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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:

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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 DiagnosesGoalNursing Interventions
1. Ineffective Gas ExchangePt will maintain oxygen saturations greater than 95% during my shift1. Give oxygen as ordered2. Monitor clients oxygen saturations
2. Fluid Volume ExcessPt will have decreased swelling in extremities by the end of my shift.1. Administer diuretic as ordered2. Monitor Intake and Output

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).

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 DiagnosesGoalNursing Interventions
1. Ineffective Gas ExchangePt will maintain oxygen saturations greater than 95% during my shift1. Give oxygen as ordered2. Monitor clients oxygen saturations
2. Fluid Volume ExcessPt 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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