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.
