Complete a Nursing Care Plan that includes the following. 1. Pathophysiology Include the Medical Diagnosis and the pathophysiology 2. Select a Nursing diagnosis related to a symptom of the medical diagnosis (use PES/PE format) 3. Goals and Outcome- Two statements are required, including assessment data to support each goal Must be Patient and/or family-focused; measurable; time- specific; and reasonable Assessment Data(Include at least two subjective and/or objective pieces of data that lead to the nursing diagnosis) 4. Nursing Interventions- Two interventions per goal with rationale Provide a reason why the intervention is indicated/ therapeutic; provide a rationale 5. Outcome/Evaluation Provide assessment information that supports whether the interventions were successful or unsuccessful. If the interventions were unsuccessful what revisions would you make to help the client be successful
Patine is 81 years old admittied diagnosis is other spasified sepsis hyperlipidimia HTN ad prostatic hyperplasia with lower urinary track symptoms

Congestive heart failure is a condition in which the heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs. This can result from various underlying conditions, such as coronary artery disease, hypertension, valvular heart disease, and cardiomyopathy. The inability of the heart to pump effectively leads to a buildup of fluid in the lungs, liver, gastrointestinal tract, and extremities, causing symptoms such as shortness of breath, edema, and fatigue. The heart's diminished pumping capacity is due to either systolic dysfunction (impaired ejection of blood) or diastolic dysfunction (impaired filling of the heart).

2. Nursing Diagnosis

Nursing Diagnosis:

Excess fluid volume related to impaired cardiac function as evidenced by bilateral lower extremity edema and shortness of breath on exertion.

3. Goals and Outcome

Goal 1:

Goal: The patient will exhibit a reduction in edema within one week, as evidenced by a decrease in lower extremity swelling from +3 to +1 pitting edema.

Outcome:

Subjective Data: Patient reports feeling "heavy" legs and difficulty putting on shoes.

Objective Data: Bilateral lower extremity edema rated at +3 pitting.

Goal 2:

Goal: The patient will demonstrate improved respiratory function within three days, as evidenced by an increase in SpO2 levels from 90% to 95% on room air and reporting reduced shortness of breath.

Outcome:

Subjective Data: Patient states, "I get out of breath just walking to the bathroom."

Objective Data: SpO2 levels at 90% on room air, respiratory rate of 24 breaths per minute.

4. Nursing Interventions

Intervention 1 for Goal 1:

Intervention: Administer prescribed diuretics (e.g., furosemide) as ordered.

Rationale: Diuretics help reduce fluid overload by increasing urine output, which can alleviate edema.

Intervention: Educate the patient on limiting sodium intake to 2 grams per day.

Rationale: Reducing sodium intake helps prevent fluid retention, which can decrease edema.

Intervention 2 for Goal 2:

Intervention: Administer supplemental oxygen therapy as needed to maintain SpO2 levels above 94%.

Rationale: Supplemental oxygen can help improve oxygenation and reduce the work of breathing.

Intervention: Teach the patient pursed-lip breathing techniques.

Rationale: Pursed-lip breathing helps improve oxygen exchange and reduce shortness of breath by promoting slower, deeper breaths.

5. Outcome/Evaluation

Outcome Evaluation for Goal 1:

Assessment:

Subjective: The patient reports a significant reduction in leg heaviness and can now wear shoes comfortably.

Objective: Edema reduced to +1 pitting in bilateral lower extremities.

Success: The interventions were successful as the patient exhibited a marked reduction in edema.

Revision: No revisions needed.

Outcome Evaluation for Goal 2:

Assessment:

Subjective: The patient reports being able to walk to the bathroom without feeling out of breath.

Objective: SpO2 levels improved to 95% on room air, respiratory rate reduced to 18 breaths per minute.

Success: The interventions were successful as the patient's respiratory function improved.

Revision: No revisions needed.

If the interventions were unsuccessful, potential revisions could include adjusting the diuretic dosage, re-evaluating the patient's sodium intake and adherence to dietary recommendations, increasing the frequency of oxygen therapy monitoring, or exploring additional respiratory exercises or interventions.

Explanation: