Example: Case Study Plan of Care and Concept Map
Mrs. J is admitted to the emergency department with a diagnosis of congestive heart failure. She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are swollen.” After further questioning, you learn that Mrs. J is strictly following the fluid and salt restriction ordered during her last hospital admission. Mrs. J reports gaining 1 to 2 pounds every day since her discharge.
Identify two (2) priority nursing diagnoses for Mrs. J and develop a concept map to illustrate them (see example below).
Primary Medical Diagnosis:
· Congestive Heart Failure
Prioritized Nursing Dx# 2
· Fluid Volume Excess r/t fluid retention as evidenced by swelling
Prioritized Nursing Dx# 6
Prioritized Nursing Dx# 5
Prioritized Nursing Dx# 3
Prioritized Nursing Dx# 1
· Impaired Gas Exchange r/t fluid overload as evidenced by shortness of breath
Prioritized Nursing Dx# 4
Nursing Plan of Care
For each of the priority nursing diagnoses, establish one (1) goal. For each goal create two (2) nursing interventions.
|Prioritized Nursing Diagnoses||Goal||Nursing Interventions|
|1. Ineffective Gas Exchange||Pt will maintain oxygen saturations greater than 95% during my shift||1. Give oxygen as ordered
2. Monitor clients oxygen saturations
|2. Fluid Volume Excess||Pt will have decreased swelling in extremities by the end of my shift.||1. Administer diuretic as ordered
2. Monitor Intake and Output