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
- Decrease cardiac output related to myocardial infarction
NOC:
- Having a heart pump effectively,
- Status of the circulation, tissue perfusion & vital signs normal status.
Criteria for outcome:
- Cardiac output is adequate, as indicated by blood pressure, pulse, normal rhythm, strong peripheral pulse, perform the activity without dipsnea and pain.
- 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
- 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
