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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,
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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.


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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


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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


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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.


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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


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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


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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


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


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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


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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


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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


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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


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.


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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


14/20



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


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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


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


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.


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.


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


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


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.


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


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.


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


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.


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


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.

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