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Problem: anxiety
Nursing Diagnosis: anxiety r/t breathlessness and restlessness secondary to inadequate oxygenation tertiary to Congestive heart failure
Taxonomy: Self-Perception – Self-concept Pattern
Cause analysis: The result from impaired oxygenation of tissues, the stress associated with respiratory difficulty and the knowledge that the heart is
not functioning properly. ( medical surgical nursing 6th edition by: Brunner/Suddarth page. 582
OBJECTIVE: Assess for other precipitators/causes of fatigue, e.g., treatments, Fatigue is a side effect of some medications (e.g., beta-
pain, medications. blockers, tranquilizers, and sedatives). Pain and stressful
regimens also extract energy and produce fatigue.
-confined in
bed Evaluate accelerating activity intolerance. May denote increasing cardiac decompensation rather than
-tachypneic overactivity.
(RR-25-36) Provide assistance with self-care activities as indicated. Meets patient’s personal care needs without undue
-bradycardic Intersperse activity periods with rest periods. myocardial stress/excessive oxygen demand.
(PR-40-50bpm)
Collaborative
IMPLEMENT GRADED CARDIAC REHABILITATION/ACTIVITY
PROGRAM. Strengthens and improves cardiac function under stress, if
cardiac dysfunction is not irreversible. Gradual increase in
activity avoids excessive myocardial workload and oxygen
consumption.
Problem: Edema
Nursing Diagnosis: Fluid Volume excess r/ t compromised cardiac functioning seconadry to CHF
Taxonomy: Nutrition-Metabolic pattern
Cause analysis: Ind. With cardiac problems frequently have difficulty with fluid balance. The greater the fluid volume, the greater the stress and
cardiac workload. Compromised cardiac functioning causes fluids to accumulate in various body tissues. These fluid overload stresses the circulatory
system and increases the workload of the heart. ( Mediacal and Health Encyclopedia page 242).
Change position frequently. Elevate feet when sitting. Inspect Edema formation, slowed circulation, altered nutritional
skin surface, keep dry, and provide padding as indicated. (Refer intake, and prolonged immobility/bedrest are cumulative
to ND: Skin Integrity, risk for impaired.) stressors that affect skin integrity and require close
supervision/preventive interventions.
Auscultate breath sounds, noting decreased and/or adventitious Excess fluid volume often leads to pulmonary congestion.
sounds, e.g., crackles, wheezes. Note presence of increased Symptoms of pulmonary edema may reflect acute left-
dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, sided HF. RHF’s respiratory symptoms (dyspnea, cough,
persistent cough. orthopnea) may have slower onset but are more difficult to
reverse.
Investigate reports of sudden extreme dyspnea/air hunger, need May indicate development of complications (pulmonary
to sit straight up, sensation of suffocation, feelings of panic or edema/embolus) and differs from orthopnea paroxysmal
impending doom. nocturnal dyspnea in that it develops much more rapidly
and requires immediate intervention.
Assess bowel sounds. Note complaints of anorexia, nausea, Visceral congestion (occurring in progressive HF) can alter
abdominal distension, constipation. gastric/intestinal function.
Provide small, frequent, easily digestible meals. Reduced gastric motility can adversely affect digestion and
absorption. Small, frequent meals may enhance
digestion/prevent abdominal discomfort.
Measure abdominal girth, as indicated. In progressive RHF, fluid may shift into the peritoneal
space, causing increasing abdominal girth (ascites).
Palpate abdomen. Note reports of right upper quadrant Advancing HF leads to venous congestion, resulting in
pain/tenderness. abdominal distension, liver engorgement (hepatomegaly),
and pain. This can alter liver function and impair/prolong
drug metabolism.
Collaborative:
Administer medications as indicated:
Diuretics, e.g., furosemide (Lasix), bumetanide (Bumex) Increases rate of urine flow and may inhibit reabsorption of
sodium/chloride in the renal tubules.
Thiazides with potassium-sparing agents, e.g.,
spironolactone (Aldactone) Promotes diuresis without excessive potassium losses.
Maintain fluid/sodium restrictions as indicated. Reduces total body water/prevents fluid reaccumulation.
Consult with dietitian. May be necessary to provide diet acceptable to patient that
meets caloric needs within sodium restriction.