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Name: Mr. Heartbreaker Age: 52 years old Ward: Andrew Hall 1Chief Complaint: abdominal pain Diagnosis: Aortic Stenosis, Cardiomegaly, CHF , Ac!te "idney n#!ry secondary to sc$emic %ep$ropat$y wit$ Complicated

Cues Diagnosis Rationale Objectives Nursing Intervention Rationale Evaluation

Subjective(%amamanas anakon mga tiil), as*erbali+ed by t$epatient.

(agan naabat ako$in b!gat ngant!bigon tak tiyan) as*erbali+ed by t$epatient.

Objective-ascites: presentabdominal girt$/0)pre$ospitali+ation(-bipedal edema 32-weig$t gain 4rom0kgs. 'o 2 kgs.

-blood press!re1/0670nnHg n120680mmHg-#!g!lar *eindistention o4 5cm-Hg115g69 n1/0-175g69-Ht0. n0./2-0.50- Hypokalemia .28mmol %.5-5.mmol69-proteins3333-creatinine 15/.25!mol69 normal71-

115!mol69-&%6; 17.08

;

8/11/2019 NCP- Excess Fluid Volume(Aortic Stenosis)

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mmol69 n2.5-8.mmol69- Additional=iagnosis: Ac!tekidney in#!rysecondary toisc$emicnep$ropat$ysecondary to CHF,complicated &'- Final diagnosis:se*ere aorticstenosis,cardiomegaly, CHF ascites

Medical G$ysiology11t$;dition, D!yton> Hall p.21

Monitored $eart rate H,

G

ecorded acc!rate intake

and o!tp!t >.

C$ange position

4re?!ently ele*ate 4eetw$en sitting. nspect skinintegrity, keep dry andpro*ide padding asindicated

A!sc!ltate breat$ so!nds

noting ad*entitio!s S.%ote presence o4 dyspnea,tac$ypnea, ort$opnea,G%= or persistent co!g$

ecommend ele*ating

lower e

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Collaborative

Administer di!retics as

ordered:

F!rosemide loop di!retic/0mg 2 @ now t$en ? 12$o!rs

Aldactone potassi!m-sparingdi!retic, aldosteroneantagonist 25mg 1 tab =

Maintain 4l!id6sodi!m

restrictions as ordered

Monitor ser!m alb!min

and electrolytes

n$ibits t$e reabsorption o4sodi!m and c$loride 4rom t$eascending limb o4 t$e loop o4Henle, leading to a sodi!m-ric$di!resis.

locks t$e e44ects o4aldosterone in t$e renal t!b!le,ca!sing loss o4 sodi!m andwater retention o4 potassi!m

ed!ces total 4l!id *ol!me

in t$e body and pre*ent4l!id reacc!m!lation.

=ecreased ser!m alb!min

a44ects plasma colloidosmotic press!re, res!ltingin edema 4ormation.