SUBJECTIVE: Independent STG: Ineffective breathing STG: After 1hr of nursing Note heart sounds. S1 and S2 may be weak After 1 hr. of nursing “Is very anxious pattern related to fatigue intervention the patient because of diminished intervention the patient and ask, “Am I and decreased lung will be able demonstrate 3 pumping action. Gallop was able to demonstrate 3 going to die?” expansion and pulmonary out of 5 procedures to rythms are common(S3 out 5 ways to improve Denies pain but congestion secondary to improve breathing pattern and S4), produced as breathing pattern. says that he feels CHF. blood flows into like he cannot get LTG: After 8hrs of nursing noncompliant chambers. GOAL MET enough air intervention the Patient’s Says that his heart respiratory pattern will Palpate peripheral pulses ↓CO may be reflected in LTG: feels like it is decrease from 34 to 28 diminished radial, After 8 hrs. of nursing “running away” cpm without exertion. popliteal, dorsalis pedis, intervention the patient’s After being and post tibial pulses respiratory pattern was weighed, he decreased from 34-28 reports, “that is Monitor BP In advanced HF, the body cpm without exertion. more than I may no longer be able to usually weigh” compensate, and GOAL MET Reports that he is profound hypotension may so exhausted he occur. can’t eat or drink by himself Inspect for pallor or Pallor is indicative of Objective Data cyanosis diminished peripheral Height: 175 cm perfusion secondary to Weight: 95.5kg inadequate CO, Temp: 37.6 vasoconstriction, and HR: 34 anemia. Cyanosis may 118bpm develop in refractory HF. BP: 90/60 Dependent area are often blue or mottled as venous Distant S1, S2, congestion increases. S3, S4 present, Monitor UO Kidneys respond to PMI at 6th ICS and reduced CO by retaining faint water and sodium (+) atrial fibrillation Note changes in May indicate inadequate sensorium, lethargy, cerebral perfuaion with ventricular confusion, disorientation, secondary to decreased rate of 132pbm anxiety, and depression CO. (+)crackles, Monitor oxygen saturation Provides information ↓breath sounds and ABGs. regarding the heart’s ability to perfuse distal RLL, +(frothy tubules with oxygenated blood-tinged blood. sputum) Encourage patient of rest Reduces cardiac workload SpO2- 82% on and assist with all and minimizes myocardial activities oxygen consumption room air (+) bowel sounds Assist the patient in Allows for better chest assuming a high fowler’s expansion, thereby Hepatomegaly position improving pulmonary (4cm below costal capacity.
margin) Assist patient to use Identifies increased work
Bilateral JVD relaxation techniques of breathing
1+ peripheral Weigh patient daily and Body weight is a sensitive
compare to previous indicator of fluid balance pulses and (+) weights and an increase indicates peripheral edema fluid volume excess.
Dependent:
Administer supplemental Increases available
oxygen as indicated oxygen for myocardial uptake to combat effects of hypoxia Administer medications as To improve patient indicated. condition