Nursing DX
Intervention
Fluid Volume Excess
Related to
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Medical History
PAD
Heart failure
ERDS
CVA
HDL
PVD
Diabetes
Tachycardia
Non-sustained Ventricle
Ischemic Cardiopathy
Bacterimeria
Cardiovascular
Defibrillator
Osteomyelitis
ALL MEDICATIONS
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decreased cardiac
output and increased
glomerular filtration
rate (GFR)
Carvedilol 3.125
Bumetanide 1mg
Proton is 40mg
Basaglar Kiki Pen U-100
Klor Con M20
Eliquis 5mg
Insulin Lispro 100
Metolazone 2.5mg
Disdol 125mcg
Zofran 4mg
Magnesium 250mg
Creator 5mg
Lacltydrin 12%
Tamsulosin 0.4
Midline 2.5
Nephro Vite 0.8
Mycophenolate 250
Prednisone 5mg
As Evidence By
pulmonary edema,
crackles ing the Left
lower lung and fine
cracked in the right
lower lung
pitting edema of the
ankles, and weight gain
LABS
Anticipated Labs to
be ordered
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BUN
Creatine
Lactic Acid
Actual DX
Systolic Heart Failure
Assess the patient’s vital
signs and characteristics of
heart beat at least every 4
hours. Assess breath
sounds via auscultation.
Observe for signs of
decreasing peripheral
tissue perfusion such as
slow capillary refill, facial
pallor, cyanosis, and cool,
clammy skin.
Rational
To assist in creating an accurate
diagnosis and monitor
effectiveness of medical
treatment. Breath sounds of
crackles/rales are important signs
of heart failure. The presence of
signs of decreasing peripheral
tissue perfusion indicate
deterioration of the patient’s
status which require immediate
referral to the physician.
2 Goal or Outcomes
Long Term: Patient will meet
with Cardio Vascular, to
modify his medications and
create a new plan of care
Short Term: Patient will have
reduces edema, and output
greater than 30mL/Hr
Intervention
Administer the
cardiac medications
and diuretic
medications as
ordered if the
patient has a weight
gain above his
maintained weight of
210 or if the Systolic
Blood pressure is
below 100
Rational
Diuretics aide in venous
return and minimize
fluid accumulation.This
will increase the
excretion of body fluids
Previous surgeries that contribute to
health
• Renal transplant
• Popliteal Bypass 2017
• Coronary Artery Bypass
• Bypass
• Pacemaker
Desired Outcome
The patient will demonstrate a balanced
input and output, and stabilized fluid volume,
Patients weight will decrease. Patient will
have no further pulmonary complication
Concerns
Patient is not compliant with his Diet or
water restrictions