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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Nursing Diagnosis and Interventions Anxiety related to CHF

Nursing Diagnosis and Interventions Anxiety related to CHF

Nursing Care Plan for CHF

Nursing Diagnosis: Anxiety related to fear of cardiovascular death, decreased health status, a crisis situation, health changes.

Goal:
Overcome anxiety

Expected outcomes are:

• The client was calm
• The client understands about the process of nursing and medicine

Nursing Intervention:

· Review the signs of verbal expressions of anxiety.
Rational: the level of anxiety may develop panic that can stimulate the sympathetic with the release of catecholamines lead to increased cardiac demand for oxygen.

· Accompany the client during the period of high anxiety, give strength, use it at ease.
Rational: the sense of empathy is a treatment and may increase the client's coping abilities.

· Orient the client with routine procedures and activities that are expected.
Rational: orientation can reduce anxiety.

· Give the client an opportunity to express his concerns.
Rational: to eliminate ketegangang to the concerns that are not expressed.

· Do the approach and communication.
Rational: to foster mutual trust.

· Give the opportunity to accompany the person closest to the client.
Rational: to improve safety on the client.

· Provide an explanation of the disease, causes and treatment to be performed.
Rational: to provide assurance about the action steps that will be provided so that clients and families to get clear information.

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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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