Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Nursing Intervention for CHF

Congestive heart failure (CHF) is a chronic condition that affects the chambers of the heart. There are four heart chambers: two atria in the upper half of the heart and two ventricles in the lower half.

Symptoms of congestive heart failure include:
  • new or worsening shortness of breath (particularly during physical activity or waking you up at night)
  • weight gain
  • muscular fatigue, tiredness
  • swelling of ankles or legs
  • swelling of abdomen
  • dizziness
  • heart palpitations
  • chest pain or discomfort in parts of the upper body
  • unexplained coughing and wheezing
  • loss of appetite
  • constipation.

Nursing Diagnosis and Nursing Intervention for CHF
  1. Decrease cardiac output related to myocardial infarction

    NOC:

    1. Having a heart pump effectively,
    2. Status of the circulation, tissue perfusion & vital signs normal status.

    Criteria for outcome:
    1. Cardiac output is adequate, as indicated by blood pressure, pulse, normal rhythm, strong peripheral pulse, perform the activity without dipsnea and pain.
    2. Free from side effects of drugs used.

    Plan of action:
    • Cardiac care: acute
    • Evaluation of chest pain
    • Auscultation of heart sounds
    • Evaluation of crackels
    • Monitor the status of neurology
    • Monitor intake / output, urine output
    • Create an environment that is conducive to rest

    Circulatory Care:
    • Evaluation of pulse and peripheral edema
    • Monitor skin and extremities
    • Monitor vital signs
    • Move the position of the client every 2 hours if necessary
    • Teach ROM during bedrest
    • Monitor compliance with liquid

    Rational:
    • The presence of pain indicates ineffective blood supply to the heart
    • Still the rhythm Gallop, crackels, tachycardia indicates heart failure
    • Disturbance in the central nervous system may be associated with decreased cardiac output
    • Output urine less than 30 ml / h showed decreased cardiac output
    • The emergence of signs of heart failure showed decreased cardiac output
  2. Activity intolerance related to imbalance between supply and demand of oxygen

    NOC:
      Perform daily activities

    Outcome:
    • Participating in physical activity with blood pressure, respiratory rate appropriate
    • Normal skin color, warm and dry
    • Verbalizing the importance of activity gradually
    • Expressing understanding of the importance of balancing exercise and rest
    • Improved activity tolerance

    Plan of action:
    • Determining the cause of activity intolerance and determine whether the cause of physical, psychological / motivational
    • Assess suitability and activities of daily recess
    • Increase activity gradually, let it participate in the change of position, movement and personal care
    • Make sure the client to change position gradually. Monitor symptoms of activity intolerance
    • When helping clients stand, observation intolerance symptoms such as nausea, pale, headache, impaired consciousness and vital signs
    • Perform ROM exercises if the client is unable to tolerate activity
    • Determining the cause can help determine intolerance

    Rational :

    • Prolonged bedrest can contribute to activity intolerance
    • Increased activity helps maintain muscle strength, tone
    • Inactivity contributes to muscle strength and joint structure

Share :

Facebook Twitter Google+

Nursing Diagnosis - Nursing Interventions

NANDA NURSING

Powered by Blogger.
Back To Top