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This Concept Map, created with IHMC CmapTools, has information related to: CHF, Chest X-ray ECG BUN=38 High r/t CHF, DM Albumin=3.2 Low r/t Thyroid or Malnutrition ALT=17 norm AST=57 high r/t poss. prev. MI Hemat=27.4 norm CHF, HTN Hmgb=8.8 norm CHF, HTN Platelets 121 low r/t CHF Potassium 4.3 norm CHF Sodium=136 norm r/t CHF,HTN, CAD WBC=2.3 norm R/out infection Creatinine=1.1 norm r/t CHF Glucose=203 high r/t DM Calcium=8.1 norm Thyroid INR=1.4 norm r/t CHF Labs and DX. Tests Congestive Heart Failure Hypertension Coronary Artery Disease Hypothyroidism Diabetes Mellitus Arthritis Low Back Pain Hyperlipedemia Depression, Congestive Heart Failure Hypertension Coronary Artery Disease Hypothyroidism Diabetes Mellitus Arthritis Low Back Pain Hyperlipedemia Depression Assessment VS: T98.0 HR96 O292%3L RR18 BP125/80 HEENT: WDL NEURO: Orientedx4 Respiratory: Regular easy on 3L trachea to midline. Expiratory Wheezes Cardiac: Distant with murmur. Cap refill ɛsec. +2 pitting edema. Upper pulse +2 bil. lower pulse+1 bil. GI: Bowel sounds active x4. Last BM 3/14 GU: WDL urine no odor and straw to clear, 1. Patients ADL's have been assessed and occupational therapist has been contacted 2. Patient reports pain using 1-10 pain scale and understands the importance of staying ahead of pain with medications 3. Physical Therapy has been initiated 4. Patient has been given a cane and a wheelchair for longer distances. 5. Patient room is free of obstacles evaluations 1. Assess for patients ability for ADL's 2. Assess pain levels and tx with prescribed meds. 3. Consult P.T. 4. Supply patient with needed ambulatory aids 5. Insure a safe environment Ackley (09), The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. This is typically associated with pulmonary or peripheral congestion. Smeltzer (p 946) Pathophysiology Congestive Heart Failure Hypertension Coronary Artery Disease Hypothyroidism Diabetes Mellitus Arthritis Low Back Pain Hyperlipedemia Depression, Impaired physical mobility (rt) limited cardiac endurance and musculoskeletal impairment (aeb) patient's low o2 sat from cardiac impairment and patients med dx. of lowback pain and arthritis Nurs. Dx Congestive Heart Failure Hypertension Coronary Artery Disease Hypothyroidism Diabetes Mellitus Arthritis Low Back Pain Hyperlipedemia Depression, Xanax prn for anxiety/depression Wellbutrin for depression Lasix diuretic for CHF and HTN Neurontin neurologic for DM and LBP Novolog insulin for DM Lantus insulin for DM Synthroid for hypothroidism Glucophage biguanide for DM (Neomycin ointment for irritation from nasal cannula) (Zofran for sleep) Roxidcodone analgesic for arthritis and LBP Protonix PPI for gut could be related upset stomach from meds or even prophylaxes for possible future shock Potassium Chloride potassium supp. for heart r/tt CHF Phenergan Prn but also a perpetuate for pain med Medications Congestive Heart Failure Hypertension Coronary Artery Disease Hypothyroidism Diabetes Mellitus Arthritis Low Back Pain Hyperlipedemia Depression, 1. Assess for patients ability for ADL's 2. Assess pain levels and tx with prescribed meds. 3. Consult P.T. 4. Supply patient with needed ambulatory aids 5. Insure a safe environment Ackley (09) interventions Impaired physical mobility (rt) limited cardiac endurance and musculoskeletal impairment (aeb) patient's low o2 sat from cardiac impairment and patients med dx. of lowback pain and arthritis, 1. Patient will be on 3L of o2 per Doctor's order 2. Vital sign will be checked q 4 hours and be WNL 3. Patient's I/O's findings will remain balanced 4. Patient will demonstrate Incentive Spirometry 5. Breath sounds will be clear 6. Patient will remain aware a person, place, and time 7. O2 saturation will remain above 93% 8. Patient will demonstrate TCDB 9. Patient has met with nutritionist and recieved acceptable diet evaluations 1. Administer 3L of o2 via nasal cannula 2. Monitor Vital signs including HR, BP, Respiratory System. 3. Monitor I/O's 4. Incentive Spirometry 5. Auscultate breath Sounds 6. Monitor LOC 7. monitor O2 saturation 8. TCDB 9. Insure adequate nutrition Ackley (09), Ineffective Tissue Perfussion (rt) impaired transport of oxygen (aeb) patient's o2 Sat is 91 on three 3L of o2 Nurs. Dx Congestive Heart Failure Hypertension Coronary Artery Disease Hypothyroidism Diabetes Mellitus Arthritis Low Back Pain Hyperlipedemia Depression, 1. Patient will have given a food diary from the past 3 days. 2. Patient will demonstrate the correct way of measuring food 3. Patient's BMI has been assessed. 4. patient will have lost no more than 2 lbs. per week evaluations 1. have patient keep a food diary for 1-3 days 2. Advise on measurement of food 3. Determine the BMI 4. Recommend client to follow U.S. Dietary Guidelines 5. Recommend client to lose no more than 1-2 lbs. per week. Ackley (09), 1. Administer 3L of o2 via nasal cannula 2. Monitor Vital signs including HR, BP, Respiratory System. 3. Monitor I/O's 4. Incentive Spirometry 5. Auscultate breath Sounds 6. Monitor LOC 7. monitor O2 saturation 8. TCDB 9. Insure adequate nutrition Ackley (09) interventions Ineffective Tissue Perfussion (rt) impaired transport of oxygen (aeb) patient's o2 Sat is 91 on three 3L of o2, 1. have patient keep a food diary for 1-3 days 2. Advise on measurement of food 3. Determine the BMI 4. Recommend client to follow U.S. Dietary Guidelines 5. Recommend client to lose no more than 1-2 lbs. per week. Ackley (09) interventions Imbalanced Nutritions: more than body requirements (rt) excessive intake in relation to metabolic need (aeb) patient presents with morbid obesity, Imbalanced Nutritions: more than body requirements (rt) excessive intake in relation to metabolic need (aeb) patient presents with morbid obesity Nurs. Dx Congestive Heart Failure Hypertension Coronary Artery Disease Hypothyroidism Diabetes Mellitus Arthritis Low Back Pain Hyperlipedemia Depression