Assessment

Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:

Objective:

o PR = 116
o BP =
200/150
o weak
peripheral
pulses
o Crackles
upon
auscultation
o Urine
Output =
450cc/day





Decreased
Cardiac Output
related to
Altered
myocardial
contractility
After 1 hour
of nursing
interventions,
the patient
will be able to
demonstrate
vital signs
within
acceptable
limits,
dysrhythmias
absent/contro
lled, and no
symptoms of
failure after 1
day
1. assess heart
rate

2. Palpate
peripheral
pulses.


3. Monitor BP

4. Inspect skin for
pallor


5. Monitor urine
output

6. Encourage rest,
semi recumbent
in bed or chair.
Assist with
physical care as
indicated.


7. Administer
medications as
indicated:
1. Tachycardia is usually present (even at
rest) to compensate for decreased
ventricular contractility.

2. Decreased cardiac output may be
reflected in diminished radial, popliteal,
dorsalis pedis, and posttibial pulses.

3. In early, moderate, or chronic HF, BP may
be elevated because of increased SVR.


4. Pallor is indicative of diminished
peripheral perfusion secondary to
inadequate cardiac output,
vasoconstriction, and anemia.

5. Kidneys respond to reduced cardiac
output by retaining water and sodium.

6. Physical rest should be maintained to
improve efficiency of cardiac contraction
and to decrease myocardial oxygen
demand/ consumption and workload.


7. A variety of medications may be used to
increase stroke volume, improve
contractility, and reduce congestion.
After 1 hour of nursing
interventions, the
patient demonstrated
vital signs within
acceptable limits,
dysrhythmias
absent/controlled, and
no symptoms of failure
after 1 day.


8. Diuretics-
furosemide
(Lasix)

9. ACE inhibitors-
captopril
(Capoten)


10. Digoxin
(Lanoxin)


11. Administer IV
solutions,
restricting total
amount as
indicated. Avoid
saline solutions.

12. Monitor/ replace
electrolytes.




8. Enhances excretion of sodium,
chloride,potassium by direct action at
ascending Limb of loop of Henle.

9. ACE inhibitors represent first-line therapy
to control heart failure by decreasing
venticular filling pressures and SVR while
increasing cardiac output with little or no
change in BP and heart rate.


10. Increases force of myocardial contraction
when diminished contractility is the cause
of HF, and slows heart rate by decreasing
conduction velocity and prolonging
refractory period of the atrioventricular
(AV) junction to increase cardiac
efficiency /output.

11. Because of existing elevated left
ventricular pressure, patient may not
tolerate increased fluid volume (preload).
Patients with HF also excrete less
sodium, which causes fluid retention and
increases myocardial workload.

12. Fluid shifts and use of diuretics can alter
electrolytes (especially potassium and
chloride), which affect cardiac rhythm and
contractility.



Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation

Subjective:

Objective:

Patient
manifested:
Edema on
extremities

Crackles,
heard on both
lung fields

RR = 30bpm
BP = 200/150
PR = 116
Weight =63kg
Urine
output=380cc
/day
Edema=
grade +1
(1mm slightly
pitting,
disappears
rapidly)










Excessive
Fluid volume r/t
sodium and
water retention






























After 1 hour of nursing
interventions, the
patient will
demonstrate adequate
fluid balance as
manifested by clearing
breath sounds, and
decreasing edema
after 1 day
1. Establish rapport


2. Monitor and record VS

3. Assess patients
general condition


4. Weigh patient daily and
compare to previous
weights.


5. Follow low-sodium diet
and/or fluid restriction


6. Assess the need for an
indwelling urinary
catheter.


7. Institute/instruct patient
regarding fluid
restrictions as
appropriate.

8. Administer diuretics as
prescribed


1. To gain patients trust and
cooperation

2. To obtain baseline data

3. To determine what approach
to use in treatment


4. Body weight is a sensitive
indicator of fluid balance and
an increase indicates fluid
volume excess.

5. May include increased fluids
or sodium intake, or
compromised regulatory
mechanisms.

6. Treatment focuses on
diuresis of excess fluid.


7. This helps reduce
extracellular volume.



8. Enhances excretion of
sodium, chloride, potassium
by direct action at
ascendinglimb of loop of
Henle. Therapeutic
Effect:Produces diuresis,
lowers B/P.


Patient has
demonstrated
adequate fluid
balance: clearing
breath sounds and
decreasing edema
after 1 day


Assessment
Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:

Objective:

Patient manifested:
presence of
crackles
upon
auscultation

RR= 30 bpm

Pallor



Impaired gas
exchange
related to
accumulation of
fluid in the
alveoli
After 30 minutes of
nursing
interventions, the
patient will be able to
demonstrate
improvement in gas
exchange as
manifested by
decrease in
respiratory rate to
normal.
1. Monitor respiratory rate


2. Elevate head of bed and
encourage frequent position
changes.



3. Promote adequate rest
periods




4. Change position q 2 hrs.


5. Administer oxygen therapy as
ordered.

1. To obtain baseline
data

2. To promote maximal
inspiration, enhance
expectoration of
secretions in order to
improve ventilation

3. Rest will prevent
weakness and
decrease oxygen
demands for
metabolic demands

4. To promote drainage
of secretions


5. O2 therapy is
indicated to increase
oxygen saturation
The patient has been
able to demonstrate
improvement in gas
exchange a decrease in
respiratory rate to normal