concept map GI

conCept map

Problem 2: fluid overload

Goal: Normal fluid balance is maintained clients has balanced intake and output, stable weight, clients maintains 60-100 beats/min

Intervention: Check weight, administer diuretics, I/O, fluid restriction, salt 2gm/day, auscultate lungs, check for pitting edema,

Problem 1: SOB

Impaired gaseous exchange

Goal: Normal gaseous exchange is maintained,unlabored respirations 12-20 per minute

Intervention:

Auscultate lungs, Fowlers position ,assess for headache dizziness lethargy reduce ability to fellow instruction

administer oxygen, check spo2, Do ABG, Nebulization if needed,assessfoheheadaches

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Problem 3: Decreased cardiac output

Goal: Normal cardiac output is maintained ,improve myocardial systemic perfusion ,reduced fluid volume overload ,prevent complications, client exhibits warm dry skin ,client explains actions and precautions to take for cardiac disease

Intervention: Check BP, vitals for the patient, Check CVP, ECG,

Administer digoxin, (Ionotropics) calcium channel blockers, beta blockers, watch for SE of medications.

Problem 8: Knowledge deficiency r/t to disease process

Goal: Adequate knowledge is gained

Intervention: asses the level of knowledge regarding disease process

Provide teaching, regarding, medication, fluid restrictions, energy conservation, activity levels, rest, diet, and follow-up. Watch for pulmonary edema, with symptoms of severe restlessness, frothy sputum, make lifestyle change.

Problem 4: Fatigue rlt to HF

Goal: Decrease fatigue

Intervention:

Provide rest, quiet environment, space activities

Initiate fall precautions

Encourage small frequent meal

Key problem: inadequate pumping action of heart. Inadequate oxygenation, caused due to heart muscle disease, MI, HTN, Infection, shock,

Key Assessments:

SOB, swelling, weight gain, crackles, nausea, lack of appetite, decrease activity, fatigue, cough, sputum, distension of abdomen, ascites, hepatomegaly, JVD, altered mental status

Problem 7: anxiety r/t outcome of the disease process

Goal: Anxiety is minimized

Intervention: Assess the level of anxiety, explain procedures done or clarify doubts. Provide distraction, encourage family to visit or support system. Provide referral if needed for psychotherapy

Problem 5: Activity intolerance

Goal: Normal activity level is maintained improve the client ability to perform daily activities without feeling excessive fatigue , improve the client physiological health over time , maintain the client respiratory and cardiovascular functions during activities

Intervention: Assess the level of activity tolerance, assist with ADLs, Refer to physical therapy to maintain joint mobility, activity rehabilitation,

Problem 6: Risk for fluid electrolytes imbalance

Goal: Normal electrolyte levels are marinated treat the underline disorder , return the extracellular fluid compartment to normal , restore fluid volume.

Intervention: watch for s/s of electrolyte imbalance, monitor complete blood count sodium level, serum creatinine

Send blood for electrolyte levels, ABG, and B type neuropeptide levels,

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