Heart Failure - 5 Nursing Diagnosis and Intervention

Nursing Care Plan for Heart Failure 

Nursing Diagnosis : 

1. Impaired Gas Exchange related to changes in the alveolar capillary membrane.
characterized by; dyspnea, orthopneu.

Goal: more effective gas exchange, the results; analysis of blood gases within normal limits and the patient was free from respiratory distress.

Interventions :

• Auscultation of breath sounds, crackles, wheezing.
• Instruct the patient to cough effectively and breathe deeply.
• Keep sitting or bed rest with semifowler position.
• Collaboration to monitor blood gas analysis and pulse oximetry.
• Collaboration for the provision of supplemental oxygen as indicated.
• Collaboration for diuretics and bronchodilators.

Rationale :

• Monitor the presence of pulmonary congestion for further intervention.
• Cleaning airway and facilitate the flow of oxygen.
• Lowers oxygen consumption and maximize lung development.
• Can be severe hypoxemia during pulmonary edema.
• Increasing alveolar oxygen concentration to improve tissue hypoxemia.
• Diuretics can reduce congestion and improve the alveolar gas exchange. Broncodilator for airway dilatation.

2. Activity intolerance related to imbalance between oxygen supply / needs, weaknesses.
characterized by; The patient said wearily continuously throughout the day, shortness of breath on exertion, changes in vital signs during activity.

Goal: Activity achieve optimal limit, as indicated by the patient participating in a desired activity and is able to meet the needs of their own care.

Interventions :

• Check vital signs before and after the activity.
• Note the cardiopulmonary response to activity, tachycardia, dysrhythmias, dyspnea, sweating, pale.
• Provide assistance in self-care activities as indicated. Interspersed periods of activity with periods of rest.
• Collaboration to implement a cardiac rehabilitation program.

Rationale :

• Orthostatic hypotension can occur with activity due to the effects of the drug, fluid shifts, influence heart function.
• The inability of the myocardium, increasing stroke volume during exercise, can increase heart rate, oxygen consumption and increased fatigue.
• Self care needs without affecting the stress myocardial / excessive oxygen demand.
• Gradual increase in the activity of the heart and avoid excessive oxygen consumption.

3. Altered Peripheral Tissue Perfusion related to decreased blood flow in the peripheral area secondary to decreased cardiac output.
characterized by; capillary filling is slow, pale or cyanotic nail color.

Goal: peripheral tissue perfusion can be improved (adequate) with expected outcomes:

• The skin is warm and dry.
• Strong pulse, capillary refill strong.
• Normal vital signs.
• No cyanosis or pale.

Interventions :

• Monitor vital signs, capillary refill, skin color, skin moisture, edema, peripheral O2 saturation in the area.
• Increase bed rest during the acute phase.
• Emphasize the importance of avoiding straining especially during defecation.
• Collaboration in the delivery of oxygen and inotropic drugs.

Rationale :

• Knowing adequacy of peripheral perfusion.
• Restrictions activity lowers oxygen and nutrient needs of peripheral areas.
• Avoid increasing hypoxia in peripheral tissues.
• Oxygen increase alveolar oxygen concentration, thereby improving tissue hypoxemia.
• Inotropic drugs to increase myocardial contractility.

4. Anxiety related to tissue oxygenation disorders, stress due to difficulty in breathing and the knowledge that the heart is not functioning properly.
characterized by; anxiety, fear, worry, stress-related illness, anxiety, anger, irritability.

Goal: The patient does not feel anxious.
with expected outcomes:

• The patient said that anxiety decreased to a level that can be overcome.
• The patient demonstrated problem-solving skills and know the feeling.

Interventions:

• Provide the opportunity for the patient to express feelings.
• Encourage friends and family to consider patients as before.
• Tell patient medical programs that have been made to lower the impending attack and increase the stability of the heart.
• Help the patient a comfortable position to sleep or rest, limit visitors.
• Collaboration for the administration of sedatives and tranquiliser.

Rationale :

• Statement of the problem can reduce tension, classify the level of coping and facilitate understanding of feelings.
• Reassure patients that role in the family and work unchanged.
• Encourage the patient to control symptoms, improve confidence in the medical program and integrate capabilities in self-perception.
• Creating an atmosphere that allows the patient to sleep.
• Help the patient relax until physically able to make adequate coping strategies.

5. Disturbed Sleep Pattern related to waking up frequently secondary to respiratory disorders (tightness, cough).
characterized by; lethargy, insomnia, shortness of breath and coughing during sleep.

Goal: The patient can sleep more comfortably.

Interventions :

• Raise the head of the bed 20 -30 cm. Chock forearm with a pillow.
• In patients with orthopnea, the patient is seated on the side of the bed with both feet supported on the seat, head and put on the table bed and lumbosacral vertebrae supported by a pillow.

Rationale :

• Venous return to the heart is reduced, pulmonary congestion is reduced and the suppression of the liver to the diaphragm is reduced and reducing muscle fatigue shoulder.
• Reduce difficulty breathing and reduces the flow back to the heart.

Tag : Heart Failure, Nursing Diagnosis and Interventions