10 Congestive Heart Failure Nursing Care Plans

NursesLabs — Tue, 24 Jan 2012 17:32:53 +0000

Heart failure is a physiologic state in which he heart cannot 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, 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 (Joyce M. Black, 2008).

1. Decreased Cardiac Output

The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that 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

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Evaluation

Subjective:(none)

Objectives:

The patient manifested the following:

with pale conjunctiva, nail beds and buccal mucosa
irregular rhythm of pulse
bradycardic
pulse rate of 34 beats/min
generalized weakness

Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

Short Term:After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.Long Term:After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

Assess for abnormal heart and lung sounds.

Monitor blood pressure and pulse.

Assess mental status and level of consciousness.

Assess patient’s skin temperature and peripheral pulses.

Monitor results of laboratory and diagnostic tests.

Monitor oxygen saturation and ABGs.

Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.

Implement strategies to treat fluid and electrolyte imbalances.

Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.

Encourage periods of rest and assist with all activities.

Assist the patient in assuming a high Fowler’s position.

Teach patient the pathophysiology of disease, medications

Reposition patient every 2 hours

Instruct patient to get adequate bed rest and sleep

Instruct the SO not to leave the client unattended
Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.

Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.

The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.

Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.

Results of the test provide clues to the status of the disease and response to treatments.

Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood

Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.

Decreases the risk for development of cardiac output due to imbalances.

Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.

Reduces cardiac workload and minimizes myocardial oxygen consumption.

Allows for better chest expansion, thereby improving pulmonary capacity.

Provides the patient with needed information for management of disease and for compliance.

To prevent occurrence of bed sores

To promote relaxation to the body

To ensure safety and reduce risk for falls that may lead to injury

Short Term:After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.Long Term:After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

10 Congestive Heart Failure Nursing Care Plans Original source at: Nurseslabs

5 Chronic Renal Failure Nursing Care Plans

NursesLabs — Wed, 21 Dec 2011 17:07:58 +0000

Chronic or irreversible, renal failure is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment. CRF can develop insidiously over many years, or it may result from an episode of a cure renal failure from which the client has not recovered.

The nursing goal for client’s with CRF is to prevent further complications and supportive care. Client education is also critical as this is a chronic disease and thus requires long-term treatment.

1 Fluid Volume Excess

Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR, nephron hyperthrophized leading to decrease ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria/anuria.

Fluid- Volume- Excess- CRF

5 Chronic Renal Failure Nursing Care Plans Original source at: Nurseslabs

Nurseslabs » excess fluid volume

10 Congestive Heart Failure Nursing Care Plans

1. Decreased Cardiac Output

5 Chronic Renal Failure Nursing Care Plans

1 Fluid Volume Excess