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Congestive heart failure is a chronic disease the patient will have to live with for the rest of their lives. It is often disabling to the patient and causes difficulties with numerous activities. Anxiety and frustration are common with this disease. Symptoms that occur with these patients often increase anxiety levels such as dyspnea. There is also a high risk for depression. Lifestyles changes and issues with quality of life can cause depression to occur months after the initial diagnosis of heart failure. This anxiety and depression may also occur in the patient's family. There may be an increase amount of stress due to having to become a caregiver for the individual. On the other hand, hope is a major indicator of well being for patients with heart failure. The patients who have hope about their diagnosis are more socially involved. (Ignatavicius & Workman, 2010)
AH show signs of anxiety if she has to lie down to sleep. She states, "It is hard to breathe when I am flat". This is the reason that AH sleeps either in a high-fowlers position in the bed or in a cardiac chair while in the hospital. AH does not take any medications to reduce anxiety or help her sleep. AH does not show any signs of depression. She stated that she feels taken care of by her son and loves that he is always around for her. She does not have any depression related to the death of her husband either. She stated, "We had a good life together and a good marriage". She shows no need for depression medications at this time.
NANDA Taxonomy Conceptual Framework
Domain 1: Health Promotion
Impaired Walking R/T Limited endurance AEB fatigue, shortness of breath, patient stating "I have a hard time walking far distances"
Ineffective health maintenance R/T sedentary lifestyle AEB Patient stating "I do not exercise", walking only short distances to bathroom and back to chair, intermittent chronic pain when patient osteoarthritis flares
Domain 2: Nutrition
Imbalanced Nutrition-More than body requirements R/T excessive intake compared to metabolic need AEB sedentary activity level, weight 20% over ideal for height and weight, body mass index at 35.72
Excessive fluid volume R/T sodium/water retention AEB jugular vein distension, hypertension, edema, intake exceeds output.
Domain 3: Elimination and Exchange
Impaired gas exchange R/T heart pump not working efficiently AEB shortness of breath, crackles heard upon auscultation, dyspnea
Domain 4: Activity/Rest
Fatigue R/T poor physical condition AEB need for assistive devices to rest with, increased need for rest periods, patient stating " I am tired".
Activity intolerance R/T imbalance between oxygen supply and demand AEB generalized weakness, sedentary lifestyle, fatigue, dyspnea
Decreased cardiac output R/T altered contractility of heart AEB shortness of breath, jugular vein distension, fatigue, edema, prolonged capillary refill, decreased peripheral pulses, left ventricular failure, and dysrhythmia.
Risk for ineffective renal perfusion R/T decreased blood supply to kidneys for insufficient pumping of the heart
Domain 5: Perception/Cognition
Deficient Knowledge R/T cardiac function AEB question about disease, misconceptions on information, development of preventable exacerbation
Domain 6: Self-Perception
Risk for situational-low self esteem R/T inability to care for all activities of daily living by self
Domain 7: Role Relationships
Patient does not have any nursing diagnoses in this category. Patient has supportive family with no family process issues. Patient does not have to care for young children, and has social interaction.
Domain 8: Sexuality
Patient does not have any nursing diagnoses in this category. Patient is past child bearing age and patient does not feel need for sexual relationships due to age of 91 years old and deceased husband.
Domain 9: Coping/Stress Tolerance
Risk for ineffective activity planning R/T deficient knowledge about importance of planning activities with adequate rest periods
Domain 10: Life Principles
Risk for impaired religiosity R/T decreased ability to attend church services due to fatigue
Domain 11: Safety/Protection
Risk for infection R/T indwelling urinary catheter
Risk for falls R/T generalized weakness, use of assistive devices, fatigue
Risk for impaired skin integrity R/T decreased mobility, obese
Domain 12: Comfort
Impaired Comfort R/T inability to sleep in bed AEB shortness of breath, dyspnea, patient stating "I cannot breath right if I lay flat", increased need to sleep in high-fowlers or in chair.
Chronic pain R/T intermittent joint pain AEB need for analgesics such as ibuprofen, need for rest to relieve joint pain, patient stating "when the pain is there it hurts terribly", weight in obese category on weight bearing joints.
Domain 13: Growth/Development
Patient does not have any nursing diagnoses in this category. Patient has gone through all growth and development throughout life. Patient is 91 years old.
Week One Phone Call and Care Plans
One week after the patient was discharged from the hospital, she was back at home with her son. It took her a couple minutes to recognize who I was, but eventually she remembered having our conversation about my case study. She seemed very happy about being back home and said she was feeling well. She was very cooperative over the phone and had no problems answering any questions.
When asked how she was feeling overall, she stated she was back to her normal everyday life with the help of her son. She stated she still had the shortness of breath she normally had before, but was not as bad as when she was in the hospital. She was not prescribed any home oxygen but feels she does not need it. When asked about her mobility, she stated she is trying to "move around more" after our talk on the importance of activity on her life and disease process. She said her son helps her a lot with this and is very encouraging. I restated the importance to monitor when rest periods are needed, and to make small changes in activity level gradually. When asked if she was keeping up with her appointments the hospital set her up with, she said she has not gone to them yet as she had to reschedule. When asked the reason why, she stated, "I just had to sweetie". I reviewed the importance of keeping these appointments due to the fact it is to set up with a new primary physician and her cardiologist. I will address this in the next follow up call. When asked if any of her home medications had changed, she said all medications were the same. She has sufficient knowledge on these medications and was able to state the reasoning for each. When asked about osteoarthritis pain, she stated it was still the same. It comes intermittently, but she is able to relieve the pain. When asked about signs and symptoms of when to go into the doctors for worsening heart failure, she stated "if I am coughing, if I gain weight, and if I see more swelling". We reviewed that the weight gain was about two pounds overnight or 3 pounds in one week. We also reviewed other symptoms such as frothy pink sputum, increased dyspnea and shortness of breath, and increased angina, frequent urination at night, and cramping, and muscle spasms.
Overall AH seemed like she was doing very well. I was pleased to hear her progress with understanding more information about her disease process. I informed her that I would have another follow up call in about a week and see how she was. She seemed pleased to hear this.
Nursing Diagnosis One
Diagnosis: Activity Intolerance R/T imbalance between oxygen supply and demand AEB generalized weakness, sedentary lifestyle, fatigue, dyspnea. Desired outcomes: patient will have decreased weakness and fatigue by statements made by the patient with use of supplemental oxygen administration as needed and rest periods as needed within 30 minutes after administration and intervention. Patient will have less than 5 reports of dyspnea throughout the day with use of oxygen as needed within 10 minutes after administration. Patient will show improvements in sedentary lifestyle by increased ambulation by two times a day for at least 100 feet within one week after discharge. Intervention/Rationale: Assess cardiopulmonary response to physical activity by measuring vital signs noting heart rate and regularity, respiratory rate and work of breathing, and blood pressure before, during, and after activity. Note progressing or acceleration degree of fatigue. Dramatic changes in heart rate and rhythm, changes in usual blood pressure, and progressively worsening fatigue result from imbalance of oxygen supply and demand. Intervention/Rationale: Assist with self care activities when needed. Adjust activities to reduce intensity level or discontinue activities that cause undesired physiologic changes (fatigue, weakness, dyspnea). Assisting with activities when needed prevents overexertion and promotes patient to assist and maintain self care routine. Intervention/Rationale: Administer supplemental oxygen as needed via nasal cannula if patient O2 saturation drops below 90%. Supplemental oxygen decreases patient fatigue by improving myocardial perfusion and systemic circulation. Intervention/Rationale: Monitor laboratory values such as red blood cells, hemoglobin, hematocrit, and assess for changes in values from baselines. Monitoring these lab values allows you to watch for any anemia and also look at oxygen carrying ability in blood for adequate tissue perfusion. Intervention/Rationale: Provide information about proper nutrition to meet metabolic demands and energy needs and obtaining a normal body weight. (Low sodium cardiac diet). Energy is improved when nutrients are sufficient to meet metabolic demands. Intervention/Rationale: Instruct client in monitoring response to activity level and in signs and symptoms that indicate need to alter activity level after discharge. This assists in self management of condition and in understanding or reportable problems. Evaluation: Patient stated she had less weakness and fatigue after discharge without the use of supplemental oxygen. She only needed to take adequate rest periods and felt better within 10 minutes. Patient reported dyspnea was better than when in hospital and is back to normal level without use of supplemental oxygen within 10 minutes after rest periods. Patient stated she had improvements in sedentary lifestyle after discharge by increased ambulation of at least three times per day of around 75 feet each time.