ASSESSMENT

DIAGNOSIS

SCIENTIFIC EXPLANATION Congestive heart failure occurs when cardic output is inadequate to meet the metabolic demands of the body. The heart rate increases as compensatory mechanism to increase cardiac output, and vasoconstriction occurs to try to maintain blood pressure. Eventually, the chronic increase in preload and afterload contribute to chamber dilation and hyperthrophy, worsening heart failure . Underlying causes of heart failure include congenital heart

PLANNING

INTERVENTION

RATIONALE >To provide baseline for comparison to follow trends and evaluate response to interventions.

EVALUATION

S-

Decreased cardiac output related to altered stroke volume as evidence by cyanosis, dyspnea and decreased SPO2.

After 5 hours of nursing interventions, the patient will be able to participate in activities that reduce the cardiac workload such as adequate rest, activity planning and stress management.

>Monitor and record VS and SPO2.

Goal partially met as evidence by absence of dyspnea and respiratory rate within normal limits but SPO2 was 83% and with cyanosis of the lips.

O>with cyanosis of lips and nails

>with dyspnea

>Elevate HOB to semifowler's position to facilitate maximum expansion. >Instructed to limit activities to level of tolerance. >Assist in ADL's of patient to prevent fatigue.

>decreased SPO2 75% VS: Temp. 35.4C BP-130/80mmHg RR-23bpm CR-76bpm

>To decrease oxygen consumption and risk of decomposition. >To maximize rest periods.

>To assess for signs of poor ventricular function and impending cardiac failure.

>Decrease stimuli by providing quiet environment to promote rest. >Change bed linens

>To promote adequate rest.

>To maintain body

disease, rheumatic heart disease, endocarditis, myocarditis, and noncardiovascular causes such as, chronic pulmonary disease, various metabolic disease, and anemia. Complication of heart failure include pneumonia, pulmonary edema, pulmonary emboli, refractory heart failure,and myocardial heart failure leading to decrease cardiac output.

to provide comfort.

temperature in normal range. >To avoid the development of pressure sores.

>Apply wet cloth on lips to moisten the mucosa.

ASSESSMENT S-

DIAGNOSIS Ineffective airway clearance related to retained secretion as evidence by crackles, tachypnea and productive cough.

SCIENTIFIC EXPLANATION Retained secretion

PLANNING

INTERVENTION >Monitor respirations and breath sounds, noting rate and sounds.

RATIONALE >Indicative of respiratory distress and accumulation of secretion.

EVALUATION Goal partially met evidence by absence of nasal flaring, with crackles and productive cough.

O>with crackles auscultated on both lung fields >with productive cough noted

>with nasal flaring

After 5 hours of nursing is an interventions, inflammation of the patient will be able to the lung demonstrate parenchyma absence of caused bronchial congestion by various observed microorganism. through normal And inflammatort respiratory rate, reaction that noiseless occurs respiration, and pulse in the alveoli oximetry results within produces exudates. normal. And as part of inflammatory rection WBC migrate to alveoli and the normally containing spaces. The exudates together with the migration of WBC produces thick secretions that blocks the airway does leading to ineffective airway clearance.

>Encourage change of position every 2 hours to enhance drainage of secretion.

>To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage or ventilation to different lung segment. >To maximize effort

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>Encourage deep breathing and coughing exercise.

>Encourage increased in fluid intake especially warm liquids to liquefy secretions.

>Hydration can help liquefy viscous secretions and improve secretion clearance.