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Outcome Criteria
Interventions
Rationale
Evaluation
Answers why, how, what your interventions will help solve, prevent or
lessen the stated problem specific to this patient.
1.
1. U = Pt's outcome
was unmet with the BP
of 98/56.
2.
2. The most common heart failure is related to the left side, which causes a back up of
fluid in the lungs. Left-sided HF results from left ventricular dysfunction. This prevents
normal, forward blood flow and causes blood to back up into the left atrium and
pulmonary veins. The increased pulmonary pressure causes fluid leakage from the
pulmonary capillary bed into the interstitium and then the alveoli. This manifests as
pulmonary congestion and edema. This can be evident by hearing crackles in the lungs, a
change in respiratory pattern, shortness of breath or orthopnea then that is an indication of
respiratory changes that are signs of fluid accumulation in the lungs. This pt had crackles
in his lungs heard while listening to his lungs and that indicates he needs to have fluid
removed from his body and/or a medication to help his heart pump more efficiently.
2. U = Pt's outcome
was unmet because pt
still had rales on d/c.
3.
3. An echocardiogram shows the ejection fraction which provides information about the
function of the left ventricle during systole. A E.F. Of 40% is low and shows that the
patients heart is not pumping effectively. This measurement can indicate that the patient
needs other medications to reduce fluid or a stricter fluid intake. Pt's ECHO showed
diastolic hear failure and severely dilated right ventricle. These results directly relate to
this pt's decreased cardiac output because diastolic heart failure is when the left ventricle
can't relax and fill during diastole. The stroke volume falls which directly effects the
cardiac output by decreasing it also. Now that it shows a dilated right ventricle in the pt's
heart, his heart is going to become even more ineffective at perfusing his body. His
ventricle is enlarged and weakened. In some cases, it prevents the heart from relaxing and
filling with blood as it should. Over time, it becomes an effective pump and cardiac output
will decrease.