Justin Stuart

NO Nursing Diagnosis 1 Decreased Cardiac Output related to impaired contractility and increased preload and afterload

out come Maintaining Adequate Cardiac Output

Interventions evaluation Place patient at physical and Normal BP and emotional rest to reduce heart rate 60-99. work of heart.
o

Provide rest in semirecumbent position or in armchair in airconditioned environment reduces work of heart, increases heart reserve, reduces BP, decreases work of respiratory muscles and oxygen utilization, improves efficiency of heart contraction; recumbency promotes diuresis by improving renal perfusion. Provide bedside commode to reduce work of getting to bathroom and for defecation. Provide for psychological rest emotional stress produces vasoconstriction, elevates arterial pressure, and speeds the heart.

Evaluate frequently for progression of left-sided heart failure. Take frequent BP readings. Auscultate heart sounds frequently and monitor cardiac rhythm.

Justin Stuart

Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature of skin, facial pallor, poor capillary refill of nail beds. Monitor clinical response of patient with respect to relief of symptoms (lessening dyspnea and orthopnea, decrease in crackles, relief of peripheral edema). Raise head of bed 8 to 10 Respiratory rate 16 inches (20 to 30 cm) reduces to 20, ABG levels venous return to heart and within normal lungs; alleviates pulmonary limits, no signs of congestion. crackles or o Support lower arms wheezes in lung with pillows to fields eliminate pull of their weight on shoulder muscles. o Sit orthopneic patient on side of bed with feet supported by a chair, head and arms resting on an overthe-bed table, and lumbosacral area supported with pillows. Auscultate lung fields at least every 4 hours for crackles and wheezes in dependent lung fields (fluid accumulates in areas affected by gravity). Observe for increased rate of respirations (could be indicative of falling arterial pH). Observe for Cheyne-Stokes

2 Impaired Gas Improving Exchange related to Oxygenation alveolar edema due to elevated ventricular pressures

Justin Stuart

respirations (may occur in elderly patients because of a decrease in cerebral perfusion stimulating a neurogenic response). Position the patient every 2 hours (or encourage the patient to change position frequently) to help prevent atelectasis and pneumonia. Give diuretic early in the Weight decrease of morning, nighttime diuresis 2.2 lb (1 kg) daily, disturbs sleep. no pitting edema of Keep input and output lower extremities record patient may lose and sacral area large volume of fluid after a single dose of diuretic. Weigh patient daily to determine if edema is being controlled: weight loss should not exceed 1 to 2 lb (0.5 to 1 kg)/day. Be alert for signs of hypokalemia, which may cause weakening of cardiac contractions and may precipitate digoxin toxicity in the form of dysrhythmias, anorexia, nausea, vomiting, abdominal distention, paralytic ileus, paresthesias, muscle weakness and cramps, confusion. Monitor patients diet. Caution patients to avoid added salt in food and foods with high sodium content.

3 Excess Fluid Volume related to sodium and water retention

Restoring Fluid Balance

Justin Stuart

4 Activity Intolerance Improving related to oxygen Activity supply and demand Tolerance imbalance

Increase patients activities gradually. Alter or modify patients activities to keep within the limits of his cardiac reserve. o Assist patient with self-care activities early in the day (fatigue sets in as day progresses). o Be alert to complaints of chest pain or skeletal pain during or after activities. Observe the pulse, symptoms, and behavioral response to increased activity. o Monitor patients heart rate during self-care activities. o Allow heart rate to decrease to preactivity level before initiating a new activity. Relieve nighttime anxiety and provide for rest and sleep patients with heart failure have a tendency to be restless at night because of cerebral hypoxia with superimposed nitrogen retention. Give appropriate sedation to relieve insomnia and restlessness. Administer oxygen as prescribed to avoid and help prevent shortness of breath. Monitor pulse ox to ensure an O2 sat of 90% or greater to ensure that good tissue perfusion is being achieved.

Heart rate within normal limits, rests between activities. O2 sat stays greater than 90% at all times.

Justin Stuart

Heart Failure Care Plan