Problem List

Name: M.A. CC: DOB, Chest pain

Age: 56 yrs.old Diagnosis: Congestive Heart Failure

CUES PROBLEMS RANK PHYSIOLOGIC BEHAVIORAL

SUBJECTIVE: ACTUAL POTENTIAL ACTUAL POTENTIAL
The patient
Ineffective Risk for Disturbed Risk for
verbalized:
breathing impaired gas sleep pattern powerlessness
“Nabudlayan gid
pattern exchanged related to related to
ko mag ginhawa
related to related to a physiologic ineffective
kada mag higda Difficulty of 1
increased possible variation as coping
ko”. Breathing
respiratory increase evidenced by strategies
He also
rate as carbon difficulty of
verbalized:
evidenced by dioxide in the breathing
“Kasakit gid sang
respiratory blood as while in
akon dughan mag
rate of 30 cpm evidenced by recumbent
ginhawa kun mag
difficulty of position
higda ko”.
breathing.
The client added
“Nakulbaan ko sa
akon gina batyag,
naga pin ot na
dayun akon
dughan”

 Orthopnea

OBJECTIVE:

 BP = 160/100
mmHg
 RR = 30 cpm
 HR = 115
bpm
 T = 37C
 Dependent
edema on
both
extremities
 Crackles
upon
auscultation
 Tender and
distended
 abdomen
 Chest X-ray
result shows
cardiomegaly
Hypertension 2 Impaired Risk of Moderate Risk of
cardiovascula decreased anxiety hopelessness
r function cardiac related to may be
related to output the threat to related to
increased related to health as deteriorating
cardiac output increase in evidenced by physiological
as evidenced heart rate as verbalizatio conditions
by a heart rate evidenced by n of fear by secondary to
of 110 and BP hypertension the client elevated blood
of 160/100 secondary to pressure.
mmHg. elevated
blood
pressure
Dependent 3 Excess fluid Risk for fluid Fear related Risk of
Edema volume overload to perceived trauma
related to related to threat of related to
decreased presence of death as emotional
cardiac fluid evidenced by disturbances
functioning as retention as panic state
evidenced by evidenced by and
presence of dependent restlessness.
crackles edema on
both
extremities