Nursing Care Plan Nursing Diagnosis: Impaired gas exchange related to presence of fluid in the lungs Cause Analysis:

Because the left heart cannot discharge its normal ejection fraction, increased end-diastolic volume causes blood to accumulate in the left atrium, into the four pulmonary veins and the pulmonary capillary bed. The pressure of blood in the PCB increases. When it reaches a certain critical point, fluid passes across the pulmonary capillary membrane, into the interstitial space around the alveoli and finally into the alveoli. (pathophysiology, p. 479) Cues
Dyspnea Cough SOB Pulmonary crackles Orthopnea Confusion, restlessness Abnormal ABG values (hypoxia and hypercapnia) Changes in vital signs Reduced tolerance for activity Paroxysmal Nocturnal dyspnea

Objectives STO:
Within 8 hours of nursing intervention, the patient will be able to
demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patients normal range and be free of symptoms of respiratory distress. LTO:

Nursing Intervention

Rationale -Promote good ventilation and breathing. -Will promote mucoid or sputum excretion from the lungs -Proper assessment will help identify early problems.

Evaluation

Independent:
-Position client in either semifowlers position or side lying position -Encourage client to cough as tolerated. -Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and thoracic or abdominal breathing. -Monitor clients behavior and mental status for onset of restlessness, agitation, confusion and in the late stages, extreme lethargy -Observe for cyanosis in skin: note especial color of tongue and oral mucous membrane. - limit fluid intake - limit sodium intake (2-3 gm / 200-300 ml) no added salt - auscultation

Palor/ashen colored skin

Within 2-3 days of nursing intervention, the patient will be able to participate in treatment
regimen within level of ability/situation.

-Changes in behavior and mental status can be early signs of impaired gas exchange

-Central cyanosis in tongue and oral mucosa is indication of serious hypoxia and is a medical emergency; Peripheral cyanosis seen in extremities may not be serious. -Promote enough oxygen supply

Collaborative: -administer Oxygen as indicated - IV Fluid

References: Nursing Care Plan Nursing Diagnosis: Impaired tissue perfussion related to altered myocardial contractility or inotropic changes Cause Analysis: As the hearts workload increases, contractility of the myocardial muscle fibers decreases. Decreased contractility results in an increase in end-diastolic blood volume in the ventricle. These responses cause resistance to ventricular filling, which increases ventricular pressure. Less blood in the ventricles causes decreased CO. (MedicalSurgical Nursing p. 827) Cues Objectives Nursing Intervention Rationale Evaluation

Increased heart rate (tachycardia), dysrhythmias, ECG changes Changes in BP (hypotension/hyper tension) Extra heart sounds (S3, S4) Decreased urine output Diminished peripheral pulses Cool, ashen skin; diaphoresis Chest pain

STO: After 5-8 hours of nursing care, the patient will be able to Report decreased episodes of dyspnea, angina.

Independent
Auscultate apical pulse; assess heart rate, rhythm (document dysrhythmia if telemetry available). Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and atrial fibrillation (AF) are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricular dysrhythmias unresponsive to medication suggest ventricular aneurysm. S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant/distended chambers. Murmurs may reflect valvular incompetence/stenosis

NOTE HEART SOUNDS.

LTO: After 3 days of nursing intervention the patient will be able to Display vital signs within acceptable limits, dysrhythmias absent/controlled,and no symptoms of failure (e.g., hemodynamic parameters within acceptable limits, urinary output adequate). Participate in activities that reduce cardiac workload.

Monitor BP

In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate, and profound/irreversible hypotension may occur.

Inspect skin for pallor, cyanosis.

Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases. Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent. May indicate inadequate cerebral perfusion secondary to decreased cardiac output.

Monitor urine output, noting decreasing output and dark/concentrated urine.

Note changes in sensorium, e.g., lethargy, confusion, disorientation, anxiety, and depression. Encourage rest, semirecumbent in bed or chair. Assist with physical care as indicated.

Physical rest should be maintained during acute or refractory HF to improve efficiency of cardiac contraction and to decrease myocardial oxygen demand/consumption and workload. Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate/work.

Provide quiet environment; explain medical/nursing management; help patient avoid stressful situations; listen/respond to expressions of feelings/fears. Provide bedside commode. Have patient avoid activities eliciting a vasovagal response, e.g., straining during defecation, holding breath during position changes.

Commode use decreases work of getting to bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function/output. Decreases venous stasis, and may reduce incidence of thrombus/embolus formation.

Elevate legs, avoiding pressure under knee. Encourage active/passive exercises. Increase ambulation/activity as tolerated.

Collaborative
Administer supplemental oxygen as indicated. Increases available oxygen for myocardial uptake to combat effects of hypoxia/ischemia.

Administer medications as indicated: Diuretics, e.g., furosemide (Lasix), ethacrynic acid (Edecrin), bumetanide (Bumex), spironolactone (Aldactone);

Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in patients with stages I and II HF. In general, type and dosage of diuretic depend on cause and degree of HF and state of renal function. Preload reduction is most useful in treating patients with a relatively normal cardiac output accompanied by congestive symptoms. Loop diuretics block chloride reabsorption, thus interfering with the reabsorption of sodium and water. Vasodilators are the mainstay of treatment in HF and are used to increase cardiac output, reducing circulating volume (venodilators) and decreasing SVR, thereby reducing ventricular workload. Note: Parenteral vasodilators (e.g., Nitropress) are reserved for patients with severe HF or those unable to take oral medications.

Vasodilators, e.g., nitrates (Nitro-Dur, Isordil); arteriodilators, e.g., hydralazine (Apresoline); combination drugs, e.g., prazosin (Minipress);

ACE inhibitors, e.g., benazepril (Lotensin), captopril (Capoten), lisinopril (Prinivil), enalapril (Vasotec), quinapril (Accupril), ramipril (Altace), moexipril (Univasc); Angiotensin II receptor antagonists, e.g., eprosartan (Teveten), ibesartan (Avopro), valsartan (Diovan);

ACE inhibitors represent first-line therapy to control heart failure by decreasing venticular filling pressures and SVR while increasing cardiac output with little or no change in BP and heart rate.

Antihypertensive and cardioprotective effects are attributable to selective blockade of AT1 (angiotensin II) receptors and angiotensin II synthesis. Increases force of myocardial contraction when diminished contractility is the cause of HF, and slows heart rate by decreasing conduction velocity and prolonging refractory period of the atrioventricular (AV) junction to increase cardiac efficiency/output. These medications are useful for short-term treatment of HF unresponsive to cardiac glycosides, vasodilators, and diuretics in order to increase myocardial contractility and produce vasodilation. Positive inotropic properties have reduced mortality rates 50% and improved quality of life.

Digoxin (Lanoxin);

Inotropic agents, e.g., amrinone (Inocor), milrinone (Primacor), vesnarinone (Arkin-Z);

Beta-adrenergic receptor antagonists, e.g., carvedilol (Coreg), bisoprolol (Zebeta), metoprolol (Lopressor);

Useful in the treatment of HF by blocking the cardiac effects of chronic adrenergic stimulation. Many patients experience improved activity tolerance and ejection fraction.

Morphine sulfate;

Decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety.

Antianxiety agents/sedatives; Promote rest/relaxation, reducing oxygen demand and myocardial workload.

Nursing Care Plan Nursing Diagnosis: Activity intolerance and fatigue related to imbalance between oxygen supply and demand Cause Analysis: As the hearts workload increases, contractility of the myocardial muscle fibers decreases. Decreased contractility results in an increase in end-diastolic blood volume in the ventricle. These responses cause resistance to ventricular filling, which increases ventricular pressure. Less blood in the ventricles causes decreased CO. (MedicalSurgical Nursing p. 827) Cues
Weakness, fatigue Changes in vital signs, presence of dysrhythmias Dyspnea Pallor, diaphoresis

Objectives STO: Within3-5 hours of nursing interventions, the patient will be able to achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity.

Nursing Intervention
Independent
Check vital signs before and immediately after activity, especially if patient is receiving vasodilators, diuretics, or beta-blockers. Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor.

Rationale
Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function. Compromised myocardium/inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue. Fatigue is a side effect of some medications (e.g., betablockers, tranquilizers, and sedatives). Pain and stressful regimens also extract energy and produce fatigue. May denote increasing cardiac decompensation rather than overactivity.

Evaluation

Assess for other precipitators/causes of fatigue, e.g., treatments, pain, medications.

Evaluate accelerating activity intolerance. Meets patients personal care needs without undue myocardial stress/excessive oxygen demand. Provide assistance with self-care activities as indicated. Intersperse activity periods with rest periods.

LTO:
Within 2-3days of nursing interventions, the patient will be able to
participate in desired activities; meet own self-care needs.

Collaborative
IMPLEMENT GRADED CARDIAC REHABILITATION/ACTIVITY PROGRAM

Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption.

Nursing Care Plan Nursing Diagnosis: Altered Sleep pattern related to frequent urination during the night Cause Analysis: A reduction in CO decreases blood flow to the kidneys, reducing urine output (oliguria). However, when the patient is sleeping, the cardiac workload is decreased, improving renal perfusion which in some patients leads to frequent urination at night (nocturia). (medical surgical nursing p. 828) Cues Verbalizes frequent urination at night Inability to go back to sleep Appears tired and restless during the day Drowsy insomnia Objectives STO: Within 8 hours of nursing interventions, the patient w Nursing Intervention Rationale Relaxation measures help induce sleep. A quiet, peaceful environmental promotes restful sleep. Simple measures can increase quality of sleep Clients have reported that uncomfortable position and pain are the most likely factors to disturb sleep To help decrease urinary frequency during sleeping To increase water reabsorption in the renal tubules Evaluation

Independent:
Provided the clients desired comfort measures or sleeping aids at or before bedtime. Provided quiet, peaceful environment as much as possible during sleep periods. Provided time before bed and back massage. Provided pain relief measure shortly before bedtime, position comfortably for sleep. Encourage not to drink water beyond 6pm Encourage to sleep right-side lying

Collaborative: Administer diuretics during the day

Diuretics increases urine output thus it should be given during the day to prevent urinary frequencies at night

Nursing Care Plan Nursing Diagnosis: Anxiety related to breathlessness from inadequate oxygenation Cause Analysis: As HF progresses, decreased CO may cause other symptoms. Decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness and anxiety due to decrease oxygenation and blood flow. (medical-surgical nursing p. 828) Cues Restless Anxious Feel overwhelmed by breathlessness Irritable Objectives Nursing Intervention Rationale Evaluation

LTO: Within 3 days, pt verbalizes awareness of healthy ways to deal anxiety and will appear relaxed and can rest appropriately as evidenced by demonstrating effective coping strategies and problem solving skills .

Independent: 1. Remain with client during acute episodes of breathing difficulty, and provide care in calm, reassuring manner. 2. Provide a quiet calm environment

1. Reassures the client competent help is available if needed. Anxiety can be contagious; remain calm.

2. Reduction of external stimuli helps promote relaxation. 3. Environmental changes may lessen the clients

STO: With in 8 hours of duty, pt reports anxiety is reduced to a manageable level as evidenced by

3. During acute episodes, open doors and curtains and limit the number of people and

demonstration of breathing retraining and relaxation techniques.

unnecessary equipment in the room 4. encourage use of breathing retraining and relaxation techniques 5. explore previous coping skills used by patient to relieve anxiety; reinforce these skills and explore other outlets 6. help client to see mild anxiety as a positive catalyst to change.

perceptions of suffocation

4. A feeling of self control and success in facilitating breathing helps reduce anxiety

5. methods of coping with anxiety that have been successful in the past are likely to be helpful again.

6. a frequent misconception is that anxiety itself is bad

and not useful. The COLLABORATIVE:

Administer drugs as indicated

client doe not need to avoid anxiety.

Morphine sulfate;

Decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety.

Antianxiety agents/sedatives; Promote rest/relaxation, reducing oxygen demand and myocardial workload.

References: Bare, Brenda G., et.al. (2010). Brunner and Suddarths Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott William and Wilkins. Bullock, Barbara L. and Reet L. Henze (2000). Focus on Pathophysiology. Philadelphia: Lippincott William and Wilkins. Doenges, Marilynn E., et. al. (2002). Nursing Care Plan. 7th Edition. Philadelphia: F.A. Davis Company