Group 2 Nursing Care plan of Heart Failure NO 1.

Nursing Diagnosis Decreased Cardiac Output related to changes in myocardial contractility / inotropic changes

Purpose The client will: Showed vital signs within acceptable limits (dysrhythmias can be in control or lost) and free of heart failure symptoms. Reported a reduction in episodes of dyspnea, angina.

Intervention

After the act of nursing for 1. Auscultation apical pulse; two days examine the frequency, heart

rhythm. 2. Record heart sounds 3. Peripheral pulse palpation 4. Monitor blood pressure 5. Assess the pale skin and cyanosis 6. Give supplemental oxygen by nasal cannula / mask and drugs as indicated (collaboration)

Rational 1. Usually tachycardia (although at rest) to compensate for decreased ventricular contractility. 2. S1 and S2 may be weak due to reduced pumping work. Common Gallop rhythm (S3 and S4). Murmurs can indicate incompetence / stenosis. 3. Decreased cardiac output may indicate decreased radial artery, popliteal, dorsalis, pedis and posttibial. Pulse may disappear fast or irregular to palpation and pulse alternan. 4. In chronic heart failure early, moderate or chronic, blood pressure may rise. 5. Pale indicating reduced peripheral perfusion secondary to

Participate in activities that reduce the heart's

workload.

inadequate cardiac output; vasoconstriction and anemia. Areas affected often blue or striped because of increased venous congestion. 6. Increase dosage myocardial oxygen to the need to counter the effects of hypoxia / ischemia. Many drugs can be used to improve contractility and reduce congestion.

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Nursing Diagnosis

purpose

intervention

rational

Acute Pain

Chest pain is lost or controlled Expected outcomes: Able to demonstrate use of relaxation techniques. Showed reduced stress, relaxed and easy to move.

1. Monitor or record the characteristics of the pain, noted the report verbal, nonverbal cues, and the haemodynamic response (grimacing, crying, anxiety, sweating, clutching his chest, rapid breathing, blood pressure / heart frequency change).

1.Variations in appearance and behavior, because the pain occurs as the findings of the assessment. Most of the Acute Myocardial Infarction looks sick, distraction, and focus on the pain. History of verbal and deeper investigation of the precipitating factors should be delayed until the pain is gone. Breathing may increase senagai caused pain and is associated with anxiety, stress cause temporary loss of catecholamines would increase heart rate and blood pressure.

2. Take a complete picture of the patient's pain including location, intensity (0-10), duration, quality (shallow / spread), and distribution.

2. Pain is a subjective experience and

should be described by the client. Help clients to rate your pain by comparing it with the experience of others.

3. Observations over the previous history of angina, pain resembling angina, or pain Myocardial Infarction. Discuss family history.

3. Can compare the pain is there from

the previous pattern, according to the identification of complications such as widespread infarction, pulmonary embolism, or pericarditis

4. Aids relaxation techniques, eg, deep breathing / slow, behavioral distraction, visualization, imagination guidance. 5. Check vital signs before and after narcotic drugs.

4. Assist in the reduction in the

perception / response to pain. Giving control of the situation, increase positive behavior.

5. Hypotension / respiratory depression

6. Collaboration:

can occur as a result of drug administration. This problem can increase the myocardial damage in the presence of ventricular failure.

Give supplemental oxygen by 6. Increasing the amount of oxygen available for myocardial usage and also nasal cannula or mask as reduce discomfort in relation to tissue indicated ischemia