Student Nurses’ Community

NURSING CARE PLAN – Congenital Heart Failure

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO N RATIONALE EVALUATION

SUBJECTIVE: “Putlang putla ang anak ko, nahihirapan sya huminga” (My baby looks very pale and she finds it difficult to breath) as verbalize by the mother. OBJECTIVE: • Cool, ashen skin. • Orthopnea • Crackles • V/S taken as follows

T: 36.2 ˚C P: 130 R: 45

Decreased cardiac output related to altered myocardial contractility /inotropic changes.

Heart failure, also called congestive heart failure , occurs when cardiac output is inadequate to meet the metabolic demands of the body. The heart rate increases as a compensatory mechanism to increase cardiac output, and vasoconstriction occurs to try to maintain blood pressure. Eventually, the chronic increase in preload and afterload contribute to chamber dilation and hyperthrophy, worsening heart failure. Underlying causes of heart failure include congenital heart disease, rheumatic heart

After 8 hours of nursing intervention the patient will display vital signs within acceptable limits, dysrhythmias controlled and no symptoms of failure.

INDEPENDENT: • Auscultate apical pulse;

assess heart rate, and rhythm.

• Inspect skin for pallor,

cyanosis. • Monitor urine output,

noting decreasing output and dark or concentrated urine.

• Tachycardia is

usually present even at rest to compensate for decreased ventricular contractility.

• Pallor is an indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory heart failure. Dependent areas are often blue or mottled as venous congestion increases.

• Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent.

After 8 hours of nursing intervention the patient was able to display vital signs within acceptable limits, dysrhythmias controlled and no symptoms of failure.

Student Nurses’ Community

disease, endocarditis, myocarditis, and noncardiovascular causes such as, chronic pulmonary disease, various metabolic diseases, and anemia. Complications of heart failure include pneumonia, pulmonary edema, pulmonary emboli, refractory heart failure, and myocardial failure.

• Note changes in sensorium.

• Provide quiet

environment. DEPENDENT: • Administer

supplemental oxygen as indicated.

• Administer diuretics as

prescribed.

• May indicate inadequate cerebral perfusion secondary to decreased cardiac output.

• Psychological rest help reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate or work.

• Increases available

oxygen for myocardial uptake to combat effects of hypoxia or ischemia.

• Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in patients with heart failure.