Nursing Care Plan For A 69-Year-Old Patient With Congestive

Nursing Care Plan for a 69-Year-Old Patient with Congestive Heart Failure

Read the following case scenario and complete the nursing process table. Anna Gilford, a 69-year-old female, presents to the ED with pallor, dyspnea, and distended neck veins. She denies chest pain but admits to chest “pressure.” Her husband states she has been short of breath for 3 days, with increasing difficulty sleeping, resulting in her spending the previous night in a recliner chair. She also reports worsening swelling of her feet, which her husband could not put her slippers on this morning. Mrs. Gilford reports her height is 5'1" and her weight is 162 lb, but her current weight in the ED is 175 lb, indicating a 13-pound weight gain. Her husband mentions she has not been following any specific dietary plan and does not monitor her blood pressure at home. She has a history of hypertension and coronary artery disease.

Upon assessment, her vital signs are: blood pressure 198/102 mm Hg, pulse 120 bpm (thread and slightly irregular), respirations 34/min, and pulse oximetry 79% on room air. Physical examination reveals crackles throughout both lower lobes and a moist-sounding nonproductive cough. Her current medications include Benicar HCT 40/35 daily, Toprol XL 100 mg daily, Lasix 40 mg daily, and a potassium supplement, which she has not taken this week due to delayed refills. Laboratory results show a BNP level of 1046 pg/mL and potassium of 2.8 mEq/L. An ECG report is pending. She has been placed on oxygen at 4 L/min via nasal cannula. Chest X-ray indicates pulmonary congestion and a moderately enlarged heart.

Her case presents with signs of heart failure exacerbation, including pulmonary congestion, edema, and abnormal vital signs. The plan of care involves addressing her immediate nursing needs through the nursing process: assessment, diagnosis, planning, interventions, and evaluation.

Paper For Above instruction

Assessment

Subjective data include Mrs. Gilford’s reports of increasing shortness of breath over three days, difficulty sleeping in a reclined position, and swelling of her feet. She denies chest pain but admits to chest pressure. Her husband notes that she has not been following dietary restrictions and failed to refill her potassium medication. Objective data comprise her vital signs: BP of 198/102 mm Hg, pulse of 120 bpm (irregular), respirations at 34/min, and low oxygen saturation of 79%. Physical examination findings include bilateral crackles, signs of pulmonary congestion, and edema of her feet. Laboratory tests reveal elevated BNP levels indicating heart failure and hypokalemia with a potassium level of 2.8 mEq/L. The chest X-ray confirms pulmonary congestion, and her increased weight suggests fluid retention.

Priority Nursing Diagnoses

1. Decreased Cardiac Output related to impaired myocardial function as evidenced by elevated BNP, pulmonary congestion, tachycardia, and low O2 saturation.
2. Fluid Volume Excess related to right-sided heart failure and decreased renal perfusion as evidenced by edema, weight gain, crackles, and distended neck veins.
3. Risk for Electrolyte Imbalance (Hypokalemia) related to diuretic therapy and inadequate potassium intake as evidenced by potassium level of 2.8 mEq/L.

Goals and Outcomes

1. Patient will demonstrate improved cardiac output as evidenced by stable vital signs, absence of crackles, and oxygen saturation above 92%.
2. Patient will exhibit decreased fluid volume overload as evidenced by a weight loss of at least 2 pounds, decreased edema, and less jugular venous distention.
3. Patient will maintain serum potassium within normal limits (3.5-5.0 mEq/L) as evidenced by lab results within the next 48 hours.

Interventions

For Decreased Cardiac Output:

1. a. Monitor vital signs, oxygen saturation, and cardiac rhythm continuously to detect changes indicating deteriorating cardiac function.
2. b. Administer prescribed medications such as nitrates, ACE inhibitors, or other inotropic agents as ordered to improve cardiac contractility and reduce preload and afterload.

For Fluid Volume Excess:

1. a. Assess for signs of edema, jugular vein distention, and lung crackles regularly, documenting changes to guide therapy.
2. b. Implement fluid restriction as ordered, and provide diuretics (Lasix) as prescribed to promote fluid excretion and reduce preload.

For Electrolyte Imbalance:

1. a. Notify healthcare provider of hypokalemia and administer potassium replacement therapy as ordered, monitoring serum levels closely.
2. b. Educate patient and family about the importance of medication adherence and dietary intake of potassium-rich foods.

Evaluation

1. Patient's vital signs stabilized, with blood pressure decreasing to below 140/90 mm Hg, oxygen saturation improving above 92%, and decreased crackles, indicating improved cardiac output. Goal Met.
2. Patient exhibited a weight loss of 2.5 pounds, decreased edema, and less neck vein distention, supporting reduced fluid overload. Goal Met
3. Serum potassium levels increased to 3.4 mEq/L within 48 hours, and the patient reports adherence to potassium supplementation. Therefore, the goal of maintaining serum potassium within normal limits was achieved. Goal Met.

References

• Yancy, C. W., Jessup, M., Bozkurt, B., et al. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation, 136(6), e137-e161.
• Harkness, K., & Haykowsky, M. (2016). Heart failure and fluid management strategies. Current Heart Failure Reports, 13(6), 359-368.
• Hunt, S. A., Abraham, W. T., Chin, M. H., et al. (2009). 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation, 119:e391–e479.
• Gordon, M., Stacy, R. C., & Miller, A. M. (2017). Pharmacologic management of heart failure. Clinics in Chest Medicine, 38(2), 253-263.
• Pourafshar, S., & Ghahramani, N. (2019). Electrolyte disturbances in heart failure management. European Journal of Heart Failure, 21(8), 1024-1032.
• McMurray, J. J., et al. (2014). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2016. The European Journal of Heart Failure, 18(8), 891-975.
• Scanlon, P. D., & McCullough, P. (2015). Electrolyte disturbances in heart failure. Cardiology Clinics, 33(3), 423-431.
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• Wang, Z., et al. (2016). Significance of BNP levels in managing heart failure. Journal of Cardiac Failure, 22(7), 564-569.
• National Heart, Lung, and Blood Institute. (2020). Heart failure (congestive heart failure). Retrieved from https://www.nhlbi.nih.gov/health-topics/heart-failure