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.
USE FORMAT OF MAP TO COMPLETE THE YOUR ASSISGEMNT
Concept Map:
Identify two (2) priority nursing diagnoses for Mrs. J and develop a concept map to illustrate them (see example below).
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 ordered2. 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 ordered2. Monitor Intake and Output |
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