muscles, (Vasotec) N2-(I) (C) 5mg R2- E2- PO daily respiratory rate Administer diuretic Diuretics mobilize Left ventricular 36 breaths/min Digoxin 0.25mg (Lasix) as per doctors’ edematous fluid, function has improved PO Moist crackles orders reduces pulmonary in both lungs venous pressure, & Furosemide reduces preload (Lasix) 40 mg The patient’s improving CO (p. 937). IV BID statement, “I’m of breath Serum Sodium levels Potassium 40 Fluid and electrolyte Pt’s serum electrolyte mEq PO BID and my ankles, will determine if management Monitor – levels came back with are so big and therapeutic measures serum electrolytes Daily Weight normal results ensuring puffy!” have been effective or especially sodium and Measurements that her treatment plan not as volume potassium Cyanotic lips has been effective imbalances are often and extremities associated with changes Evaluation of in serum sodium levels Frequent Outcomes and serum potassium coughing (address each levels indicate outcome) Has to sleep secondary HTN 1.restricted with head sodium intake elevated on 3 will reduce fluid pillows volume Monitor respiratory Enables early detection pattern for symptoms of of pulmonary respiratory difficulty congestion (p. 943). Monitor hemodynamic Evaluates the status, including CVP, Pt responded to effectiveness of therapy MAP, and PAOP, if treatment well and no (p. 943). available longer displays symptoms associated Monitor renal function with hypovolemia and and intake and output edema To monitor fluid Monitor for the balance (p. 943). therapeutic effect of a diuretic (↑ urine To assess the patient’s output,↑ CVP, response to treatment improvement of breath (p. 943). sounds) Patient’s weight has Ensures valid been consistent Weigh the patient, same comparisons day to day
muscles, respiratory rate 36 breaths/min Moist crackles in both lungs The patient’s statement, “I’m of breath and my ankles, are so big and puffy!” Cyanotic lips and extremities Frequent coughing Has to sleep with head elevated on 3 pillows (Vasotec) 5mg PO daily Digoxin 0.25mg PO Furosemide (Lasix) 40 mg IV BID Potassium 40 mEq PO BID Daily Weight Measurements Evaluation of Outcomes (address each outcome) 1.restricted sodium intake will reduce fluid volume N2-(I) (C) Administer diuretic (Lasix) as per doctors’ orders Fluid and electrolyte management – Monitor serum electrolytes especially sodium and potassium R2- Diuretics mobilize edematous fluid, reduces pulmonary venous pressure, & reduces preload improving CO (p. 937). Serum Sodium levels will determine if therapeutic measures have been effective or not as volume imbalances are often associated with changes in serum sodium levels and serum potassium levels indicate secondary HTN E2- Left ventricular function has improved Pt’s serum electrolyte levels came back with normal results ensuring that her treatment plan has been effective Monitor respiratory pattern for symptoms of respiratory difficulty Monitor hemodynamic status, including CVP, MAP, and PAOP, if available Monitor renal function and intake and output Monitor for the therapeutic effect of a diuretic (↑ urine output,↑ CVP, improvement of breath sounds) Weigh the patient, same Enables early detection of pulmonary congestion (p. 943). Evaluates the effectiveness of therapy (p. 943). To monitor fluid balance (p. 943). To assess the patient’s response to treatment (p. 943). Ensures valid comparisons day to day Pt responded to treatment well and no longer displays symptoms associated with hypovolemia and edema Patient’s weight has been consistent
semester_4_-_nurs_201-3_chf.docx