A nurse on the cardiac floor is preparing a nursing care plan for a patient with congestive heart failure and excess fluid volume. An appropriate nursing diagnosis for this patient would be which of the following?

Excess fluid volume related to decreased cardiac output as evidenced by weight gain, shortness of breath, and edema.

Explanation

•Nursing diagnoses are based on findings that are subjective (patient's own complaints) and objective (symptoms observed by the nurse).

•Nursing diagnoses should not include medical diagnoses like "congestive heart failure." The nursing diagnosis is based on the medical diagnosis but is symptoms and condition related.

•The nurse knows that congestive heart failure results in decreased cardiac output, which causes an increase of fluid retained in the body. This excess fluid backs up into the lungs causing shortness of breath. It can also cause fluid to remain in the body and extremities causing edema. The overall excess fluid volume in the body also causes weight gain.

•Nursing diagnoses includes these components that can be measured and observed, along with the patient's stated symptoms.

Visit our website for other NCLEX topics now!