CCF NURSING CARE PLAN

                   CONGESTIVE CARDIAC FAILURE

 NURSING CARE PLAN

Nursing problem	Nursing diagnosis	Objectives/goal	Nursing interventions	Evaluation
Impaired gas exchange	Impaired gas exchange related to increased preload, mechanical failure, or immobility as manifested by increased respiratory rate, shortness of breath, dyspnoea on exertion	The patient will maintain normal gas exchange within 45 minutes of intervention  evidenced by ease of breathing, reduced respiratory rate	-Monitor the rate, rhythm, depth and effort of respirations. - Auscultate breath sounds, noting the areas of decreased/absent ventilation, and presence of adventitious sounds to assess congestion - Monitor for dyspnoea and events that improve and worsen it to detect events that can influence ADLs. - Administer supplemental oxygen as prescribed to maintain oxygen levels. - Change oxygen delivery levels from mask to nasal prongs during meals as tolerated to sustain oxygen levels. - Position to alleviate dyspnoea (e.g. semi fowler‘s position) as appropriate, to improve ventilation by decreasing venous return to the heart and increasing thoracic capacity. - Monitor effectiveness of oxygen saturation to identify hypoxemia and establish range of oxygen saturation.	The patient has maintained normal gas exchange within 45minutes of intervention
Disturbed sleep pattern	Disturbed sleep pattern related to nocturnal dyspnoea, inability to assume favoured sleep position manifested by inability to sleep throughout the night	The patient will be able to have uninterrupted sleep throughout the night	- Determine patient‘s sleep/activity pattern to establish routine. - Encourage patient to establish a bedtime routine to facilitate transition from wakefulness to sleep in order to establish a pattern and decrease number of waking periods. - Adjust environment to promote sleep. - Regulate environmental stimuli to maintain normal day-night cycles to help promote sleep cycle. - Adjust medication administration schedule to support patient‘s sleep cycle. - Monitor patient‘s sleep pattern and number of sleep hours to determine hours of sleep.	The patient is able to sleep throughout the night
Activity Intolerance	Activity intolerance related to fatigue secondary to cardiac and pulmonary congestion as manifested by dyspnoea, shortness of breath, weakness, increase in heart rate on exertion.	The patient will tolerate activity and report performance of activities of daily living (ADLs) throughout hospital stay	Encourage alternate rest and activity periods to reduce cardiac workload. - Provide emotional and physical rest to reduce oxygen consumption and relieve dyspnoea and fatigue. - Monitor cardiorespiratory response to activity to determine level of activity that can be performed. - Teach patient and significant other the techniques of self care to minimise oxygen consumption. - Assist to choose activities consistent with physical, psychological, and social capabilities to determine level of activity that can be performed. - Collaborate with occupational, physical and/or recreational therapists to plan and monitor activity programme.	The patient has tolerated activity and reported carrying out ADLS throughout his/her hospital stay
Anxiety	Anxiety related to dyspnoea or perceived threat of death as manifested by restlessness, irritability, and expressions of feelings of life threat	Patient will verbalize a reduction in the level of anxiety experienced within two hours of intervention	Assess the patient‘s level of anxiety to enhance the patient‘s awareness and ability to identify and solve problems. - Establish a working relationship with the patient through continuity of care to form a basis for comfort in communicating anxious feelings. - Use a calm, reassuring approach to increase confidence in caregiver and relieve anxiety. - Explain all procedures, including sensations likely to be experienced during a procedure, to promote sense of security. - Encourage the patient and family to talk about their fears and concerns to increase the awareness the patient. - Provide reassurance when possible, but always answer questions honestly. - Instruct the patient on the use of relaxation techniques to help alleviate anxiety. - If possible, psychological counselling can be arranged to help the patient cope	Patient has verbalized a reduction in the level of anxiety experienced within two hours of intervention