- Decrease Cardiac Output related to :
- Changes in myocardial contractility or inotropic changes
- Changes in frequency, rhythm, cardiac conduction
- Structural changes (eg, valve abnormalities, ventricular aneurysm)
- Activity Intolerance related to :
- Weakness, weakness
- Changes in vital signs, dysritmia
- Dyspnea
- Pale
- Sweating
- Excess Fluid Volume related to
- The reduced glomerular filtration rate (decrease in cardiac output) or increased production of ADH and sodium and water retention.
- Risk for Impaired Skin Integrity related to
- Bed rest
- Edema, decreased tissue perfusion.
Nursing Intervention For Heart Failure
- Assess cardiovascular status, vital sign and hemodynamic variable to detect signs of reduced cardiac output.
- Assess respiratory status to detect increasing fluid in the lungs and respiratory failure.
- Keep the client in semi-fowler's position to increase chest expansion and improve ventilation.
- Administer medication as prescribed, to enhance cardiac performance and reduce excess fluids.
- Administer oxygen to enhance arterial oxygenation.
- Measure and record intake and output, Intake greater than output may indicated fluid retention.
- Monitor laboratory to detect electrolyte imbalances, renal failure, and impaired cardiac circulation.
- Provide suctioning, if necessary assist with turning and encourage coughing and deep breathing to prevent pulmonary complication.
- Restrict oral fluid to avoid worsening the client's condition.
- Weigh the client daily to detect fluid retention. A weight gain of 2lb (0,9 kg) in 1 day or 5 lb (2,3 kg) in 1 week indicates fluid gain.
- Measure and record the client's abdominal girth. An increased in abdominal girht suggests worsening fluid retention and right-sided heart failure.
- Make sure the client maintains a low-sodium diet to reduce fluid accumulation.
- Encourage the client to express feelings, such as a fear of dying to reduce anxiety.
http://articlesofnursing.blogspot.com/
http://nandanursingdiagnosis.blogspot.com