Mrs. J is admitted to the emergency department with a diagnosis of congestive heart failure

Example: Case Study Plan of Care and Concept Map

Case Scenario:

Mrs. J is admitted to the emergency department with a diagnosis of congestive heart failure. She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are swollen.” After further questioning, you learn that Mrs. J is strictly following the fluid and salt restriction ordered during her last hospital admission. Mrs. J reports gaining 1 to 2 pounds every day since her discharge.

 

Concept Map:

Identify two (2) priority nursing diagnoses for Mrs. J and develop a concept map to illustrate them (see example below).

 

 

 

 

 

 

 

 

 

 

 

Mrs. J is admitted to the emergency department with a diagnosis of congestive heart failure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Medical Diagnosis:

· Congestive Heart Failure

Prioritized Nursing Dx# 2

· Fluid Volume Excess r/t fluid retention as evidenced by swelling

Prioritized Nursing Dx# 6

·

Prioritized Nursing Dx# 5

·

Prioritized Nursing Dx# 3

·

Prioritized Nursing Dx# 1

· Impaired Gas Exchange r/t fluid overload as evidenced by shortness of breath

Prioritized Nursing Dx# 4

·

 

 

Nursing Plan of Care

For each of the priority nursing diagnoses, establish one (1) goal. For each goal create two (2) nursing interventions.

 

Prioritized Nursing Diagnoses	Goal	Nursing Interventions
1. Ineffective Gas Exchange	Pt will maintain oxygen saturations greater than 95% during my shift	1. Give oxygen as ordered 2. Monitor clients oxygen saturations
2. Fluid Volume Excess	Pt will have decreased swelling in extremities by the end of my shift.	1. Administer diuretic as ordered 2. Monitor Intake and Output

Concept Map:

 

Primary Medical Diagnosis:

 

• Congestive Heart Failure

 

Prioritized Nursing Dx# 2

 

• Fluid Volume Excess r/t fluid retention as evidenced by swelling

 

Prioritized Nursing Dx# 6

 

 

Prioritized Nursing Dx# 5

 

 

Prioritized Nursing Dx# 3

 

 

Prioritized Nursing Dx# 1

 

• Impaired Gas Exchange r/t fluid overload as evidenced by shortness of breath

 

Prioritized Nursing Dx# 4

 

 

 

Nursing Plan of Care

 

For each of the priority nursing diagnoses, establish one (1) goal. For each goal create two (2) nursing interventions.

 

Prioritized Nursing Diagnoses

 

Goal

 

Nursing Interventions

 

1. Ineffective Gas Exchange

 

Pt will maintain oxygen saturations greater than 95% during my shift

 

1. Give oxygen as ordered

 

2. Monitor clients oxygen saturations

 

2. Fluid Volume Excess

 

Pt will have decreased swelling in extremities by the end of my shift.

 

1. Administer diuretic as ordered

 

2. Monitor Intake and Output

 

Mrs. J’s priority nursing diagnoses include ineffective gas exchange and fluid volume excess.

 

Goal for Ineffective Gas Exchange:

Mrs. J will maintain oxygen saturations greater than 95% during my shift.

 

Nursing Interventions:

1. Administer oxygen as ordered to improve oxygenation.
2. Continuously monitor Mrs. J’s oxygen saturations to assess for any changes and adjust oxygen therapy accordingly.

 

Goal for Fluid Volume Excess:

Mrs. J will have decreased swelling in extremities by the end of my shift.

 

Nursing Interventions:

1. Administer diuretic medication as ordered to promote diuresis and decrease fluid volume.
2. Monitor Mrs. J’s intake and output closely to assess for fluid balance and effectiveness of diuretic therapy.

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