Question

Mrs. E., a 70-year-old Hispanic woman, was admitted to the medical unit with complaints of increasing dyspnea on exertion.

Subjective Data

·     Had a severe MI at 58 years of age

·     Has experienced increasing dyspnea on exertion during the last 2 years

·     Recently had a respiratory tract infection, frequent cough, and edema in legs 2 weeks ago

·     Cannot walk two blocks without getting short of breath

·     Has to sleep with head elevated on three pillows

·     Does not always remember to take medication

Objective Data

Physical Examination

·     In respiratory distress, use of accessory muscles, respiratory rate 36 breaths/min

·     Heart murmur

·     Moist crackles in both lungs

·     Cyanotic lips and extremities

·     Skin cool and diaphoretic

Diagnostic Studies

·     Chest x-ray results: cardiomegaly with right and left ventricular hypertrophy; fluid in lower lung fields

Collaborative Care

·     Digoxin 0.25 mg PO qd

·     Furosemide (Lasix) 40 mg IV bid

·     Potassium 40 mEq PO bid

·     Enalapril (Vasotec) 5 mg PO qd

·     2 g sodium diet

·     Oxygen 6 L/min

·     Daily weights

·     Daily 12-lead ECG, cardiac enzymes q8hr x 3

  Based on the assessment data presented, write two or more appropriate nursing diagnoses along with the related to and AEB.

Answer 1

1 Risk for impaired gas exchange

risk for deficit in oxygenation and elimination of carbon dioxide at the alveolar- capillary membrane related to in- adequate tissue perfusion due to cardiomegaly as evidenced by increasing dyspnea on exertion

2 Increase in isotonic fluid retension due to increase in total body water content as evidenced by edema in legs and fluid in lower lung

3 activity intolerence

insufficient physiological energy to endure desired activity related to imbalance between oxygen supply and demand as evidenced by dyspnea   and diaphoresis