Nursing Diagnoses : Heart Failure
- Nursing Diagnoses
- Impaired gas exchange related to increased preload and alveolar-capillary membrane changes
- Decreased cardiac output related to altered contractility, altered preload, and/or altered stroke volume
- Excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to heart failure
- Activity intolerance related to imbalance between O2 supply and demand secondary to cardiac insufficiency and pulmonary congestion
- Nursing planning
- Overall Goals
- Decrease in symptoms
- Decrease in peripheral edema
- Increase in exercise tolerance
- Compliance with the treatment regimen
- No complications related to HF
- Nursing intervention
- Monitor respiratory status
- Administer oxygen therapy
- Semi-Fowler’s position
- Monitor hemodynamic status
- Daily weights
- I and O
- Administer prescribed drugs
- Monitor edema
- Alternate rest with activity
- Provide diversionary activities
- Monitor response to activity
- Collaborate with OT/PT
- Reduce anxiety
- Evaluate support system
- Patient teaching
- Signs and symptoms of HF exacerbations – what to do/report
- Importance of early detection
- Can have positive outlook with chronic health problem if treatment plan is followed
- Drug therapy
- Expected actions
- Signs of drug toxicity
- How to take HR and what to report
- Signs and symptoms of hypokalemia and hyperkalemia
- BP monitoring as needed
- Dietary therapy
- Dietary therapy
- Written plan
- Reading labels for sodium
- No added salt
- Daily weights
- Smaller, more frequent meals
- Activity/rest
- Energy-conserving and energy-efficient behaviors
- Exercise training (cardiac rehab)
- Increase gradually
- Avoid heat and cold extremes
- Rest after exertion
- Avoid emotional upsets
- Ongoing monitoring
- Know FACES
- Reappearance of symptoms
- What to report
- Weight gain of 3 lb (1.4 kg) in 2 days, or 3-5 lb (2.3 kg) in a wk
- Difficulty breathing, especially with activity or when lying lat
- Waking up breathless at night
- Frequent dry, hacking cough, especially when lying down
- Fatigue, weakness
- Swelling of ankles, feet, or abdomen. Swelling of face or difficulty breathing (if taking ACE inhibitors)
- Nausea with abdominal swelling, pain, and tenderness
- Dizziness or fainting
- Regular follow-up
- Support group
- Health promotion
- Vaccinations
- Annual flu vaccination
- Pneumococcal vaccine
- Reduce risk factors
- Ambulatory Care
- Explain to patient and caregiver physiologic changes that have occurred
- Assist patient to adapt to both physiologic and psychologic changes
- Include patient and caregiver(s) in overall care plan
- Nursing evaluation
- Monitoring to assess outcomes and prevent/ limit future hospitalizations
- Vital signs
- Weight
- Pulse oximetry
- Dyspnea
- Home health nurses can be essential
- Can use electronic monitoring