CONCEPT MAP

Predisposing Factor: Age Gender Genetics Precipitating Factor: Nutritional Status Activity / Stress Lifestyle

CHF 74 years old

S/sx: With difficulty of breathing With productive cough With phlegm green in color Body Malaise Unable to perform like ADL With x-ray result pulmonary edema.

Outcome: Monitor vital sign q1. Appeared comfortable. Assume the pt. In semi-fowlers position. Monitor the respiratory rate and pulse rate.

Decreased cardiac output related to disease process as manifested by laboratory result (pulmonary edema).

Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by weakness and dyspnea.

Impaired gas exchange related to lack of altered oxygen supply as evidenced by dyspnea secondary to CHF.

Report decreased episodes of weakness dyspnea and participation activities that reduce cardiac workload.

The patient will be able to reduce weakness and maintain mobility at the highest possible level.

The patient will be able to demonstrate improve ventilation and adequate oxygenation of tissues by ABGs, pulse oximetry progress and improve respiratory distress.

Place the patient in semi-fowlers Monitored vital signs Monitor cardiac rhythm continuously Provide quiet and comfortable environment Provided assistance with self-care activities as indicated.

Check vital sign before and immediately after activities especially if patient is receiving vasodilators diuretics or bblocker. Instruct client to avoid increasing abdominal pain. Provided assistance with self-care activities as indicated. Assess for other precipitators/ causes of fatigue.

Explain to patient the disease process and management of symptoms Assist the patient in a comfortable position, sitting or semifowlers Monitor respiratory status, including rate, pattern of respirations, and breath sounds Demonstrate and help the patient perform diaphragmatic and pursed lip breathing. Advise the patient to allow the patient to rest and limit activities. The patient will be able to demonstrate improve ventilation and adequate oxygenation of tissues by ABGs, pulse oximetry progress and improve respiratory distress.

Report decreased episodes of weakness dyspnea and participation activities that reduce cardiac workload.

The patient was able to reduce weakness and maintain mobility at the highest possible level.