Name: Mr.
Heartbreaker Age: 52 years old Ward: Andrew Hall 1
Chief Complaint: abdominal pain Diagnosis: Aortic Stenosis, Cardiomegaly, CHF , Ac!te "idney n#!ry secondary to sc$emic %ep$ropat$y wit$ Complicated &'
Cues Diagnosis Rationale Objectives Nursing Intervention Rationale Evaluation
Subjective
(%amamanas an
akon mga tiil), as
*erbali+ed by t$e
patient.
(,agan naabat ako
$in b!gat ngan
t!bigon tak tiyan) as
*erbali+ed by t$e
patient.
Objective
-ascites: present
abdominal girt$./0)
1pre$ospitali+ation.
(2
-bipedal edema 32
-weig$t gain 4rom
50kgs. 'o 52 kgs.
-blood press!re.
1/0670nnHg 1n
.120680mmHg2
-#!g!lar *ein
distention o4 5cm
-Hg.115g69 1n.1/0-
175g692
-Ht.0.:5 1n.0./2-
0.502
- Hypokalemia .
:.28mmol 1%.:.5-5.:
mmol692
-proteins.3333
-creatinine .15/.25
!mol69 1normal.71-
115!mol692
-,&%6; .17.08
;<cess 4l!id
*ol!me related
to red!ced
glomer!lar
4iltration rate
as e*idenced
by ascites and
bipedal
edema.
;<cess 4l!id *ol!me
is de4ined as
increased isotonic
4l!id retention.
%!rsing =iagnosis
Handbook: A g!ided
to planning care 7
t$
ed. ,y Ackley >
9adwig p. 5/0
4 t$e $eart
becomes se*erely
damaged, no
amo!nt o4
compensation,
eit$er by
sympat$etic
ner*o!s re4le< or by
4l!id retention, can
make t$e
e<cessi*ely
weakened $eart
p!mp a normal
cardiac o!tp!t. As a
conse?!ence, t$e
cardiac o!tp!t
cannot rise $ig$
eno!g$ to make t$e
kidneys e<crete
normal ?!antities o4
4l!id. '$ere4ore,
4l!id contin!es to be
retained, t$e person
de*elops more and
more edema.
Short !erm "oal
A4ter 5 $o!rs o4
n!rsing inter*ention,
client will
demonstrate
!nderstanding o4
related 4actors as
mani4ested by:
@erbali+e
!nderstanding o4
dietary and 4l!id
restrictions.
=emonstrat
e be$a*iors to
monitor 4l!id
stat!s.
#ong !erm "oal
A4ter 1 week o4
n!rsing inter*ention,
client will
demonstrate
stabili+ed 4l!id
*ol!me as
e*idenced by:
=emonstrat
e balanced >A.
Absence6de
crease o4
edema.
=emonstrat
e stable lab
res!lts.
Independent
Monitor !rine o!tp!t,
noting amo!nt, color and
time o4 day di!resis occ!rs
Maintain c$air or bed rest
in semi-FowlerBs position
d!ring ac!te p$ase
;stablis$ 4l!id intake
sc$ed!le i4 restrictedC
incorporate be*erage
pre4erences i4 possible.
Di*e 4re?!ent mo!t$
care6ice c$ips as part o4
4l!id allotment
Eeig$ed daily at same
time o4 day, on same
scale, wit$ same
e?!ipment and clot$ing.
Assess skin t!rgor.
&rine o!tp!t may be scanty
and concentrated 1d!ring
t$e day2 w$ic$ res!lted
4rom red!ced renal
per4!sion. &rine o!tp!t may
be increased at nig$t6d!ring
bed rest beca!se o4
rec!mbent position.
Fec!mbent position
increases DFF and
decreases prod!ction o4
A=H w$ic$ en$ances
di!resisC impro*es
respiratory e44ort
n*ol*ing patient in t$erapy
regimen may en$ance
sense o4 control and
cooperation wit$
restrictions.
Fed!ce discom4ort o4 4l!id
restrictions.
=aily body weig$t is best
monitor o4 4l!id stat!s. A
weig$t gain o4 more t$an
0.5 kg6day s!ggests 4l!id
retention.
Skin t!rgor re4lects
ade?!ate $ydration
"oals full$ met
A4ter 5 $o!rs o4 n!rsing
inter*ention, client
demonstrated
!nderstanding o4 related
4actors as mani4ested by:
4ollowing dietary
and 4l!id
restrictions
ca!tio!sly
monitored 4l!id
intake and o!tp!t
metic!lo!sly
"oals partiall$ met
A4ter : days o4 n!rsing
inter*ention, client
GatientBs edema
decreased to
grade 1.
%o increase o4
abdominal girt$
noted.
demonstrated
stable lab res!lts
mmol69 1n.2.5-8.:
mmol692
- Additional
=iagnosis: Ac!te
kidney in#!ry
secondary to
isc$emic
nep$ropat$y
secondary to CHF,
complicated &'
- Final diagnosis:
se*ere aortic
stenosis,
cardiomegaly, CHF
ascites
Medical G$ysiology
11
t$
;dition, D!yton
> Hall p.251
Monitored $eart rate 1HF2,
,G
Fecorded acc!rate intake
and o!tp!t 1>A2.
C$ange position
4re?!entlyC ele*ate 4eet
w$en sitting. nspect skin
integrity, keep dry and
pro*ide padding as
indicated
A!sc!ltate breat$ so!nds
noting ad*entitio!s ,S.
%ote presence o4 dyspnea,
tac$ypnea, ort$opnea,
G%= or persistent co!g$
Fecommend ele*ating
lower e<tremities
"eeps linen dry and 4ree o4
wrinkles
;nco!rage amb!lation
n*asi*e monitoring may be
needed 4or assessing
intra*asc!lar *ol!me,
especially in pts. wit$ poor
cardiac 4!nction.
Acc!rate >A are
necessary 4or determining
renal 4!nction and 4l!id
replacement needs and
red!cing risk o4 4l!id
o*erload.
;dema 4ormation, slowed
circ!lation and prolonged
immobility are stressors
t$at a44ect skin integrity t$at
will re?!ire pre*enti*e
inter*entions.
;<cess 4l!id *ol!me o4ten
leads to p!lmonary
congestion. Fespiratory
symptoms may $a*e slower
onset b!t more di44ic!lt to
re*erse.
;n$ances *eno!s ret!rn
and red!ces edema
4ormation in t$e lower
e<tremities.
Moist!re predisposes to
skin breakdown
Gromote circ!lation
Collaborative
Administer di!retics as
ordered:
F!rosemide 1loop di!retic2
/0mg 2 @ now t$en ? 12
$o!rs
Aldactone 1potassi!m-sparing
di!retic, aldosterone
antagonist2 25mg 1 tab A=
Maintain 4l!id6sodi!m
restrictions as ordered
Monitor ser!m alb!min
and electrolytes
n$ibits t$e reabsorption o4
sodi!m and c$loride 4rom t$e
ascending limb o4 t$e loop o4
Henle, leading to a sodi!m-ric$
di!resis.
,locks t$e e44ects o4
aldosterone in t$e renal t!b!le,
ca!sing loss o4 sodi!m and
water retention o4 potassi!m
Fed!ces total 4l!id *ol!me
in t$e body and pre*ent
4l!id reacc!m!lation.
=ecreased ser!m alb!min
a44ects plasma colloid
osmotic press!re, res!lting
in edema 4ormation.
