Congestive Heart Failure Nursing Care Plan

Document Sample
Congestive Heart Failure Nursing Care Plan Powered By Docstoc
					  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
    antianxiety agents
    promotes relaxation
    thereby decreasing the
    demand and workload
    of the heart;
    Anticoagulants may be
    used to prevent
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
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
16. BUN/creatinine shows
    renal function, liver
    function tests
    determine liver
    congestion, while
    coagulation studies
    denote the effectivity
    of anticoagulant
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

Shared By: