15.7: Putting It All Together

Patient Scenario

Mr. Hernandez is a 54-year-old patient admitted to the medical telemetry floor with a diagnosis of heart failure exacerbation. He tells the nurse, “My breathing has gotten worse the past last three days and I have a lot of swelling in my feet.”

Applying the Nursing Process

Assessment: Vital signs at the start of shift were blood pressure 154/94, heart rate 88, respiratory rate 24, and oxygen saturation 88%. On assessment, the nurse finds fine crackles in bilateral posterior lower lung bases, an S3 heart sound, and 2+ pitting edema in bilateral lower extremities midway to the knee. The nurse reviews the patient’s chart and discovers Mr. Hernandez has gained 10 pounds since his previous office visit last week.

Based on the assessment information that has been gathered, the nurse creates the following nursing care plan for Mr. Hernandez:

Nursing Diagnosis: Excess Fluid Volume related to compromised regulatory mechanism as evidenced by fine crackles in bilateral posterior lung bases, S3 heart sound, weight gain of 10 pounds in the past week, and the patient states, “My breathing has gotten worse the past last three days and I have a lot of swelling in my feet.”

Overall Goal: The patient will demonstrate stabilization in fluid volume.

SMART Expected Outcomes:

• Mr. Hernandez’s vital signs and weight will return to his baseline in the next 48 hours.
• Mr. Hernandez will verbalize three rules of dietary and fluid restriction to follow at home following his educational session.

Planning and Implementing Nursing Interventions:

The nurse will weigh the patient daily and analyze weight trends and 24-hour intake and output. The nurse will closely monitor lung sounds, respiratory rate, and oxygenation status. The nurse will establish a 24-hour schedule for fluid intake and educate the patient regarding fluid restriction. The nurse will closely monitor lab results, especially sodium and potassium, and monitor for symptoms of fluid shifts. The nurse will provide patient education regarding fluid and sodium restrictions.

Sample Documentation:

The patient was admitted with acute heart failure exacerbation and stated, “My breathing has gotten worse the past last three days and I have a lot of swelling in my feet.” On admission to the unit at 0900, vital signs were blood pressure 154/94, heart rate 88, respiratory rate 24, and oxygen saturation 88%. Fine crackles were present in bilateral posterior lower lung bases, an S3 heart sound was present, and there was 2+ pitting edema in bilateral lower extremities midway to the knee. The chart indicates he has gained 10 pounds since his previous office visit last week. Provider orders and fluid restrictions were implemented. Lab results are within normal ranges. Patient education regarding fluid and sodium restrictions and a handout were provided. At the end of the session, Mr. Hernandez was able to report back three rules of dietary and fluid restrictions to follow at home when discharged.

Evaluation:

By the end of the shift, the second SMART outcome was “met” when Mr. Hernandez was able to report back three rules of dietary and fluid restrictions after the patient education session. The first SMART outcome was not yet met but will be reevaluated every shift for the next 24 hours.