Excess Fluid Volume related to Heart Failure

Nursing Care Plan for Heart Failure

Heart failure is often called congestive heart failure is the inability of the heart to pump adequate blood to meet the needs of tissues for oxygen and nutrients.
The term congestive heart failure is most often used in case of heart failure, left and right sides.

Signs and symptoms

In general can be described as follows:

1. Shortness of breath (dyspnea)
Increased pressure filling the left ventricle, causing transudation of fluid into the lung tissue. Decreased compliance (strain) lung add breath work. Sensation of shortness of breath is also caused by decreased blood flow to the respiratory muscles. Initially, shortness of breath occurs when the activity (dyspnea on effort) and if the more heavily congested heart failure also arise when resting.

2. Orthopnea (shortness of the time lying down)
At the time lying down position, then there is a decrease in peripheral blood flow and increase in central blood volume (chest cavity). This resulted in an increase in pressure of the left ventricle and pulmonary edema. Vital capacity also decreases when lying position.

3. Paroxysmal nocturnal dyspnea (PND) is chock suddenly at night with coughing.

4. Tachycardia and palpitations are increased heart rate due to increased sympathetic tone.

5. Coughing
Caused by edema in the bronchus and emphasis bronchus by left atrial dilatation. Cough is often a wet cough and frothy, sometimes accompanied by blood spots.

6. Easy tired
Caused by cardiac output less that inhibits tissue from normal circulation and oxygen as well as decreasing the disposal of catabolism. Also occur due to increased energy used for breathing and insomnia that occurs due to respiratory distress and cough.

7. Cyanosis
Decreased oxygen pressure in peripheral tissues and increased oxygen extraction resulted in an increase in methemoglobin approximately 5 grams / 100 ml causing cyanosis.

8. The presence of heart sounds P2, S3, S4 shows mitral insufficiency due to dilation of the left ventricle or papillary muscle dysfunction.

9. Edema (usually pitting edema) that starts in the feet and ankles and gradually grow up with weight gain.

10. Hepatomegaly (enlarged liver)
Caused by enlargement of veins in the liver. When this process develops, the pressure in the portal vein increases so that the liquid is pushed out of the abdominal cavity called ascites.

11. Anorexia and nausea due to the enlargement of veins and venous stasis in the abdominal cavity.

12. Nocturia (feeling to urinate at night)
Occurs because of renal perfusion and improves cardiac output at rest.


Nursing Diagnosis : Excess Fluid Volume related to the initial load increases, a decrease in cardiac output secondary to heart failure.
characterized by; weight gain, edema, ascites, hepatomegaly, crackles breath sounds, wheezing.

Goal: Excess fluid volume can be reduced to the following criteria:

• balance intake and output.
• breath sounds clean / clear.
• vital signs within normal limits.
• stable weight.
• no edema.

Interventions :

• Monitor urine output, color, quantity.
• Monitor intake and output for 24 hours.
• Maintain a sitting position or semifowler during the acute period.
• Measure weight every day.
• Assess distended neck and peripheral vessels, edema in the body.
• Auscultation of breath sounds, record additional sound eg crackles, wheezing. Note the increase in dyspnea, tachypnea, persistent cough.
• Assess complaints sudden extreme dyspnea, sensation of breathlessness, panic.
• Monitor blood pressure and central venous pressure.
• Measure the circumference of the abdomen.
• Palpation hepatomegaly. Record complaints right upper quadrant abdominal pain.
• Collaboration in drug delivery.
• Collaboration to maintain fluid / sodium restriction as indicated.
• Consultation with nutrition section.
• Collaboration for monitoring X-ray of the thorax.

Rationale:

• Monitor decreased renal perfusion.
• Diuretic therapy can cause a sudden loss of fluid although edema is still there.
• Supine position increases renal filtration and decrease the production of ADH thus increasing diuresis.
• Monitor response to therapy.
• Excessive fluid retention manifested by the damming of the veins and edema formation.
• Excess fluid volume often lead to pulmonary congestion.
• Indicates the presence of complications of pulmonary edema or pulmonary embolism.
• Hypertension and increased central venous pressure showed excess fluid volume.
• Monitor the presence of ascites.
• Expansion of the heart causing venous congestion, causing abdominal distension, liver enlargement and pain.
• Diuretics increase urine flow rate and can inhibit sodium and chloride reabsorption in the renal tubules.
• Increase diuresis without excessive potassium loss.
• Lowering the total body water / prevent re-accumulation of fluid.
• Provide an acceptable diet of patients who meet caloric needs in sodium restriction.
• Showed changes indicative of improvement / repair the lung.

Tag : Excess Fluid Volume, Heart Failure, Nursing Care Plan, Nursing Interventions