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8/3/2019 Chf Research

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NO Nursing Diagnosis out come Interventions evaluation

1 Decreased Cardiac

Output related to

impairedcontractility and

increased preloadand afterload

Maintaining

Adequate

CardiacOutput

Place patient at physical and emotional rest to

reduce work of heart.

Provide rest in semi-recumbent position or in

armchair in air-conditioned 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.

Observe for signs and symptoms of reduced

peripheral tissue perfusion: cool temperature

of skin, facial pallor, poor capillary refill of

nail beds.

Administer pharmacotherapy as directed.

Monitor clinical response of patient with

respect to relief of symptoms (lessening

dyspnea and orthopnea, decrease in crackles,

relief of peripheral edema).

Normal BP and

heart rate

2 Impaired Gas

Exchange related to

alveolar edema due

to elevatedventricular pressures

Improving

Oxygenation

Raise head of bed 8 to 10 inches (20 to 30

cm) reduces venous return to heart and lungs;

alleviates pulmonary congestion.Support lower arms with pillows to eliminate

pull of their weight on shoulder muscles.

Sit orthopneic patient on side of bed with feet

supported by a chair, head and arms resting

on an over-the-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 respirations (mayoccur 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.

Encourage deep-breathing exercises every 1

to 2 hours to avoid atelectasis.

Respiratory rate 16

to 20, ABG levels

within normal

limits, no signs ofcrackles or wheezes

in lung fields


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Offer small, frequent feedings to avoidexcessive gastric filling and abdominal

distention with subsequent elevation of

diaphragm that causes decrease in lung

capacity.

Administer oxygen as directed.

3 Excess FluidVolume related tosodium and water

retention

RestoringFluid Balance

Administer prescribed diuretic as ordered.Give diuretic early in the morning nighttime

diuresis disturbs sleep.

Keep input and output record patient may

lose 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.

Assess for signs of hypovolemia caused by

diuretic therapy thirst, decreased urine output,

orthostatic hypotension, weak, thready pulse,

increased serum osmolality, and increased

urine specific gravity.

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.

Give potassium supplements as prescribed.

Be aware of disorders that may be worsened

by diuretic therapy including hyperuricemia,

gout, volume depletion, hyponatremia,

magnesium depletion, hyperglycemia, and

diabetes mellitus. Also, note that some

patients allergic to sulfa drugs may also beallergic to thiazide diuretics.

Watch for signs of bladder distention in

elderly male patients with prostatic

hyperplasia.

Administer I.V. fluids carefully through an

intermittent access device to prevent fluid

overload.

Monitor for pitting edema of lower

extremities and sacral area. Use convoluted

foam mattress and sheepskin to prevent

pressure ulcers (poor blood flow and edema

increase susceptibility).

Observe for the complications of bed restpressure ulcers (especially in edematous

patients), phlebothrombosis, pulmonary

embolism.

Be alert to complaints of right upper quadrant

abdominal pain, poor appetite, nausea, and

abdominal distention (may indicate hepatic

and visceral engorgement).

Monitor patients diet. Diet may be limited in

sodium to prevent, control, or eliminate

Weight decrease of2.2 lb (1 kg) daily,no pitting edema of

lower extremities

and sacral area


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edema; may also be limited in calories.

Caution patients to avoid added salt in food

and foods with high sodium content.

4 Activity Intolerance

related to oxygen

supply and demand

imbalance

Improving

Activity

Tolerance

Increase patients activities gradually. Alter

or modify patients activities to keep within

the limits of his cardiac reserve.

Assist patient with self-care activities early inthe day (fatigue sets in as day progresses).

Be alert to complaints of chest pain or

skeletal pain during or after activities.

Observe the pulse, symptoms, and behavioral

response to increased activity.

Monitor patients heart rate during self-care

activities.

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 relieveinsomnia and restlessness.

Heart rate within

normal limits, rests

between activities

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