Risk for Fluid Volume Excess and Activity Intolerance related to CHF

Nursing Diagnosis and Interventions for Congestive Heart Failure (CHF)

Nursing Diagnosis : Risk for Excess Fluid Volume ; extravascular related to decreased renal perfusion, increased sodium / water retention, increased hydrostatic pressure or a decrease in plasma protein (absorbing fluid in the interstitial area / tissue).

Goal :
Fluid volume balance can be maintained.

Outcomes :
  • Maintaining fluid balance as evidenced by blood pressure within normal limits, no peripheral venous distention / vein and dependent edema, pulmonary clean and ideal weight.

Intervention :
  • Measure input / output, note the decline, expenditure, the nature of concentration, calculate fluid balance.
  • Observation of dependent edema.
  • Measure body weight per day.
  • Maintain fluid intake in cardiovascular tolerance.
  • Collaboration: the low-sodium diet, give diuretics.
  • Assess the JVP after diuretic therapy.
  • Monitor CVP and blood pressure.

Nursing Diagnosis : Activity Intolerance related to imbalance between myocardial oxygen supply and demand, the presence of ischemic / necrotic myocardial tissue.

possibility evidenced by :
  • cardiac frequency interference,
  • occurrence of dysrhythmias and general weakness.

Goal :
There was an increase in the client's activity tolerance after nursing actions implemented.

outcomes :
  • Heart rate ; 60-100 X / min,
  • Blood pressure ; 120/80 mmHg

Intervention :
  • Record the heart rate , rhythm and change in BP during and after activity.
  • Increase rest (in bed).
  • Limit activity on the basis of pain and provide sensory activities that are not heavy.
  • Describe the pattern of a gradual increase in the level of activity, for example ; get up from the chair in the absence of pain, ambulation and rest for 1 hour after eating.

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