Nursing Diagnosis

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Nursing Diagnosis: Excess fluid volume related to inactivity, secondary to congestive heart failure, as manifested by rapid weight gain, pitting edema in extremities, elevated blood pressure, bilateral crackle lung sounds, bradypnea, and dyspnea. Goal: Absence of fluid retention by discharge

Desired Outcomes:
1. Blood pressure within regular limits by discharge
2. Absence of edema by discharge
3. Slow progression of weight gain by day 2 of admission
4. Ease of respirations within 2 hours of admission
Priority Nursing Responses:
1. Measure and record Intake/Output
2. Monitor patient diet
3. Measure patient weight at the same time each day
4. Position patient in Fowlers position to help ease respirations 5. Administer oxygen to ensure oxygenation
6. Apply anti-embolism stockings to increase venous return 7. Maintain sodium-restricted diet
8. Teach patient importance of proper diet
9. Reposition patient every 2 hours
10. Administer diuretics
Evaluation: After 48 hours on diuretics, patient demonstrates significantly less edema in extremities, clear lung sounds bilaterally and no added weight gain. Patient can now breathe with ease, and his blood pressure is 130/84. Patient was educated on his diet, and states that he “will do a better job maintaining a healthy diet”. There are no signs or symptoms of DVT, no signs of skin breakdown, and SPo2 is at a 99% on room air. Patient seems to be in good spirits with a positive outlook with his prognosis. We scheduled him an appointment with his cardiologist for a follow up in 1 week from discharge.
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