry couah 3. PT walked twice as far today 11/2/10 as ferday and pt tolerated it with minimal SOB, goal met and will continue. Collaborative Ini + Consult with PT about a bed in the SNU for appropriate Rehab + Consult with dietician about appropriate menu and fluid restriction upon discharge. ly knowledge of disease process causing excess fluid volume. Teach about disease process and complications of excess fluid volume, including when to contact physician. + Have pt verbalize what the s/s of volume excess (Jugular vein distention; weight gain greater than 2ibs in 1 day or 5 in 1 week; changes in respiratory pattern, dyspnea or shortness of breath; orthopnea; pulmonary congestion; intake exceeds output; change in mental status; restlessness; anxiely; edema) + Assess client and family knowledge and compliance with medical regimen, including medications, di rest, and exercise. Be sure they monitor Morning Point's comp! to devise a schedule for intake of fluids throughout entire day so the care team at Morning Point can follow it. SK