, EASTWICK COLLEGE — N108
MEDICAL-SURGICAL NURSING
Comprehensive Nursing Concept Map: Heart Failure
Admitting Diagnosis, Patient Assessment, Three Priority Nursing Problems, Nursing
Interventions, Clinical Rationales, Expected Outcomes, and Evaluation
1. ADMITTING MEDICAL DIAGNOSIS
Primary Admitting Diagnosis: Acute Decompensated Heart Failure (ADHF) with
Pulmonary Congestion and Fluid Volume Overload
The patient is admitted with acute decompensated heart failure, a condition characterized by
worsening cardiac function that results in inadequate forward blood flow, increased cardiac
filling pressures, and fluid accumulation in the pulmonary and peripheral circulation.
Heart failure occurs when the heart cannot pump or fill sufficiently to meet the body's circulatory
needs without abnormally elevated cardiac pressures. The resulting decrease in effective
circulation activates compensatory mechanisms, including the sympathetic nervous system and
the renin-angiotensin-aldosterone system (RAAS). Although initially intended to maintain blood
pressure and organ perfusion, these responses may increase sodium and water retention, elevate
cardiac workload, and worsen congestion.
The patient's condition is associated with shortness of breath, reduced oxygenation, bilateral
pulmonary crackles, peripheral edema, and fatigue. These findings are consistent with fluid
congestion and impaired cardiopulmonary function.
The immediate nursing priority is to support adequate oxygenation and ventilation, identify
worsening respiratory distress, monitor fluid balance, and assist with prescribed therapies
intended to reduce congestion.
2. COMPREHENSIVE ASSESSMENT FINDINGS
Illustrative patient scenario: An adult patient is admitted with progressive shortness of breath,
lower-extremity swelling, and reduced exercise tolerance. The following values are fictional
examples rather than documented findings from the uploaded file.
A. Subjective Assessment Data
During admission, the patient reports:
Increasing shortness of breath during routine activities.
Difficulty breathing when lying flat, requiring additional pillows.
MEDICAL-SURGICAL NURSING
Comprehensive Nursing Concept Map: Heart Failure
Admitting Diagnosis, Patient Assessment, Three Priority Nursing Problems, Nursing
Interventions, Clinical Rationales, Expected Outcomes, and Evaluation
1. ADMITTING MEDICAL DIAGNOSIS
Primary Admitting Diagnosis: Acute Decompensated Heart Failure (ADHF) with
Pulmonary Congestion and Fluid Volume Overload
The patient is admitted with acute decompensated heart failure, a condition characterized by
worsening cardiac function that results in inadequate forward blood flow, increased cardiac
filling pressures, and fluid accumulation in the pulmonary and peripheral circulation.
Heart failure occurs when the heart cannot pump or fill sufficiently to meet the body's circulatory
needs without abnormally elevated cardiac pressures. The resulting decrease in effective
circulation activates compensatory mechanisms, including the sympathetic nervous system and
the renin-angiotensin-aldosterone system (RAAS). Although initially intended to maintain blood
pressure and organ perfusion, these responses may increase sodium and water retention, elevate
cardiac workload, and worsen congestion.
The patient's condition is associated with shortness of breath, reduced oxygenation, bilateral
pulmonary crackles, peripheral edema, and fatigue. These findings are consistent with fluid
congestion and impaired cardiopulmonary function.
The immediate nursing priority is to support adequate oxygenation and ventilation, identify
worsening respiratory distress, monitor fluid balance, and assist with prescribed therapies
intended to reduce congestion.
2. COMPREHENSIVE ASSESSMENT FINDINGS
Illustrative patient scenario: An adult patient is admitted with progressive shortness of breath,
lower-extremity swelling, and reduced exercise tolerance. The following values are fictional
examples rather than documented findings from the uploaded file.
A. Subjective Assessment Data
During admission, the patient reports:
Increasing shortness of breath during routine activities.
Difficulty breathing when lying flat, requiring additional pillows.
