Nursing Diagnosis and Nursing Intervention

Assessment in patients with CHF

Congestive heart failure (CHF) is generally classified as systolic or diastolic heart failure and becomes progressively more common with increasing age.

Systolic heart failure: The pumping action of the heart is reduced or weakened. A common clinical measurement is the ejection fraction (EF). The ejection fraction is a calculation of how much blood is ejected out of the left ventricle (stroke volume), divided by the maximum volume remaining in the left ventricle at the end of diastole or relaxation phase. A normal ejection fraction is greater than 50%. Systolic heart failure has a decreased ejection fraction of less than 50%.

Diastolic heart failure: The heart can contract normally but is stiff, or less compliant, when it is relaxing and filling with blood. This impedes blood filling into the heart and produces backup into the lungs and CHF symptoms. Diastolic heart failure is more common in patients older than 75 years, especially in women with high blood pressure. In diastolic heart failure, the ejection fraction is normal.

Heart failure affects 1% of people aged 50 years, about 5% of those aged 75 years or older, and 25% of those aged 85 years or older.
Heart failure is the most common reason for Medicare patients to be admitted to the hospital.
As the number of elderly people continues to rise, the number of people diagnosed with this condition will continue to increase.

Nursing Assessment for Congestive Heart Failure (CHF)

1. Activity / rest
Symptoms: Fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
Signs: Restlessness, changes in mental status such as: lethargy, changes in vital signs of activity.

2. Circulation
Symptoms: history of hypertension, new myocardial infarction / acute, previous episodes of congestive heart failure, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
Signs: blood pressure may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia,

3. Ego integrity
Symptoms: Anxiety, worry and fear. Stress related to illness / financial keperihatinan (work / cost of medical care)
Signs: A variety of behavioral manifestations, such as: anxiety, anger, fear and irritability.

4. Elimination
Symptoms: Decreased urination, dark colored urine, nighttime urination (nocturia), diarrhea / constipation.

5. Food / fluid
Symptoms: Loss of appetite, nausea / vomiting, significant weight gain, swelling of the lower extremities, clothes / shoes felt tight, high-salt diet / food that has been processed and the use of diuretics.
Signs: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, stress and pitting).

6. Hygiene
Symptoms: Fatigue / weakness, fatigue during Self-care activities.
Signs: Appearances indicate neglect of personal care.

7. Neuro Sensory
Symptoms: weakness, dizziness, fainting episodes.
Symptoms: Lethargy, tangled thought, oriented, behavior changes and irritability.

8. Pain / Leisure
Symptoms: Chest pain, acute or chronic angina, right upper abdominal pain and muscle pain.
Signs: No quiet, restless, the focus narrows danperilaku protect themselves.

9. Breathing
Symptoms: Dyspnea on exertion, while sitting or sleeping with several pillows, cough with / without the formation of sputum, history of chronic disease, use of rescue breathing.
Signs: Respiratory: tachypnea, shallow breathing, use of accessory respiratory muscles. Cough: Dry / loud / non-productive or persistent cough may be with / without pemebentukan sputum. Sputum; Perhaps blood Flushed, pink / frothy (pulmonary edema). Breath sounds; may not be heard. Mental function; may decrease, anxiety, lethargy. Skin color; Pallor and cyanosis.

10. Security
Symptoms: Changes in mental function, kehilangankekuatan / muscle tone, skin abrasions.

11. Social interaction
Symptoms: Decreased participation in social activities are wont to do.

12. Learning / teaching
Symptoms: use / forgot to use cardiac drugs, such as: calcium channel blockers.
Signs: Evidence of the lack of success to improve.

Nursing Assessment Nursing Care Plan for Congestive Heart Failure (CHF)
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