NURSING CONCEPT

MAP
Ashley Deyerle
2/9/2013
B.G.
51 y.o. male w/
Cardiomyopat
hy ejection
fraction of
Excess fluid volume related to increased venous pressure and
decreased renal perfusion secondary to cardiac failure as
evidenced by rapid weight gain, edema, adventitious breath
sounds, oliguria, and patients statement, My ankles are so
swollen.
Implementations
Administer prescribed diuretics
Monitor for therapeutic effect of diuretic (e.g., increased urine output
and decreased adventitious breath sounds
Monitor potassium levels after diuresis to detect excessive electrolyte
loss.
Monitor intake and output to assess fluid status.
Monitor respiratory pattern for symptoms of respiratory difficulty to
detect pulmonary edema.
!"IE#" G$!%! "#periences reduction or absence of edema and stable
!ctivity intolerance related to fatigue secondary to cardiac insufficiency and
pulmonary congestion as evidenced by dyspnea, shortness of breath, weakness,
increase in heart rate on e#ertion, and patients statement, $ feel too weak to do
anything
Implementations
!"IE#" G$!% %ill achieve a realistic program of activity that balances physical
activity with energy&conserving activities
Impaired
&as exchan&e related to increased preload and
alveolar&capillary membrane changes as
evidenced by abnormal arterial blood gases,
hypo#emia, dyspnea, tachypnea, tachycardia,
restlessness, and patients statement, $ am so
short of breath
Implementations
!"IE#" G$!% Maintains ade'uate
o#ygen(carbon dio#ide e#change at the alveolar&
capillary membrane to meet o#ygen needs of the
body
'ecreased cardiac output related to altered
contractility, altered preload, and(or altered stroke
volume as evidenced by decreased e)ection fraction,
increased *+,, decreased peripheral pulses, )ugular
vein distention, orthopnea, -. and -/ sounds, and
oliguria
Implementations
'eficient (nowled&e related to lack of
information about disease process as
evidenced by 'uestions about the disease and
patients statement, $ dont know why $ keep
getting sick
Implementation
!"IE#" G$!% 0escribes disease
process and rationales for dietary, medication,
and e#ercise regimen
1. ,erform a comprehensive appraisal of peripheral circulation (e.g., check peripheral pulses, edema, capillary
refill, color, and temperature of e#tremity to determine circulatory status.
2. 1ote signs and symptoms of decreased cardiac output to detect changes in status.
3. Monitor fluid balance (e.g., $(2 and daily weight to evaluate renal perfusion.
4. Monitor for cardiac dysrhythmias to detect cardiac decomposition.
5. Monitor for dyspnea, fatigue, tachypnea, and orthopnea to identify involvement of respiratory system.
!"IE#" G$!% Maintains ade'uate blood pumped by the heart to meet metabolic demands of the body
Monitor rate, rhythm, depth, and effort of respirations.
Auscultate breath sounds, noting areas of decreased(absent ventilation and presence of adventitious sounds
Monitor for increased restlessness, an#iety, and air hunger
Administer supplemental 23 as ordered to maintain O2 levels.
,osition to alleviate dyspnea (e.g., semi&4owlers position)
1. Appraise the patients current level of knowledge related to specific disease process to identify needed areas of
teaching.
2. 0escribe common signs and symptoms of the disease so patient will know signs and symptoms to report to
health care provider.
3. $nstruct the patient and caregiver on measures to prevent(minimi5e side effects of treatment for the disease so
patient may be able to decrease number of acute episodes of 64.
4. Appraise the patients and caregivers current level of knowledge about prescribed diet to assess areas needing
additional instruction.
5. 7eview patients knowledge of medications to determine where further teaching is needed.
1. "ncourage alternate rest and activity periods to reduce cardiac workload and conserve energy.
2. ,rovide calming diversionary activities to promote rela#ation to reduce 23 consumption and to relieve dyspnea
and fatigue.
3. Monitor patients 23 response (e.g., pulse rate, cardiac rhythm, and respiratory rate to self&care or nursing
activities to determine level of activity that can be performed.
4. 8each patient and caregiver techni'ues of self&care that will minimi5e 23 consumption
5. *ollaborate with occupational, physical, and(or recreational therapists to plan and monitor activity(e#ercise
program.
.9&3