Problem
Case Scenario
Tom, 67 -year -old pensioner who has a history of heart disease, has experienced a weight gain of 4 to 5 kg (9-11 lb) during the past months. He states his rings are too tight to remove, his ankles are swollen, his heart pounds at times, he gets breathless with exertion, and he feels bloated. Physical findings reveals jugular vein distension above 3 cm, delayed emptying of hand veins, bounding pulse (860, pitting edema in feet, ankles, and lower legs, and moist lung sounds (rales/crackles)
Activities:
A. Identify nursing diagnoses, outcomes, and Interventions in Client with Fluid Volume Excess
B. Preparation of Functional Health Pattern
C. Preparation of Structured Health Teachings: Home Care, Wellness Care
D. Make Nursing Care Plan for Ineffective Airway Clearance
E. Journal reading