Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 35: Nursing Management: Heart ailure Care !lans - Customi"a#le NC! 35-$: Nursing Care !lan Patient with Heart Failure N%&S'N( )'*(N+S'SE,cess -luid .olume related to increased venous pressure and decreased renal perfusion secondary to cardiac failure as evidenced by rapid weight gain, edema, adventitious breath sounds, oliguria, and patients statement, My ankles are so swollen !*/'EN/ (+*LExperiences reduction or absence of edema and stable baseline weight +%/C+MES 0N+C1 'N/E&2EN/'+NS 0N'C1 *N) RATIONALES Fluid Balance table body weight !!!!! "eripheral pulses !!!!! erum electrolytes !!!!! #" !!!!! $%" !!!!! &'(hour )*+ balance !!!!! Measurement Scale , - everely compromised & - ubstantially compromised . - Moderately compromised ' - Mildly compromised / - 0ot compromised 1scites !!!!! 0eck vein distention !!!!! "eripheral edema !!!!! 1dventitious breath sounds !!!!! Hypervolemia ana!ement 1dminister prescribed diuretics, as appropriate, to treat hypervolemia. Monitor for therapeutic effect of diuretic 2e3g3, increased urine output, decreased $%"*"$4", and ( decreased adventitious breath sounds5 to assess response to treatment3 Monitor potassium levels after diuresis to detect excessive electrolyte loss3 4eigh patient daily and monitor trends to evaluate effect of treatment. Monitor intake and output to assess fluid status. Monitor respiratory pattern for symptoms of respiratory difficulty to detect pulmonary edema3 Monitor hemodynamic status, including $%", M1", "14", if available, to evaluate effectiveness of therapy. Monitor changes in peripheral edema to assess response to treatment3

Measurement Scale , - evere & - ubstantial . - Moderate ' - Mild / - 0one N%&S'N( )'*(N+S'S'mpaired gas e,change related to increased preload and alveolar(capillary membrane changes as evidenced by abnormal arterial blood gases, hypoxemia, dyspnea, tachypnea, tachycardia, restlessness, and patients statement, ) am so short of breath !*/'EN/ (+*L Maintains ade6uate oxygen*carbon dioxide exchange at the alveolar(
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$are "lans ( $ustomi:able capillary membrane to meet oxygen needs of the body +%/C+MES 0N+C1 'N/E&2EN/'+NS 0N'C1 *N) RATIONALES Re"piratory Statu"# $a" E%chan!e $ognitive status !!!!! Ease of breathing !!!!! +& saturation !!!!! "a+& !!!!! Measurement Scale , - everely compromised & - ubstantially compromised . - Moderately compromised ' - Mildly compromised / - 0ot compromised <yspnea with exertion !!!!! <yspnea at rest !!!!! =estlessness !!!!! Measurement Scale , - evere & - ubstantial . - Moderate ' - Mild / - 0one

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Re"piratory onitorin! Monitor rate, rhythm, depth, and effort of respirations to evaluate changes in respiratory status. 1uscultate breath sounds, noting areas of decreased*absent ventilation and presence of adventitious sounds to detect presence of pulmonary edema. Monitor for increased restlessness, anxiety, and air hunger to detect increasing hypoxemia. O%y!en Therapy 1dminister supplemental +& as ordered to maintain O2 levels. Monitor the +& liter flow and position of +& delivery device to ensure +& is adequately delivered3 $hange +& delivery device from mask to nasal prongs during meals as tolerated to sustain O2 levels while eating. Monitor the effectiveness of +& therapy to identify hypoxemia and establish range of O2 saturation.

Po"itionin! "osition to alleviate dyspnea 2e3g3, semi(;owlers position5, as appropriate, to improve ventilation by decreasing venous return to the heart and increasing thoracic capacity. N%&S'N( )'*(N+S'S *cti.it3 intolerance related to fatigue secondary to cardiac insufficiency and pulmonary congestion as evidenced by dyspnea, shortness of breath, weakness, increase in heart rate on exertion, and patients statement, ) feel too weak to do anything !*/'EN/ (+*L 4ill achieve a realistic program of activity that balances physical activity with energy(conserving activities +%/C+MES 0N+C1 'N/E&2EN/'+NS 0N'C1 *N) RATIONALES Activity Tolerance Ener!y ana!ement "ulse rate with activity Encourage alternate rest and activity periods to !!!!! reduce cardiac workload and conserve energy3 +& saturation with activity "rovide calming diversionary activities to promote !!!!! relaxation to reduce O2 consumption and to relieve =espiratory rate with dyspnea and fatigue. activity !!!!! Monitor patients +&response 2e3g3, pulse rate, ystolic #" with activity cardiac rhythm, and respiratory rate5 to self(care or !!!!! nursing activities to determine level of activity that <iastolic #" with activity can be performed.

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$are "lans ( $ustomi:able !!!!! Electrocardiogram findings !!!!! kin color !!!!! Ease of performing 1<>s !!!!!

./(. ?each patient and caregiver techni6ues of self(care that will minimize O2 consumption 2e3g3, self monitoring and pacing techni6ues for performance of 1<>s53

Activity Therapy Measurement Scale $ollaborate with occupational, physical, and*or , - everely compromised recreational therapists to plan and monitor & - ubstantially activity/exercise program3 compromised <etermine patients commitment to @ fre6uency . - Moderately compromised and*or range of activities*exercise to provide patient ' - Mildly compromised with obtainable goals3 / - 0ot compromised N%&S'N( )'*(N+S'S )ecreased cardiac output related to altered contractility, altered preload, and*or altered stroke volume as evidenced by decreased eAection fraction, increased $%", decreased peripheral pulses, Augular vein distention, orthopnea, . and ' sounds, and oliguria !*/'EN/ (+*L Maintains ade6uate blood pumped by the heart to meet metabolic demands of the body +%/C+MES 0N+C1 'N/E&2EN/'+NS 0N'C1 *N) RATIONALES &ardiac Pump &ardiac &are E''ectivene"" "erform a comprehensive appraisal of peripheral EAection fraction !!!!! circulation 2e3g3, check peripheral pulses, edema, ystolic #" !!!!! capillary refill, color, and temperature of extremity5 "eripheral pulses !!!!! to determine circulatory status. Brinary output !!!!! 0ote signs and symptoms of decreased cardiac output to detect changes in status. Monitor fluid balance 2e3g3, )*+ and daily weight5 Measurement Scale to evaluate renal perfusion. , - everely compromised Monitor for cardiac dysrhythmias to detect cardiac & - ubstantially decompensation. compromised Monitor for dyspnea, fatigue, tachypnea, and . - Moderately orthopnea to identify involvement of respiratory compromised system. ' - Mildly compromised )nstruct patient and caregivers on activity / - 0ot compromised restriction and progression to allay fears and anxiety. 0eck vein distention !!!!! 1bnormal heart sounds !!!!! <ysrhythmia !!!!! <yspnea !!!!!

Mosby items and derived items 7 &8,,, &889 by Mosby, )nc3, an affiliate of Elsevier, )nc3

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Measurement Scale , - evere & - ubstantial . - Moderate ' - Mild / - 0one N%&S'N( )'*(N+S'S )e-icient 4nowledge related to lack of information about disease process as evidenced by 6uestions about the disease and patients statement, ) dont know why ) keep getting sick !*/'EN/ (+*L <escribes disease process and rationales for dietary, medication, and exercise regimen +%/C+MES 0N+C1 'N/E&2EN/'+NS 0N'C1 *N) RATIONALES (nowled!e# )i"ea"e Proce"" Teachin!# )i"ea"e Proce"" <escription of specific 1ppraise the patients current level of knowledge disease process !!!!! related to specific disease process to identify <escription of complications needed areas of teaching. !!!!! <escribe common signs and symptoms of the <escription of signs and disease so patient will know signs and symptoms to symptoms !!!!! report to health care provider. <escriptions of measures to )nstruct the patient and caregiver on measures to minimi:e disease prevent*minimi:e side effects of treatment for the progression !!!!! disease so patient may be able to decrease number <escriptions of precautions of acute episodes of H . to prevent complications !!!!! Teachin!# Pre"cri*ed )iet 1ppraise the patients and caregivers current level of knowledge about prescribed diet to assess areas Measurement Scale needing additional instruction. , - 0one & - >imited Teachin!# Pre"cri*ed edication . - Moderate =eview patients knowledge of medications to ' - ubstantial determine where further teaching is needed. / - Extensive )nclude the caregiver in teaching to provide support for the patient. !"#s$ 1ctivities of daily livingC %&$ blood pressureC '(&$ central venous pressureC )/O$ intake and outputC H $ heart failureC *!&$ mean arterial pressureC &aO2$ partial pressure of oxygen in arterial bloodC &!+&$ pulmonary artery wedge pressure3

Mosby items and derived items 7 &8,,, &889 by Mosby, )nc3, an affiliate of Elsevier, )nc3