Nursing Interventions: a. Providing Oxygenation Administer oxygen therapy per nasal cannula at 2 to 6 L/ min as ordered.

. Evaluate arterial blood gas analysis results. Maintain semi-fowlers or high-fowlers position to maximize oxygenation by promoting greater lung expansion. b. Promoting rest and activity Bed rest or limited activity may be necessary during the acute phase. Provide an overbed table close to the patient to allow resting the head and arms. The arms may be supported on pillows to reduce the pull on the shoulder muscles when in high-fowlers position, which is most comfortable for the patient. Administer Diazepam (Valium) 2 to 10 mg. Three to four times a day as ordered to allay apprehension. Gradual ambulation is encouraged to prevent risk of venous thrombosis and embolism due to prolonged immobility. Activities should progress through dangling, sitting up in a chair and then walking in increased distances under close supervision. Assess for signs of activity intolerance such as dyspnea, fatigue and increased pulse rate that do not stabilize readily. c. Decreasing anxiety Identifying feelings and concerns related to these feelings. Identify strengths that can be used for coping. Learn what can be done to decrease anxiety. d. Facilitating fluid balance Control of sodium intake. Administer diuretics and digitalis as prescribed. Monitor intake and output, weight and vital signs. e. Providing skin care Edematous skin is poorly nourished and susceptible to pressure sores. Change position at frequent intervals. Assess the sacral area regularly. Use protective devices to prevent pressure sores.

f. Promoting nutrition Provide bland, low-calorie, low-residue with vitamin supplement during the acute phase. Frequent small feedings minimize exertion and reduce gastrointestinal blood requirements. There may be no need to severely restrict sodium intake of the client who receives diuretic. However, no added salt diet is prescribed. Salty foods must be omitted. g. Promoting elimination Advise the client to avoid straining at defecation which involves Valsalvas maneuver. Valsalva maneuver increases cardiac workload. Administer laxative as ordered e.g. Colace (docussate sodium) Encourage use of bedside commode. h. Facilitating learning Teach the client and his family about the disorder and self-care. Monitoring signs and symptoms of recurring CHF, e.g weight gain, loss of appetite, dyspnea, orthopnea, edema of the legs, persistent cough. Report these to the physician. Avoid fatigue, balance rest with activity. Observe prescribed sodium restrictions. Eat small, frequent meals rather than 3 large meals a day. Take prescribed medications at regular basis, e.g. digitalis, diuretics, vasodilators. Observe regular follow-up care as directed. i. If acute pulmonary edema occurs in the client with CHF, the following are the appropriate collaborative management: Place in high-fowlers position, with legs slightly lowered to facilitate breathing and to reduce preload. Morphine sulfate 10 to 15 mg/ IV as ordered. To primarily reduce preload and afterload, and to allay anxiety. Oxygen therapy at 40% to 70% by nasal cannula or face mask. Aminophylline/ IV as ordered. To relieve bronchospasm, increase urinary output and increase cardiac output. Rapid digitalization. Diuretic therapy.

 Vasodilators. Dopamine or dobutamine. Monitor serum potassium. Diuresis may result to hypokalemia.

Imaging Assessment Chest X-rays- can be helpful in diagnosing left ventricular failure. Typically the heart is enlarged (cardiomegaly), representing hypertrophy or dilation. Pleural effusions develop less often and generally reflect biventricular failure. Echocardiography- is considered the best tool diagnosing heart failure. Cardiac valvular changes, pericardial effusion, chamber enlargement, and ventricular hypertrophy can be diagnosed using this non-invasive technique. The test can also be used to determine ejection fraction. Radionuclide studies (thallium imaging or technetium pyrophosphate scanning) - can also indicate the presence and causes of heart failure. Other Diagnostic Assessment Electrocardiogram (ECG) - is also performed. It may show ventricular hypertrophy, dysrhythmias, and any degree of myocardial ischemia, injury, or infarction. Pulmonary Artery Catheters- allow the assessment of cardiac function and volume status in acutely ill patients. These measurements can confirm the diagnosis and guide the management of heart failure.