Nursing Concept Map – Claudia Guardado
Heart Failure Exacerbation
Pathophysiology = RT Nursing Diagnosis
Risk for Developing
- Heart failure is an impairment of the - Impaired Gas Exchange related to
- Risk for Decreased cardiac tissue perfusion
ventricles ability to fill or eject blood. difficulty breathing, secondary to HF
related to presence of edema
HF is caused by many conditions such exacerbation as evidence by
- Risk for Shock related to decreased contractibility
as CAD, HTN, COPD, MI, renal tachypnea, shortness of breath,
of heart
dysfunction, diabetes mellitus, or atrial decreased oxygen saturation.
fibrillation. - Deficient knowledge related to lack of
understanding about interrelatedness
of cardiac failure as evidence by being
Disease Process noncompliant with diet and smoker.
Diagnostics Medication - Excess Fluid Volume related to
- Lipid profile - Metoprolol sodium/water retention as evidence by
- CBCs - Simvastin S3 heart sounds, 2+ peripheral edema,
- BMP - Aspirin respiratory distress.
- ECG - Furosemide
- Enoxaparin
Signs & Symptoms Nursing Interventions
- Dyspnea Education - Administer supplemental oxygen at 2L
- Crackles in lungs
- Teach client to avoid fats, fried foods, decrease from 90% to 92%
- Rapid weight gain
sodium intake to only 2 grams per day, and avoid - Assess the patency of the oxygen
- Jugular venous distention
drinking alcoholic beverages. delivery device to make sure the client
- Fatigue
- Dependent edema - Teach client to follow an exercise plan of walking at is receiving the appropriate oxygen.
- Lightheadness least 30 minutes per day every 5 days a week. - Assist the client in a comfortable
- Tachycardia - Teach client the importance of smoking cessation to position such as elevating the bed of
- Nausea decrease the risk of worsening complications such as the head to ease breathing.
- Pallor heart attack or recurring heart failure exacerbation. - Educate the client on modifying their
Heart Failure Exacerbation
Pathophysiology = RT Nursing Diagnosis
Risk for Developing
- Heart failure is an impairment of the - Impaired Gas Exchange related to
- Risk for Decreased cardiac tissue perfusion
ventricles ability to fill or eject blood. difficulty breathing, secondary to HF
related to presence of edema
HF is caused by many conditions such exacerbation as evidence by
- Risk for Shock related to decreased contractibility
as CAD, HTN, COPD, MI, renal tachypnea, shortness of breath,
of heart
dysfunction, diabetes mellitus, or atrial decreased oxygen saturation.
fibrillation. - Deficient knowledge related to lack of
understanding about interrelatedness
of cardiac failure as evidence by being
Disease Process noncompliant with diet and smoker.
Diagnostics Medication - Excess Fluid Volume related to
- Lipid profile - Metoprolol sodium/water retention as evidence by
- CBCs - Simvastin S3 heart sounds, 2+ peripheral edema,
- BMP - Aspirin respiratory distress.
- ECG - Furosemide
- Enoxaparin
Signs & Symptoms Nursing Interventions
- Dyspnea Education - Administer supplemental oxygen at 2L
- Crackles in lungs
- Teach client to avoid fats, fried foods, decrease from 90% to 92%
- Rapid weight gain
sodium intake to only 2 grams per day, and avoid - Assess the patency of the oxygen
- Jugular venous distention
drinking alcoholic beverages. delivery device to make sure the client
- Fatigue
- Dependent edema - Teach client to follow an exercise plan of walking at is receiving the appropriate oxygen.
- Lightheadness least 30 minutes per day every 5 days a week. - Assist the client in a comfortable
- Tachycardia - Teach client the importance of smoking cessation to position such as elevating the bed of
- Nausea decrease the risk of worsening complications such as the head to ease breathing.
- Pallor heart attack or recurring heart failure exacerbation. - Educate the client on modifying their
