Nursing Care Plan for Heart Failure
Heart failure or chronic heart failure (CHF), occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body. The terms congestive heart failure (CHF) or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure. Signs and symptoms commonly include shortness of breath, excessive tiredness, and leg swelling. The shortness of breath is usually worse with exercise, when lying down, and at night while sleeping. There is often a limitation on the amount of exercise people can perform, even when well treated.
Heart failure symptoms are traditionally and somewhat arbitrarily divided into "left" and "right" sided, recognizing that the left and right ventricles of the heart supply different portions of the circulation. However, heart failure is not exclusively backward failure (in the part of the circulation which drains to the ventricle).
There are several other exceptions to a simple left-right division of heart failure symptoms. Additionally, the most common cause of right-sided heart failure is left-sided heart failure. The result is that patients commonly present with both sets of signs and symptoms.
Nursing Diagnosis :
1. Impaired Gas Exchange related to changes in the alveolar capillary membrane.
characterized by; dyspnea, orthopneu.
Goal: more effective gas exchange, the results; analysis of blood gases within normal limits and the patient was free from respiratory distress.
Interventions :
Nursing Diagnosis :
Activity Intolerance related to imbalance between oxygen supply / needs, weaknesses.
characterized by; The patient said wearily continuously throughout the day, shortness of breath on exertion, changes in vital signs during activity.
Goal: Activity achieve optimal limit, as indicated by the patient participating in a desired activity and is able to meet the needs of their own care.
Interventions :
Source :
http://nandacareplan.blogspot.com/2014/11/heart-failure-5-nursing-diagnosis-and.html
Heart failure or chronic heart failure (CHF), occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body. The terms congestive heart failure (CHF) or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure. Signs and symptoms commonly include shortness of breath, excessive tiredness, and leg swelling. The shortness of breath is usually worse with exercise, when lying down, and at night while sleeping. There is often a limitation on the amount of exercise people can perform, even when well treated.
There are several other exceptions to a simple left-right division of heart failure symptoms. Additionally, the most common cause of right-sided heart failure is left-sided heart failure. The result is that patients commonly present with both sets of signs and symptoms.
Nursing Diagnosis :
1. Impaired Gas Exchange related to changes in the alveolar capillary membrane.
characterized by; dyspnea, orthopneu.
Goal: more effective gas exchange, the results; analysis of blood gases within normal limits and the patient was free from respiratory distress.
Interventions :
- Auscultation of breath sounds, crackles, wheezing.
- Instruct the patient to cough effectively and breathe deeply.
- Keep sitting or bed rest with semifowler position.
- Collaboration to monitor blood gas analysis and pulse oximetry.
- Collaboration for the provision of supplemental oxygen as indicated.
- Collaboration for diuretics and bronchodilators.
- Monitor the presence of pulmonary congestion for further intervention.
- Cleaning airway and facilitate the flow of oxygen.
- Lowers oxygen consumption and maximize lung development.
- Can be severe hypoxemia during pulmonary edema.
- Increasing alveolar oxygen concentration to improve tissue hypoxemia.
- Diuretics can reduce congestion and improve the alveolar gas exchange. Broncodilator for airway dilatation.
Nursing Diagnosis :
Activity Intolerance related to imbalance between oxygen supply / needs, weaknesses.
characterized by; The patient said wearily continuously throughout the day, shortness of breath on exertion, changes in vital signs during activity.
Goal: Activity achieve optimal limit, as indicated by the patient participating in a desired activity and is able to meet the needs of their own care.
Interventions :
- Check vital signs before and after the activity.
- Note the cardiopulmonary response to activity, tachycardia, dysrhythmias, dyspnea, sweating, pale.
- Provide assistance in self-care activities as indicated. Interspersed periods of activity with periods of rest.
- Collaboration to implement a cardiac rehabilitation program.
- Orthostatic hypotension can occur with activity due to the effects of the drug, fluid shifts, influence heart function.
- The inability of the myocardium, increasing stroke volume during exercise, can increase heart rate, oxygen consumption and increased fatigue.
- Self care needs without affecting the stress myocardial / excessive oxygen demand.
- Gradual increase in the activity of the heart and avoid excessive oxygen consumption.
Source :
http://nandacareplan.blogspot.com/2014/11/heart-failure-5-nursing-diagnosis-and.html
