Chf Research
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Transcript of Chf Research
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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