Congestive Heart Failure (CHF)

 

Decreased Cardiac Output

Assessment

The patient may manifest the following:

• Pale conjunctiva, nail beds, and buccal mucosa
• irregular rhythm of pulse
• bradycardia
• generalized weakness

Diagnosis

• Decreased cardiac output r/t [altered heart rate and rhythm] AEB [bradycardia]

Planning

• Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.
• Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

Nursing Interventions

• Assess for abnormal heart and lung sounds.
  • Rationale: Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.
• Monitor blood pressure and pulse.
  • Rationale: Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.
• Assess mental status and level of consciousness.
  • Rationale: The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
• Assess patient’s skin temperature and peripheral pulses.
  • Rationale: Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
• Monitor results of laboratory and diagnostic tests.
  • Rationale: Results of the test provide clues to the status of the disease and response to treatments.
• Monitor oxygen saturation and ABGs.
  • Rationale: Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
• Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
  • Rationale: Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
• Implement strategies to treat fluid and electrolyte imbalances.
  • Rationale: Decreases the risk for development of cardiac output due to imbalances.
• Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.
  • Rationale: Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
• Encourage periods of rest and assist with all activities.
  • Rationale: Reduces cardiac workload and minimizes myocardial oxygen consumption.
• Assist the patient in assuming a high Fowler’s position.
  • Rationale: Allows for better chest expansion, thereby improving pulmonary capacity.
• Teach patient the pathophysiology of disease, medications
  • Rationale: Provides the patient with needed information for management of disease and for compliance.
• Reposition patient every 2 hours
  • Rationale: To prevent occurrence of bed sores
• Instruct patient to get adequate bed rest and sleep
  • Rationale: To promote relaxation to the body
• Instruct the SO not to leave the client unattended
  • Rationale: To ensure safety and reduce risk for falls that may lead to injury

Evaluation

• After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.
• After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

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Excess Fluid Volume

Assessment

The patient may manifest the following:

• Edema of extremities
• Difficulty of breathing
• Crackles
• Change in mental status
• Restlessness and anxiety

Diagnosis

• Excessive Fluid volume related to decreased cardiac output and sodium and water retention

Planning & Desired Outcomes

• Patient will verbalize understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.
• Patient will demonstrate adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema.

Nursing Interventions

• Establish rapport
  • Rationale: To gain patient’s trust and cooperation
• Monitor and record VS
  • Rationale: To obtain baseline data
• Assess patient’s general condition
  • Rationale: To determine what approach to use in treatment
• Monitor I&O every 4 hours
  • Rationale: I&O balance reflects fluid status
• Weigh patient daily and compare to previous weights.
  • Rationale: Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess.
• Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production
  • Rationale: When increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema
• Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic.
  • Rationale: Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular absorption of sodium Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.
• Follow low-sodium diet and/or fluid restriction
  • Rationale: The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.
• Encourage or provide oral care q2
  • Rationale: Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatis pressure exceeds interstitial pressure, fluids leak out of ht ecpaillaries and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart.
• Obtain patient history to ascertain the probable cause of the fluid disturbance.
  • Rationale: May include increased fluids or sodium intake, or compromised regulatory mechanisms.
• Monitor  for distended neck veins and ascites
  • Rationale: Indicates fluid overload
• Evaluate urine output in response to diuretic therapy.
  • Rationale: Focus is on monitoring the response to the diuretics, rather than the actual amount voided
• Assess the need for an indwelling urinary catheter.
  • Rationale: Treatment focuses on diuresis of excess fluid.
• Institute/instruct patient regarding fluid restrictions as appropriate.
  • Rationale: This helps reduce extracellular volume.

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Acute Pain

Assessment

Patient may manifest the following

• Difficulty of breathing
• Chest pain
• Restlessness

Diagnosis

• Acute Pain

Planning & Desired Outcomes

• Patient’s pain will be decreased.
• Patient will demonstrate activities and behaviors that will prevent the recurrence of pain.

Nursing Interventions

• Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
  • Rationale: To identify intensity, precipitating factors and location to assist in accurate diagnosis.
• Administer or assist with self-administration of vasodilators, as ordered.
  • Rationale: The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
• Assess the response to medications every 5 minutes
  • Rationale: Assessing response determines effectiveness of medication and whether further interventions are required.
• Provide comfort measures.
  • Rationale: To provide nonpharmacological pain management.
• Establish a quiet environment.
  • Rationale: A quiet environment reduces the energy demands on the patient.
• Elevate head of bed.
  • Rationale: Elevation improves chest expansion and oxygenation.
• Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
  • Rationale: Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
• Teach patient relaxation techniques and how to use them to reduce stress.
  • Rationale: Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
• Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
  • Rationale: In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.

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Ineffective Tissue Perfusion

Assessment

• Pale conjunctiva, nail beds, and buccal mucosa
• Generalized weakness
• Chest pain
• Difficulty of breathing
• Abnormal pulse rate and rhythm
• Bradycardia
• Altered BP readings
• With pitting edema on both forearms and hands
• Bipedal pitting edema

Diagnosis

• Ineffective tissue perfusion related to decreased cardiac output.

Planning & Desired Outcomes

• Patient will demonstrate behaviors to improve circulation.
• Display vital signs within acceptable limits, dysrhythmias absent/controlled,and no symptoms of failure

Nursing Interventions

• Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
  • Rationale: To identify intensity, precipitating factors and location to assist in accurate diagnosis.
• Administer or assist with self administration of vasodilators, as ordered.
  • Rationale: The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
• Assess the response to medications every 5 minutes.
  • Rationale: Assessing response determines effectiveness of medication and whether further interventions are required.
• Give beta blockers as ordered.
  • Rationale: Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.
• Establish a quiet environment.
  • Rationale: A quiet environment reduces the energy demands on the patient.
• Elevate head of bed.
  • Rationale: Elevation improves chest expansion and oxygenation.
• Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
  • Rationale: Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
• Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered.
  • Rationale: Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain.
• Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by physician.
  • Rationale: These enzymes elevate in the presence of myocardial infarction at differing times and assist in ruling out a myocardial infarction as the cause of chest pain.
• Assess cardiac and circulatory status.
  • Rationale: Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.
• Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.
  • Rationale: Notes abnormal tracings that would indicate ischemia.
• Teach patient relaxation techniques and how to use them to reduce stress.
  • Rationale: Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
• Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
  • Rationale: In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.
• Reposition the patient every 2 hours
  • Rationale: To prevent bedsores
• Instruct patient on eating a small frequent feedings
  • Rationale: To prevent heartburn and acid indigestion

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Hyperthermia

Assessment

Patient may manifest the following:

• Pale palpebral
• Conjunctiva and nail beds
• Warm to touch
• Weakness
• Increased in body temperature
• Fluid or electrolyte imbalance
• Diaphoresis
• Hot flushed skin

Diagnosis

• Hyperthermia RT increased metabolic rate secondary to pneumonia

Planning & Desired Outcomes

• Patient’s temperature will  be on normal level.

Nursing Interventions

• Assess vital signs, the temperature.
  • Rationale: Vital signs provide more accurate indication.
• Monitor and record all sources of fluid loss such as urine, vomiting and diarrhea.
  • Rationale: For potential fluid and electrolyte losses.
• Performed tepid sponge bath.
  • Rationale: To promote heat loss by evaporation and conduction.
• Maintain bed rest.
  • Rationale: To reduce metabolic demands and oxygen consumption.
• Remove excess clothing and covers.
  • Rationale: Decreases warmth and increase evaporative cooling.
• Increase fluid intake.
  • Rationale: To prevent dehydration.
• Provide adequate nutrition, a high caloric diet.
  • Rationale: The meet the metabolic demands.
• Control environmental temperature.
  • Rationale: To prevent an increase in body temperature and prevent shivering of the patient.
• Adjust cooling measures on the basis of physical response.
  • Rationale: Shivering, which burns calories and increases metabolic rate in order to produce heat.
• Provide information regarding normal temperature and control.
  • Rationale: This is especially necessary for patients with conditions at risk for hyperthermia.
• Explain all treatments.
  • Rationale: Patients’ S.O. needs to be oriented.
• Administer antipyretics as ordered.
  • Rationale: To decrease body temperature.
• Control excessive shivering with medications such as Chlorpromazine and Diazepam if necessary.
  • Rationale: Shivering increases metabolic rate and body temperature.
• Provide ample fluids by mouth or intravenously as ordered.
  • Rationale: If the patient is dehydrated or diaphoretic, fluid loss contributes to fever.
• Provide oxygen therapy in extreme cases as ordered.
  • Rationale: Hyperthermia increases metabolism.

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Ineffective Breathing Pattern

Assessment

Patient may manifest the following:

• weakness
• rales on BLF
• productive cough
• frothy sputum
• pursed lip breathing
• tachypnea

Diagnosis

• Ineffective breathing pattern related to fatigue and decreased lung expansion and pulmonary congestion secondary to CHF

Planning & Desired Outcomes

• Patient’s respiratory pattern will be effective without causing fatigue

Nursing Interventions

• Establish rapport
  • Rationale: To gain comfort feelings form the pt and pts SO
• Monitor VS
  • Rationale: To gain baseline data
• Inspect thorax for symmetry of respiratory movement
  • Rationale: Determines adequacy of breathing
• Observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory phase and use of accessory muscles
  • Rationale: Identifies increased work of breathing
• Measure tidal volume and vital capacity
  • Rationale: Indicates volume of air moving in and out of lungs
• Assess emotional response
  • Rationale: Detects use of hyperventilation as a causative factor
• Position patient in optimal body alignment in semi- fowler’s position for breathing
• Assist patient to use relaxation techniques
  • Rationale: Reduces muscle tension, decreases work of breathing

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Activity Intolerance

Assessment

• Weakness
• Limited range of motion
• Abnormal pulse rate and rhythm

Diagnosis

• Activity intolerance r/t imbalance O2 supply and demand

Planning & Desired Outcomes

• Patient will use identified techniques to improve activity intolerance
• Patient will report measurable increase in activity intolerance

Nursing Interventions

• Establish Rapport
  • Rationale: To gain clients participation and cooperation in the nurse patient interaction
• Monitor and record Vital Signs
  • Rationale: To obtain baseline data
• Assess patient’s general condition
  • Rationale: To note for any abnormalities and deformities present within the body
• Adjust client’s daily activities and reduce intensity of level. Discontinue  activities that cause undesired psychological changes
  • Rationale: To prevent strain and overexertion
• Instruct client in unfamiliar activities and in alternate ways of conserve energy
  • Rationale: To conserve energy and promote safety
• Encourage patient to have adequate bed rest and sleep
  • Rationale: to relax the body
• Provide the patient with a calm and quiet environment
  • Rationale: to provide relaxation
• Assist the client in ambulation
  • Rationale: to prevent risk for falls that could lead to injury
• Note presence of factors that could contribute to fatigue
  • Rationale: fatigue affects both the client’s actual and perceived ability to participate in activities
• Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
  • Rationale: to determine current status and needs associated with participation in needed or desired activities
• Give client information that provides evidence of daily or weekly progress
  • Rationale: to sustain motivation of client
• Encourage the client to maintain a positive attitude
  • Rationale: to enhance sense of well being
• Assist the client in a semi-fowlers position
  • Rationale: to promote easy breathing
• Elevate the head of the bed
  • Rationale: to maintain an open airway
• Assist the client in learning and demonstrating appropriate safety measures
  • Rationale: to prevent injuries
• Instruct the SO not to leave the client unattended
  • Rationale: to avoid risk for falls
• Provide client with a positive atmosphere
  • Rationale: to help minimize frustration and rechannel energy
• Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms
  • Rationale: to indicate need to alter activity level