Terms in this set (16)

The overall goals for the Definition
Congestive Heart Failure (CHF) or heart failure is a condition in which the heart can't pump enough blood to the body's other organs.
To fully understand CHF, see the pathophysiology here.
Nursing Care Plans
Fluid Volume Excess
Goals:
Body weight will remain within normal limits
Electrolyte levels will be within normal limits
Will demonstrate adequate knowledge concerning medical condition.
Will maintain optimal fluid balance
Will verbalize less dyspnea and be more comfortable.
Interventions:
Administer Oxygen as ordered
Assess for symptoms such as dizziness, weakness/fatigue, nausea/vomiting, confusion, sweatiness, cyanosis. Notify physician as appropriate.
Assess for presence of edema
Check breath sounds and assess for labored breathing.
Check Vital Signs
Keep head of bed elevated
Monitor fluid intake, restrict sodium intake as ordered.
Monitor Lab work; K+, NA, BUN, Creatinine
Observe for signs and symptoms of malnutrition, Do not force resident to eat. Offer small frequent feedings. Assess food preferences.
Weigh patient daily
(Potential for) Decreased cardiac output
Goal:
Will maintain optimal cardiac output aeb vital signs within acceptable limits, no s/sx of decreased cardiac output.
Interventions:
Administer medications as ordered by MD and check for side effects.
Assess and document breath sounds such as dyspnea, cough, extended expiration, wheezing.
Assess and document heart sounds, apical heart rate, presence of any abnormal heart sounds.
Check for symptoms related to decreased cardiac output, such as chest pain, dyspnea, orthopnea, dependent edema, JVD, fluid overload.
Discourage smoking. Discuss avoiding allergens when possible.
Encourage activity as tolerated, rest as needed.
Encourage proper posture (stand/sit upright, elevate head as needed) to optimize air exchange and comfort.
Monitor breathing pattern; include rate, rhythm, depth, pursed lips, nasal flaring, fatigue.
Obtain lab/diagnostic work as ordered and report results to MD.
Potential for fluid volume overload.
Goals:
Will be free from s/sx or complications related to fluid overload.
Interventions:
Administer diuretics as ordered and monitor for side effects.
Encourage adequate fluid intake within fluid restrictions as ordered by MD
Ensure that snacks and beverages offered at activities comply with all ordered diet and fluid restrictions.
Monitor fluid intake and record
Monitor for s/sx of fluid overload (edema, shortness of breath, dyspnea, jugular vein distention, bounding pulses) and report to MD
Episodes of dyspnea
Goal(s)
Episodes of dyspnea will decrease to less than [daily/weekly/monthly] by ___
Intervention(s)
Administer oxygen at __ L/min as ordered.
Elevate head of bed as needed to promote comfort
Monitor and report signs of dyspnea
Reduce stress and anxiety as much as possible
Report signs of respiratory distress or infection to MD immediately
Speak to patient in calm, low voice to help reduce anxiety.
Potential for decreased endurance
NDx: Potential for decreased endurance due to decreased cardiac output
Intervention(s)
Allow for periods of rest between activities
Determine factors that contribute to intolerance (ie sleep disturbance)
Encourage patient to conserve energy
If applicable, discourage smoking.
Monitor food intake to ensure that activity is supported.
Monitor vital signs during activities.
Slowly increase activity level. Continue to monitor vitals.
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