Please view explanation and answer below.
View attached explanation and answer. Let me know if you have any questions.

1

Concept Map
Name
Professor
Course
Date

2

Concept Map
Case Scenario
Mr. T. a 55-year-old male patient is brought to the emergency room by his son. He
appears unstable and needs help to walk into the room. He is in respiratory distress, and
unable to complete words while talking. The son reports that he has been well until a week
ago when he developed an inability to work due to fatigue, cough, and weakness. He is
unable to breathe when he lies flat and needs to elevate the bed at night when sleeping. He is
known hypertensive with poor drug compliance. The legs are swollen with bilateral pitting
edema. Vital signs are blood pressure 180/100mmHg, pulse rate 54b/m, respirations 14
cycles, temperature 37.0 degrees centigrade, and weight of 107kgs. The chest was wet, with
pulmonary crackles heard on examination.
Medical diagnosis
Congestive Cardiac Failure

3

Goals & Outcomes

Nursing Diagnosis: Acute Pain related decreased
myocardial blood flow evidenced by chest pain, and
patient verbalizing of sudden onset of pain.

Short term goals
To relieve pain within half an hour
To provide satisfactory nonpharmacological pain control within
one hour
Long term goals
To use appropriate diversion and
relaxation skills to control pain
within 24 hours

Client’s Medical
Diagnosis: Heart
Failure

To teach the patient signs and
symptoms of angina within 24 hours

Assessment Data:
Chest pain, and
restlessness

Expected outcomes
The patient will report satisfactory
pain relief

Evaluation:

Interventions

No reports of chest pain

Assess the patient to establish the intensity of pain using
the pain rating scale. The rationale for this is to help in
...