Upload
jazzmin-angel-comaling
View
228
Download
0
Embed Size (px)
Citation preview
8/13/2019 Dec. Card. Output
1/20
HomeNursing Care Plans 10 Congestive Heart Failure Nursing Care Plans
10 Congestive Heart Failure Nursing Care Plans
By:Matt Vera inNursing Care Plans July 14, 2013 Updated: September 22nd, 20132 Comments 12,664 Views
Definition & PathophysiologyContents [hide]
1 Definition & Pathophysiology 2 Nursing Care Plans
o 2.1 Decreased Cardiac Outputo 2.2 Excess Fluid Volumeo 2.3 Acute Paino 2.4 Ineffective Tissue Perfusiono 2.5 Hyperthermiao 2.6 Ineffective Breathing Patterno 2.7 Activity Intoleranceo 2.8 Ineffective Airway Clearanceo 2.9 Impaired Gas Exchangeo 2.10 Fatigue
3 More CHF Nursing Care PlansHeart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which he heartcannot pump enough blood to meet the metabolic needs of the body. Heart failure results from
changes in systolic or diastolic function of the left ventricle. The heart fails when, because of
intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease,cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself; instead,
the term refers to a clinical syndrome characterized by manifestations of volume overload,
http://nurseslabs.com/http://nurseslabs.com/http://nurseslabs.com/category/nursing-care-plans/http://nurseslabs.com/category/nursing-care-plans/http://nurseslabs.com/category/nursing-care-plans/http://nurseslabs.com/author/admin/http://nurseslabs.com/category/nursing-care-plans/http://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#commentshttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/http://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Definition_Pathophysiologyhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Nursing_Care_Planshttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Decreased_Cardiac_Outputhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Excess_Fluid_Volumehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Acute_Painhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Ineffective_Tissue_Perfusionhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Hyperthermiahttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Ineffective_Breathing_Patternhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Activity_Intolerancehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Ineffective_Airway_Clearancehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Impaired_Gas_Exchangehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Fatiguehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#More_CHF_Nursing_Care_Planshttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#More_CHF_Nursing_Care_Planshttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Fatiguehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Impaired_Gas_Exchangehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Ineffective_Airway_Clearancehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Activity_Intolerancehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Ineffective_Breathing_Patternhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Hyperthermiahttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Ineffective_Tissue_Perfusionhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Acute_Painhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Excess_Fluid_Volumehttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Decreased_Cardiac_Outputhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Nursing_Care_Planshttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#Definition_Pathophysiologyhttp://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/http://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/#commentshttp://nurseslabs.com/category/nursing-care-plans/http://nurseslabs.com/author/admin/http://nurseslabs.com/category/nursing-care-plans/http://nurseslabs.com/8/13/2019 Dec. Card. Output
2/20
inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure
results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.
Because heart failure causes vascular congestion, it is often called congestive heart failure,although most cardiac specialist no longer use this term. Other terms used to denote heart failure
include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular
failure.Nursing Care PlansHere are 10 nursing care plans for patients with Congestive Heart Failure.
Decreased Cardiac OutputThe heat fails to pump enough blood to meet the metabolic needs of the body. The blood flowthat supplies the heart is also decreased thus decrease in cardiac output occurs, blood then is
insufficient and making it difficult to circulate the blood to all parts of the body thus may cause
altered heart rate and rhythm, weakness and paleness
NDx: Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia
Assessment Planning Nursing
Interventions
Rationale Evaluation
Subjective:
(none)Objectives:Thepatient manifested the
following:
with paleconjunctiva, nail
beds and buccal
mucosa
irregular rhythm ofpulse
bradycardic pulse rate of 34
beats/min
generalizedweakness
Short Term:After
3-4 hours ofnursing
interventions, thepatient will
participate in
activities thatreduce the
workload of theheart.Long
Term:After 2-3
days of nursinginterventions, the
patient will be able
to displayhemodynamic
stability.
1. Assess forabnormal heartand lung
sounds.
2. Monitor bloodpressure and
pulse.
3. Assess mentalstatus and level
of
consciousness.4. Assess patients
skin temperature
and peripheral
pulses.
5. Monitor resultsof laboratoryand diagnostic
tests.
6. Monitor oxygensaturation and
ABGs.
7. Give oxygen asindicated by
patient
symptoms,
oxygen
saturation and
ABGs.
8. Implement
1. Allowsdetection ofleft-sided heart
failure that mayoccur with
chronic renal
failure patientsdue to fluid
volume excessas the diseased
kidneys are
unable toexcrete water.
2. Patients withrenal failure aremost often
hypertensive,
which is
attributable to
excess fluid andthe initiation of
the rennin-
angiotensin
mechanism.3. The
accumulation ofwaste products
in the
bloodstreamimpairs oxygen
transport and
Short Term:After
nursinginterventions, the
patient shall haveparticipated in
activities that
reduce theworkload of the
heart.LongTerm:After 2-3
days of nursing
interventions, thepatient shall have
been able to display
hemodynamicstability.
8/13/2019 Dec. Card. Output
3/20
strategies totreat fluid and
electrolyte
imbalances.
9. Administercardiacglycoside
agents, as
ordered, forsigns of left
sided failure,
and monitor for
toxicity.
10. Encourageperiods of restand assist with
all activities.
11.Assist thepatient in
assuming a high
Fowlers
position.
12. Teach patientthepathophysiology
of disease,
medications
13. Repositionpatient every 2
hours14. Instruct patient
to get adequate
bed rest andsleep
15. Instruct the SOnot to leave the
client
unattended
intake bycerebral tissues,
which may
manifest itself
as confusion,
lethargy, andaltered
consciousness.
4. Decreasedperfusion and
oxygenation of
tissues
secondary to
anemia andpump
ineffectiveness
may lead to
decreased in
temperature andperipheral
pulses that are
diminished anddifficult to
palpate.
5. Results of thetest provide
clues to the
status of thedisease and
response to
treatments.6. Provides
information
regarding the
hearts ability to
perfuse distaltissues with
oxygenated
blood
7. Makes moreoxygen
available for gas
exchange,assisting to
alleviate signsof hypoxia and
subsequent
activity
intolerance.
8. Decreases the
8/13/2019 Dec. Card. Output
4/20
risk fordevelopment of
cardiac output
due to
imbalances.
9. Digitalis has apositiveisotropic effect
on themyocardium
that strengthens
contractility,
thus improving
cardiac output.
10. Reduces cardiacworkload and
minimizesmyocardial
oxygen
consumption.
11. Allows forbetter chest
expansion,
thereby
improving
pulmonary
capacity.
12. Provides thepatient withneeded
information for
management ofdisease and for
compliance.
13. To preventoccurrence of
bed sores
14. To promoterelaxation to the
body
15. To ensure safetyand reduce riskfor falls that
may lead toinjury
Excess Fluid VolumeWhen blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and
rennin is released into the bloodstream. Renin interacts with angiotensinogen to produce
angiotensin I. When angiotensin I contacts ACE, it is converted to angiotensin II, a potent
8/13/2019 Dec. Card. Output
5/20
vasoconstrictor. Angiotensin II increases arterial vasoconstriction, promote release of
norepinephrine from sympathetic nerve endings, and stimulates the adrenal medulla to secrete
aldosterone, which enhances sodium and water absorption. Stimulation of the rennin-angiotensinsystem causes plasma volume to expand and preload to increase.
NDx: Excessive Fluid volume r/t decreased cardiac output and sodium and water retention AEB
crackles on both lung field and edema on extremities secondary to CHF and IHDAssessment Planning Interventions Rationale Evaluation
Subjective:(none)Objective:Patient
manifested:
Edema on extremities DOB Crackles heard on both lung
fields
Patient may manifest:
Change in mental status(lethargy or confusion)
Restlessness and anxiety
Short
Term:After 3-4
hours ofinterventions,
the patient will
verbalize
understanding of
causative factorsand demonstrate
behaviors toresolve excess
fluid
volume.Long
Term:After 3-4
days of nursing
interventions,the patient will
demonstrate
adequate fluid
balanced AEB
output equal to
exceeding
intake, clearingbreath sounds,and decreasing
edema.
1. Establish rapport2. Monitor and
record VS
3. Assess patientsgeneral condition
4. Monitor I&Oevery 4 hours
5. Weigh patientdaily andcompare to
previousweights.
6. Auscultatebreath sounds q
2hr and pm for
the presence of
crackles and
monitor for
frothy sputum
production
7. Assess forpresence ofperipheraledema. Do not
elevate legs ifthe client is
dyspneic.
8. Follow low-sodium diet
and/or fluid
restriction
9. Encourage orprovide oral careq2
10. Obtain patienthistory to
ascertain the
probable causeof the fluid
disturbance.
1. To gainpatients
trust andcooperation
2. To obtainbaseline data
3. To determinewhat
approach to
use intreatment
4. I&O balancereflects fluidstatus
5. Body weightis a sensitive
indicator of
fluid balance
and anincrease
indicates
fluid volumeexcess.
6. Whenincreased
pulmonary
capillaryhydrostatic
pressure
exceedsoncotic
pressure,
fluid moves
within thealveolarseptum and
is evidenced
by the
auscultation
of crackles.Frothy, pink-
Short Term:Pt
shall have
verbalizedunderstanding of
causative factors
and demonstrate
behaviors to
resolve excessfluid
volume.LongTerm:Pt shall
have
demonstrated
adequate fluid
balance AEB
output equal toexceeding
intake, clearing
breath sounds
and decreasing
edema.
8/13/2019 Dec. Card. Output
6/20
11. Monitor fordistended neck
veins and ascites
12. Evaluate urineoutput in
response todiuretic therapy.
13. Assess the needfor an indwelling
urinary catheter.
14. Institute/instructpatient regarding
fluid restrictions
as appropriate.
tingedsputum is an
indicator that
the client is
developing
pulmonaryedema
7. Decreasedsystemicblood
pressure to
stimulation
of
aldosterone,which causes
increased
renal tubular
absorption of
sodium Low-sodium diet
helps prevent
increasedsodium
retention,
whichdecreases
waterretention.
Fluid
restrictionmay be used
to decreasefluid intake,
hence
decreasingfluid volume
excess.
8. The clientsenses thirst
because the
body senses
dehydration.
Oral care can
alleviate thesensation
without an
increase in
fluid intake.
9. Heart failurecauses
venous
8/13/2019 Dec. Card. Output
7/20
congestion,resulting in
increased
capillary
pressure.
Whenhydrostatis
pressure
exceeds
interstitial
pressure,
fluids leak
out of ht
ecpaillaries
and present
as edema in
the legs, and
sacrum.
Elevation oflegs
increases
venous
return to the
heart.
10. May includeincreased
fluids orsodium
intake, or
compromised regulatory
mechanisms.
11. Inidicatesfluid
overload
12. Focus is onmonitoring
the response
to thediuretics,
rather than
the actual
amount
voided
13. Treatmentfocuses on
diuresis of
excess fluid.
14. This helpsreduce
8/13/2019 Dec. Card. Output
8/20
extracellularvolume.
Acute PainIn ischemic heart disease, atherosclerosis develops in the coronary arteries, causing them to
become narrowed or blocked. When a coronary artery is blocked, blood flow to the area of theheart supplied by that artery is reduced. If the remaining blood flow is inadequate to meet the
oxygen demands of the heart, the area may become ischemic and injured and myocardialinfarction may result. Neural pain receptors are stimulated by local mechanical stress resulting
from abnormal myocardial contraction.
Assessment Planning Interventions Rationale E
Subjective:PainObjective:Patient
manifested:
(+) DOB with a rate of 7 out of 10 with complaints of chest pain
unprovoked
Patient may manifest:
Restlessness
Short Term:After
3-4 hours ofnursing
interventions, the
patients pain willdecrease from 7 to
3 as verbalized by
the patient.Long
Term:After 2-3
days of nursinginterventions, the
patient will
demonstrateactivities and
behaviors that willprevent the
recurrence of pain.
1. Assess patientpain for intensityusing a pain
rating scale, for
location and forprecipitating
factors.
2. Administer orassist with self-
administration
of vasodilators,as ordered.
3. Assess theresponse to
medications
every 5 minutes
4. Provide comfortmeasures.5. Establish a quiet
environment.
6. Elevate head ofbed.
7. Monitor vitalsigns, especially
pulse and bloodpressure, every 5
minutes untilpain subsides.
8. Teach patientrelaxation
techniques and
how to use them
to reduce stress.
9. Teach thepatient how to
distinguish
1. To identifyintensity,precipitating factors
and location to
assist in accuratediagnosis.
2. The vasodilatornitroglycerinenhances blood
flow to the
myocardium. Itreduces the amount
of blood returning
to the heart,decreasing preload
which in turndecreases the
workload of theheart.
3. Assessing responsedetermines
effectiveness of
medication and
whether further
interventions are
required.
4. To providenonpharmacological pain management.
5. A quietenvironment
reduces the energy
demands on the
patient.
6. Elevation improveschest expansion and
Short
shall verba
decre
from 3.Lon
patien
demo
activi
behavpreve
recurr
8/13/2019 Dec. Card. Output
9/20
between anginapain and signs
and symptoms
of myocardial
infarction.
oxygenation.
7. Tachycardia andelevated blood
pressure usually
occur with angina
and reflectcompensatory
mechanisms
secondary tosympathetic
nervous system
stimulation.
8. Anginal pain isoften precipitated
by emotional stressthat can be relieved
non-pharmacological
measures such as
relaxation.
9. In some case, the chest pain may
be more serious
than stable angina.
The patient needs to
understand the
differences in order
to seek emergency
care in a timely
fashion.
Ineffective Tissue PerfusionDue to decreased cardiac output, there is decreased preload and stroke volume thus there is
decreased blood pumped out from the blood. Decrease in stroke volume decreases perfusion
throughout the body.NDx: Ineffective tissue perfusion r/t decreased cardiac output.
Assessment Planning Interventions Rationale Evalu
Subjective:Objective:Patientmanifested:
with pale conjunctiva, nailbeds and buccal mucosa
(+)chest pain (+) DOB Generalized weakness Abnormal pulse rate and
rhythm
Short Term:After 6hours of nursing
interventions thepatient will
demonstrate
behaviors toimprove
circulation.Long
Term:After 3-4 daysof nursing
interventions the
1. Assess patientpain for intensity
using a painrating scale, for
location and for
precipitatingfactors.
2. Administer orassist with self
administration of
vasodilators, as
1. To identifyintensity,
precipitatingfactors and
location to assist
in accuratediagnosis.
2. The vasodilatornitroglycerin
enhances blood
flow to the
Short Termpatient sha
demonstrabehaviors
improve
circulationTerm:The
shall have
demonstraincreased p
as individu
8/13/2019 Dec. Card. Output
10/20
Bradycardic Altered BP readings. With pitting edema on both
forearms and hands
Bipedal pitting edema
patient willdemonstrate
increased perfusion
as individually
appropriate.
ordered.
3. Assess theresponse to
medications
every 5 minutes.
4. Give betablockers asordered.
5. Establish a quietenvironment.
6. Elevate head ofbed.
7. Monitor vitalsigns, especiallypulse and blood
pressure, every 5
minutes untilpain subsides.
8. Provide oxygenand monitor
oxygen
saturation via
pulse oximetry,
as ordered.
9. Assess results ofcardiacmarkers
creatinine
phosphokinase,
CK- MB, totalLDH, LDH-1,LDH-2, troponin,
and myoglobin
ordered byphysician.
10. Assess cardiacand circulatory
status.
11. Monitor cardiacrhythms onpatient monitor
and results of 12lead ECG.
12. Teach patientrelaxation
techniques and
how to use them
to reduce stress.
13. Teach the patient
myocardium. Itreduces the
amount of blood
returning to the
heart, decreasing
preload which inturn decreases
the workload of
the heart.
3. Assessingresponse
determines
effectiveness of
medication andwhether further
interventions are
required.
4. Beta blockersdecrease oxygen
consumption bythe myocardium
and are given to
preventsubsequent
angina episodes.
5. A quietenvironment
reduces the
energy demands
on the patient.
6. Elevationimproves chestexpansion and
oxygenation.
7. Tachycardia andelevated blood
pressure usually
occur with
angina and
reflect
compensatory
mechanisms
secondary tosympathetic
nervous system
stimulation.
8. Oxygenationincreases the
amount ofoxygen
appropriat
8/13/2019 Dec. Card. Output
11/20
how todistinguish
between angina
pain and signs
and symptoms of
myocardialinfarction.
14. Reposition thepatient every 2hours
15. Instruct patienton eating a small
frequent feedings
circulating in theblood and,
therefore,
increases the
amount of
available oxygento the
myocardium,
decreasing
myocardial
ischemia and
pain.
9. These enzymeselevate in thepresence of
myocardial
infarction at
differing times
and assist inruling out a
myocardial
infarction as thecause of chest
pain.
10. Assessmentestablishes a
baseline and
detects changesthat may indicate
a change in
cardiac output orperfusion.
11.Notes abnormaltracings that
would indicate
ischemia.
12. Anginal pain isoften precipitated
by emotional
stress that can berelieved non-
pharmacological
measures such asrelaxation.
13. In some case, the chest pain
may be more
serious than
stable angina.
The patient needs
8/13/2019 Dec. Card. Output
12/20
to understand thedifferences in
order to seek
emergency care
in a timely
fashion.14. To prevent bed
sores
15. To preventheartburn and
acid indigestion
HyperthermiaPresence of microorganisms stimulates the release of pyrogen from the leukocytes resetting the
bodys thermostat to febrile level and then there would be activation of the hypothalamus, which
will result in increase in epinephrine and norepinephrine, vasoconstriction of cutaneous vessels.
The heat will be produced as peripheral vasodilation results in skin flushing and skin is warm to
touch.NDx: Hyperthermia RT increased metabolic rate secondary to pneumonia
Assessment Planning Interventions Rationale Evaluation
Subjective:(none)Objective:Patient
manifested:
Pale palpebral Conjunctiva and nail beds Warm to touch Weakness
Temperature of 38.9
o
CPatient may manifest:
Fluid or electrolyte imbalance Diaphoresis Hot flushed skin
Short
Term:After 3-4 hours of
nursing
interventionsthe patient will
havedemonstrate
bodytemperaturefrom 38.9C
to37.5CLong
Term:After 3
days of nursing
interventions
the patient will
have maintain a
coretemperature
that is within
the normalrange.
1. Assess vitalsigns, thetemperature.
2. Monitor andrecord all
sources of
fluid loss such
as urine,
vomiting and
diarrhea.
3. Performedtepid sponge
bath.
4. Maintain bedrest.
5. Removeexcess
clothing and
covers.
6. Increase fluidintake.
7. Provideadequate
nutrition, a
high caloric
diet.
8. Control
1. Vital signsprovide moreaccurate
indication.
2. For potentialfluid and
electrolyte
losses.
3. To promoteheat loss by
evaporationand
conduction.
4. To reducemetabolic
demands and
oxygen
consumption.
5. Decreaseswarmth andincrease
evaporative
cooling.
6. To preventdehydration.
7. The meet themetabolic
Short Term:The
patient shallhave
demonstrated
bodytemperature
from 38.9Cto37.5CLong
Term:Thepatient shallhave
maintained a
core
temperature that
is within the
normal range.
8/13/2019 Dec. Card. Output
13/20
environmentaltemperature.
9. Adjust coolingmeasures on
the basis of
physicalresponse.
10. Provideinformation
regardingnormal
temperature
and control.
11. Explain alltreatments.
12. Administerantipyretics as
ordered.
13. Controlexcessive
shivering with
medications
such as
Chlorpromazi
ne andDiazepam if
necessary.
14. Provide amplefluids by
mouth orintravenously
as ordered.
15. Provideoxygentherapy in
extreme cases
as ordered.
demands.
8. To prevent anincrease in
body
temperature
and preventshivering of
the patient.
9. Shivering,which burnscalories and
increases
metabolic rate
in order to
produce heat.
10. This isespecially
necessary forpatients with
conditions at
risk for
hyperthermia.
11. Patients S.O.needs to beoriented.
12. To decreasebody
temperature.
13. Shiveringincreasesmetabolic rate
and body
temperature.
14. If the patientis dehydrated
or diaphoretic,
fluid loss
contributes to
fever.
15. Hyperthermiaincreases
metabolism.
Ineffective Breathing PatternIneffective Breathing Pattern occurs when there is presence of spasm and inflammation of thelung tissue and parenchyma , these results in inability of the pt to move air in and out of the
lungs as needed to maintain adequate tissue oxygenation and perfusion.
NDx: Ineffective breathing pattern r/t fatigue and decreased lung expansion and pulmonarycongestion secondary to CHF
8/13/2019 Dec. Card. Output
14/20
Assessment Planning Interventions Rationale Evaluation
Subjective:(none)Objective:Patient
manifested:
weakness rales on BLF productive cough frothy sputumPatient may manifest:
pursed lip breathing tachypnea
Short
Term:After 3- 4
hours of
nursinginterventions,
the patient andpatients SO
will verbalized
understandingof pts
conditionLongTerm:After 3-4
days of nursing
interventions,the pts
respiratory
pattern will beeffective
without causingfatigue
1. establishrapport
2. monitor VS3. inspect
thorax for
symmetry of
respiratorymovement
4. observebreathing
pattern forSOB, nasal
flaring,pursed-lip
breathing or
prolongedexpiratory
phase anduse of
accessory
muscles
5. measuretidal volume
and vital
capacity
6. assessemotional
response7. position
patient in
optimalbody
alignment in
semi-
fowlers
position for
breathing
8. assist patientto use
relaxationtechniques
1. to gain comfortfeelings form
the pt and pts
SO2. to gain
baseline data
3. determinesadequacy of
breathing
4. identifiesincreased workof breathing
5. indicatesvolume of airmoving in and
out of lungs
6. detects use ofhyperventilatio
n as a
causative
factor
7. optimizesdiaphragmaticcontraction
8. reduces muscletension,
decreases work
of breathing
9. facilitates deepbreathing
Short Term:The
patient and
patients SO
shall haveverbalized
understandingof patients
condition]Long
Term:Thepatient s
respiratorypattern shall
have been
effectivewithout causing
fatigue
Activity IntoleranceAs heart failure becomes more severe, the heart is unable to pump the amount of blood requiredto meet all of the bodys needs. To compensate, blood is diverted away from less-crucial areas,
including the arms and legs, to supply the heart and brain. As a result, people with heart failure
8/13/2019 Dec. Card. Output
15/20
often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary
activities such as walking, climbing stairs or carrying groceries
NDx: Activity intolerance r/t imbalance O2 supply and demand AEB limited ROM, generalizedweakness and DOB
Assessment Planning Interventions Rationale Evaluati
Subjective:Objective:Patientmanifested:
generalized weakness limited range of motion as
observed
abnormal pulse rate andrhythm
(+) DOB
Short Term:After3-4 hours of
nursinginterventions, the
patient will use
identifiedtechniques to
improve activity
intoleranceLongTerm:After 2-3
days of nursinginterventions, the
patient will report
measurableincrease in activity
intolerance..
1. Establish Rapport2. Monitor and record
Vital Signs
3. Assess patientsgeneral condition
4. Adjust clientsdaily activities and
reduce intensity oflevel.
Discontinue activities that cause
undesired
psychologicalchanges
5. Instruct client inunfamiliar
activities and in
alternate ways of
conserve energy
6. Encourage patientto have adequate
bed rest and sleep
7.
Provide the patientwith a calm and
quiet environment
8. Assist the client inambulation
9. Note presence offactors that could
contribute to
fatigue
10. Ascertain clientsability to stand and
move about and
degree ofassistance needed
or use of
equipment
11. Give clientinformation that
provides evidenceof daily or weekly
1. To gain clientsparticipation
and cooperationin the nurse
patient
interaction
2. To obtainbaseline data
3. To note for anyabnormalities
and deformities
present withinthe body
4. To preventstrain and
overexertion
5. To conserveenergy and
promote safety
6. to relax thebody
7. to providerelaxation
8. to prevent riskfor falls that
could lead toinjury
9. fatigue affectsboth the clients
actual and
perceived
ability toparticipate in
activities
10. to determinecurrent statusand needs
associated with
participation in
needed ordesired
activities
Short Term:Tpatient shall h
used identifietechniques to
improve activ
intoleranceLoTerm:The pat
shall have rep
measurableincrease in ac
intolerance.
8/13/2019 Dec. Card. Output
16/20
progress
12. Encourage theclient to maintain a
positive attitude
13. Assist the client ina semi-fowlersposition
14. Elevate the head ofthe bed
15. Assist the client inlearning anddemonstrating
appropriate safety
measures
16. Instruct the SO notto leave the client
unattended
17. Provide client witha positive
atmosphere
18. Instruct the SO tomonitor response
of patient to anactivity and
recognize the signs
and symptoms
11. to sustainmotivation of
client
12. to enhancesense of well
being13. to promote easy
breathing
14. to maintain anopen airway
15. to preventinjuries
16. to avoid risk forfalls
17. to helpminimize
frustration andrechannel
energy
18. to indicate needto alter activitylevel
Ineffective Airway Clearance
Mucus is produced at all times by the membranes lining the air passages. When the membranesare irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree.
The inflammation and increased in secretions block the airways making it difficult for the personto maintain a patent airway. In order to expel excessive secretions, cough reflex will be
stimulated. An increased in RR will also be expected as a compensatory mechanism of the body
due to obstructed airways.NDx: Ineffective airway clearance RT retained secretions AEB presence of rales on both lung
fields.
Assessment Planning Interventions Rationale Evaluation
Subjective:Objective:Patient
manifested: with productive cough
yellowish in color
presence of rales uponauscultation
(+) DOB with pale conjunctiva,
nail beds and buccal
Short Term:After
3-4 hours ofnursing
interventions, thepatient will be able
to establish andmaintain airway
patency AEB
absence of signs ofrespiratory
1. Monitor andrecord vitalsigns.
2. Assess patientscondition.
3. Monitorrespirations and
breath sounds,noting rate and
1. To obtainbaseline data
2. To know thepatients
general
condition
3. To determinerespiratorydistress and
Short Term:The
patient shall havebeen able to
establish andmaintain airway
patency AEBabsence of
respiratory
distress.LongTerm:The patient
8/13/2019 Dec. Card. Output
17/20
mucosa distress.LongTerm:After 2-3
days of NI, the
patient will be able
to demonstrate
improve airwayclearance AEB
reduction of
congestion with
breath sounds clear
and improved RR.
sounds.
4. Position headproperly
5. Positionappropriately
and discourageuse of oil-basedproducts around
nose.
6. Auscultatebreath sounds
and assess air
movement.
7. Encourage deepbreathing and
coughingexercises
8. Elevate head ofbed and
encourage
frequent
position
changes.
9. Keep back dryand loosenclothing
10. Observed forsigns and
symptoms of
infection.
11. Instruct patienthave adequate
rest periods and
limit activities
to level of
activity
intolerance.
12. Giveexpectorants
andbronchodilators
as ordered.
13. Suctionsecretions PRN
14. Administeroxygen therapy
and other
medications as
accumulation ofsecretions.
4. To open ormaintain open
airway.
5. To preventvomiting withaspiration into
lungs.
6. To ascertainstatus and note
progress.
7. To maxixmizeeffort
8. To promotemaximal
inspiration,enhance
expectoration
of secretions in
order to
improve
ventilation
9. To promotecomfort andadequate
ventilation
10. To identifyinfectious
process andpromote timelyintervention.
11. Rest willprevent fatigue
and decrease
oxygen
demands for
metabolic
demands
12. To furthermobilize
secretions
13. To clear airwaywhen secretionsare blocking the
airway
14. Indicated toincrease oxygen
shall have beenable to
demonstrate
improve airway
clearance AEB
reduction ofcongestion with
breath sounds
clear and
improved RR.
8/13/2019 Dec. Card. Output
18/20
ordered. saturation.
Impaired Gas ExchangeThe exchange in oxygenation and carbon dioxide gases is impeded due to the obstruction caused
by the accumulation of bronchial secretions in the alveoli. Oxygen cannot diffuse easily.NDx: Impaired gas exchange related to inflammation of airways and accumulation of fluid in the
alveoli
Assessment Planning Interventions Rationale Evaluation
Subjective:Objective:Patient
manifested:
productive coughyellowish in color
presence of rales uponauscultation
(+) DOB Tachypnic AEB RR=
27bpm
with pale conjunctiva,nail beds and buccal
mucosa
fatiguePatient may manifest:
Metabolic acidosis Circum-oral cyanosis
Short Term:After
6 hours of nursing
interventions, thepatient will be
able todemonstrate
improvement in
gas exchange AEBa decrease in
respiratory rate tonormal, and
absence of
pallorLongTerm:After 3-4
days of nursing
interventions, thepatient will be
able todemonstrate
improvedventilation andadequate
oxygenation of
tissues AEB
absence of
symptoms of
respiratory distress
1. Monitor andrecord vital
signs
2. Observe colorof skin,
mucous
membranes andnail beds,
noting presence
of peripheral
cyanosis.
3. Elevate head ofbed and
encouragefrequent
position
changes.
4. Keep back dry.5. Promoteadequate rest
periods
6. Changeposition q 2
hrs.
7. Keepenvironment
allergen free
8. Suctionsecretions PRN
9. Administeroxygen therapyas ordered.
1. To obtainbaseline data
2. Cyanosis of nailbeds may
represent
vasoconstriction
or the bodysresponse to
fever/ chills
3. To promotemaximal
inspiration,enhance
expectoration ofsecretions in
order to improve
ventilation
4. To avoidcoughing
5. Rest will preventfatigue and
decrease oxygen
demands formetabolic
demands
6. To promotedrainage ofsecretions
7. To reduceirritant effects
on airways8. To clear airway
when secretionsare blocking the
airway.
9. O2 therapy isindicated to
increase oxygen
Short Term:The
patient shall have
been able todemonstrate
improvement ingas exchange AEB
a decrease in
respiratory rate tonormalLong
Term:The patientshall have been
able to
demonstrateimproved
ventilation and
adequateoxygenation of
tissues AEBabsence of
symptoms ofrespiratory distres
8/13/2019 Dec. Card. Output
19/20
saturation
FatigueHeart failure is a physiologic state in which the heart cannot pump enough blood to meet the
metabolic demands of the body. Since the patient has inadequate cardiac output, it can lead to
hypoxic tissue and slowed removal of metabolic wastes, which in turn cause the patient to tireeasily.
Assessment Planning Interventions Rationale Evaluation
Subjective:(none)Objective:Patientmanifested:
Generalized weakness (+) DOB Limited range of motion
ShortTerm:After 6
hours of nursing
interventionsthe patient will
identify basis offatigue and
individual areas
of control.LongTerm:After 3-4
days of nursinginterventions,
the patient will
report improvedsense of energy
1. Reviewmedication
regimen.
2. Assess vitalsigns.
3. Determinepresence or
degree ofsleep
disturbances.
4. Obtain clientdescriptions
of fatigue.
5. Ask client torate fatigue.
6. Note dailyenergypatterns.
7. Establishrealistic
activity
goals with
client and
encourage
forward
movement.
8. Planinterventions
to allowindividually
adequate rest
periods.
9. Assist withself-care
needs andambulation.
10. Avoidexposure totemperature
1. Certainmedications
are known to
cause orexacerbate
fatigue.
2. To evaluatefluid statusand
cardiopulmon
ary response
to activity.
3. Fatigue can bea consequence
of sleepdeprivation.
4. To assist inevaluating
impact on
clients life.5. To determine
degree of
fatigability.
6. Helpful indeterminingpattern or
timing of
activity.
7. Enhancescommitment
to promoting
optimaloutcomes.
8. To maximizeparticipation.
9. To conserveenergy for
other tasks.
10. Has negative
Short Term:Thepatient shall
have identified
basis of fatigueand individual
areas ofcontrol.Long
Term:The
patient shallhave reported
improved senseof energy
8/13/2019 Dec. Card. Output
20/20
andhumidity
extremes
11. Instructclient in
ways tomonitor
responses to
activity andsignificant
signs or
symptoms.
12. Promoteoverall
healthmeasures
13. Providesupplemental oxygen, as
indicated.
14. Assist clientto identify
appropriate
copingbehaviors.
impact onenergy level.
11. Indicate theneed to alter
activity level
12. To promoteenergy
13. Presence ofhypoxemia
reduces
oxygen
available for
cellular
uptakes and
contributes to
fatigue.
14. Promote senseof control andimproves self-esteem.
More CHF Nursing Care Plans