NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION Short term goal: 1. Obtain baseline vital 1. This is to assess the Client will be able to DECREASED CARDIAC signs and degree of debilitation demonstrate stability in OUTPUT Client will be able to hemodynamic and to check for vital signs, display stability in vital parameters including presence of absence/controlled Possible Etiologies: signs and hemodynamic peripheral pulses. tachycardia which is a dysrhythmias, and no (Related to) such as blood pressure, When assessing, compensatory symptoms of heart failure cardiac output, urinary auscultate apical mechanism of the as evidenced by *Mechanical: altered perfusion, and pulse for rate and heart for CHF; also to hemodynamic parameters myocardial contractility peripheral pulses; rhythm. determine if client is within normal limits (blood due to alteration in reduced episodes of 2. Monitor vital signs experiencing pressure, cardiac output, preload; alteration in dyspnea, dysrhythmia or frequently, especially dysrhythmias. urinary output, and afterload and inotropic angina within 2 weeks of the blood pressure 2. Decreased cardiac palpable peripheral changes nursing care. including before and output can be denoted pulses); as well as verbalize after exertion/ from diminished a reduction in episodes of *Electrical: alteration in activity. radial, popliteal, dyspnea, dysrhythmias, or cardiac rate, rhythm and Long term goal: 3. Assess skin for dorsalis pedis, and angina within 2 weeks of conduction cyanosis or pallor. posttibial nursing care. Client will be able to Note also for capillary pulses.During early *Structural changes i.e. participate in activities refill. CHF, blood pressure Client will be able to valvular defects, that reduce cardiac 4. Emphasize diet may be elevated due participate in activity and ventricular aneurysm workload and verbalize restrictions like low to increased systemic diet restrictions indicated increased tolerance to sodium, bland, soft, vascular resistance and will be compliant to Defining characteristics: activities. low calorie/ residue/ however, in advanced medical regimen and as (Evidenced by) fat diet or as CHF, a profound/ well verbalize increased indicated; frequent irreversible tolerance to activities. Subjective Data: small feedings may hypotension may be encouraged. occur. “I am easily tired these 5. Strictly monitor fluid 3. Cyanosis and pallor of days…and I am catching (IV/PO) intake and the skin plus delayed my breath every time I do output; Monitor IV capillary indicate this and that…” rate closely, restrict diminished peripheral verbalization of client. fluid intake as perfusion as CHF ordered by the progress. Objective Data: physician and as well 4. -Diet restrictions go note for decreased along with Restlessness and concentrated medications to Weakness urinary output. prevent water Cool, ashen skin, 6. Observe for changes retention; and small diaphoresis in mentation and frequent feedings Tachycardia, sensorium. could be encouraged dysrhythmias, ECG 7. Emphasize complete to supply adequate changes bed rest in semi- metabolic needs of the Variations in blood recumbent position client. pressure and assist client in 5. It helps determine (hypotenstion/ doing physical care. how client’s kidney hypertenstion) 8. Provide bedside respond to the disease Extra heart sounds commode and condition; Kidneys like S3 and S4 instruct client to react by retaining Diminished peripheral avoid straining during sodium and water in pulses defecation. the body resulting to Decreased urine 9. Promote adequate decreased urine output rest by decreasing output. Dyspnea stimuli and providing 6. It may correspond to Orthopnea, crackles, a quiet environment. decreased cerebral cough 10. Elevate client’s leg tissue perfusion due to Distended jugular (acute states) and decreased cardiac vein encourage active and output. Edema passive exercises as 7. Bed rest helps Liver engorgement/ tolerated and as maintain effective ascites indicated. myocardial contraction Chest pain 11. Administer oxygen as and also to decrease Change in mental indicated. the demand for status 12. Administer oxygen and heart medications as workload. prescribed while 8. The presence of observing 10 Rs: commode in the bedside decreases Diuretics client’s effort in going Vasodilators to the bathroom and ACE inhibitors as well decrease Digoxin vasovagal response. Anxiolytics/ sedatives 9. Reducing stressful Anticoagulants stimuli also reduces 13. Administer IV fluids episodes of alterations as indicated.*Avoid in vasoconstriction, saline solutions. fluctuations in blood 14. Monitor electrolyte pressure, and cardiac lab results and workload. replace accordingly as 10. It helps reduce venous indicated. stasis and thrombos 15. Monitor ECG and X- formation. ray results. 11. It increases the 16. Monitor laboratory amount of oxygen for results like myocardial uptake. BUN/Creatinine, Liver 12. Diuretics are usually function tests, and given to client stage I coagulation studies. and II CHF. The degree of CHF and the renal 17. Educate client about function are put into the risk factors for consideration when CHF like smoking, giving the type and obesity and stress; dose of diuretic; medication regimen Vasodilators are used and activity to increase cardiac limitations; and signs output, reduce SVR and symptoms and circulatory needed to be volume; ACE inhibitors reported immediately aid in decreasing like dizziness, muscle ventricular filling cramps, and dyspnea. pressures and SVR while increasing CO; Digoxin assists in increasing the force of myocardial contractility; antianxiety agents promotes relaxation thereby decreasing the demand and workload of the heart; Anticoagulants may be used to prevent thromboembolus formation. 13. Client may not tolerate increased fluid volume and since client excrete less sodium and in order to avoid further water retention, normal saline solutions are avoided. 14. The use of diuretics may also alter the electrolyte levels of the client affecting cardiac contractility. 15. ST segment depression may develop due to increased myocardial demand while X- ray results determine enlarged heart and changes in pulmonary congestion. 16. BUN/creatinine shows renal function, liver function tests determine liver congestion, while coagulation studies denote the effectivity of anticoagulant therapy. 17. -Teaching the client about the disease condition and importance of medication regimen and activities promotes acceptance, compliance and participation to procedures and treatment- hastening the recovery of the client.