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This Concept Map, created with IHMC CmapTools, has information related to: B_snapp_Complex MEDSURG_Cmap 1 pg. 1, V. Expected Outcomes 1. 2. 3. Evaluation VII. Evaluation of expected Outcomes 1. 2. 3., IV. Priority Nursing Diagnosis (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. 2. 3., III. Focused Assessment 1.0800 B/P 118/59, Temp 97.5, HR 76, O2 92, Pain 0, RR 16 2. Fluid restriction 3. BiPap 4. 1500 ml emptied from catheter at 1000 5. 1000 ml emptied from catheter at 1400 6. Non pitting Edema in Left leg and Right leg 7. FC 16 french 8. Fluid Restriction 9. 5 liters O2 ???? III. Abnormal Assessment Findings: 1. 22 RFA S/L 2.22 RH 16 ml/he Netrocore 3.20 LH 10 ml/hr of Bumex S/L at 0940 4. 5., III. Focused Assessment 1.0800 B/P 118/59, Temp 97.5, HR 76, O2 92, Pain 0, RR 16 2. Fluid restriction 3. BiPap 4. 1500 ml emptied from catheter at 1000 5. 1000 ml emptied from catheter at 1400 6. Non pitting Edema in Left leg and Right leg 7. FC 16 french 8. Fluid Restriction 9. 5 liters O2 Generate Nursing Diagnosis IV. Secondary Nursing Diagnosis 2. 3. 4. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis R.D. age 62 year old white male Medical Diagnosis: 1. CHF 2. Pnuemonia 3. Pulmonary Hypertension assess III. Focused Assessment 1.0800 B/P 118/59, Temp 97.5, HR 76, O2 92, Pain 0, RR 16 2. Fluid restriction 3. BiPap 4. 1500 ml emptied from catheter at 1000 5. 1000 ml emptied from catheter at 1400 6. Non pitting Edema in Left leg and Right leg 7. FC 16 french 8. Fluid Restriction 9. 5 liters O2, III. Focused Assessment 1.0800 B/P 118/59, Temp 97.5, HR 76, O2 92, Pain 0, RR 16 2. Fluid restriction 3. BiPap 4. 1500 ml emptied from catheter at 1000 5. 1000 ml emptied from catheter at 1400 6. Non pitting Edema in Left leg and Right leg 7. FC 16 french 8. Fluid Restriction 9. 5 liters O2 Generate Nursing Diagnosis IV. Priority Nursing Diagnosis (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis R.D. age 62 year old white male Medical Diagnosis: 1. CHF 2. Pnuemonia 3. Pulmonary Hypertension affects II. Pathophysiology 1. Heart failure is the inability of the heart to pump enough blood to meet the metabolic demands of the body. It may be acute or chronic. It is more common in older adults. 2. Decreased tissue perfusion stimulates compensatory mechanisms tha lead to vascular congestion and congestive heart failure. These mechanisms are as follows: a. The sypmathetic nervous system increases heart rate and contractility. b. Vasoconstriction increases venous return and ventricular filling, increasing the force of contraction. c. Renin-angiostension-aldosterone system activation leads to soduim and water retention. d. Ventricular remodeling with dilation and hypertrophy. 3.Cardiac reserve (the ability to adjust output to metabolic needs) falls in heart failure, leading to activity intolerance and dyspnea on exertion. (Lemone & Burke, 2008), V. Expected Outcomes 1. 2. 3. Interventions & Rationals VI. Interventions 1. 2. 3. 4. 5. (Lemone & Burke 2009), IV. Secondary Nursing Diagnosis 2. 3. 4. (Wilkenson & Ahern 2009) Prioritized to IV. Priority Nursing Diagnosis (Wilkenson & Ahern 2009), II. Pathophysiology 1. Heart failure is the inability of the heart to pump enough blood to meet the metabolic demands of the body. It may be acute or chronic. It is more common in older adults. 2. Decreased tissue perfusion stimulates compensatory mechanisms tha lead to vascular congestion and congestive heart failure. These mechanisms are as follows: a. The sypmathetic nervous system increases heart rate and contractility. b. Vasoconstriction increases venous return and ventricular filling, increasing the force of contraction. c. Renin-angiostension-aldosterone system activation leads to soduim and water retention. d. Ventricular remodeling with dilation and hypertrophy. 3.Cardiac reserve (the ability to adjust output to metabolic needs) falls in heart failure, leading to activity intolerance and dyspnea on exertion. (Lemone & Burke, 2008) leads to III. Focused Assessment 1.0800 B/P 118/59, Temp 97.5, HR 76, O2 92, Pain 0, RR 16 2. Fluid restriction 3. BiPap 4. 1500 ml emptied from catheter at 1000 5. 1000 ml emptied from catheter at 1400 6. Non pitting Edema in Left leg and Right leg 7. FC 16 french 8. Fluid Restriction 9. 5 liters O2