After 1 month of nursing intervention, the patient will display hemodynamic stability (BP, cardiac output, urinary output and peripheral pulses within normal limits) Independent: Auscultate apical pulse; assess heart rate, rhythm Note heart sounds. Palpate peripheral pulses. Monitor BP. Inspect skin for pallor, cyanosis. Monitor urine output, noting decreasing output and dark/concentrated urine. O: Decreased cardiac output related to decreased myocardial contractility Short Term Goals: After 12 hours of nursing intervention: -Patient's breath sounds will be clear to auscultation -Patient will have no signs of dyspnea -Patient will demonstrate an increase in activity tolerance 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. 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. Elevate legs, avoiding pressure under knee. Encourage active/ passive exercises. Increase ambulation/ activity as tolerated. Check for calf tenderness; diminished pedal pulse; swelling, local redness, or pallor of extremity. Educate patient and caregivers about the importance of taking prescribed medications at prescribed times Dependent: Administer supplemental oxygen as indicated. Administer medications as indicated O: Decreased cardiac output related to decreased myocardial contractility Short Term Goals: After 12 hours of nursing intervention: -Patient's breath sounds will be clear to auscultation -Patient will have no signs of dyspnea -Patient will demonstrate an increase in activity tolerance Administer IV solutions, restricting total amount as indicated. Avoid saline solutions. Monitor/ replace electrolytes. Educate patient and caregivers about the importance of taking prescribed medications at prescribed times Assessment Diagnosis Goal of Care Intervention Long Term Goal: After 1 month of nursing intervention, the patient will demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear, vital signs within acceptable range, stable weight, and absence of edema. Independent: Monitor urine output, noting amount and color, as well as time of day when diuresis occurs. Monitor/ calculate 24-hour intake and output (I&O) balance. Maintain chair or bedrest in semi-Fowlers position. Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care/ ice chips as part of fluid allotment. O: Decreased cardiac output related to decreased myocardial contractility Short Term Goals: After 12 hours of nursing intervention: -Patient's breath sounds will be clear to auscultation -Patient will have no signs of dyspnea -Patient will demonstrate an increase in activity tolerance Fluid volume excess O: Orthopnea S3 heart sound Oliguria Hypertension abnormal breath sounds Short Term Goal: After 12 hours of nursing intervention, the patient will display understanding of individual dietary/fluid restrictions evidenced by verbalization of at least 3 required dietary changes Weigh daily. Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema with/ without pitting; note presence of generalized body edema (anasarca). Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated. Auscultate breath sounds, noting decreased and/or adventitious sounds, e.g., crackles, wheezes. Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough. Investigate reports of sudden extreme dyspnea/ air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom. Monitor BP Fluid volume excess O: Orthopnea S3 heart sound Oliguria Hypertension abnormal breath sounds Short Term Goal: After 12 hours of nursing intervention, the patient will display understanding of individual dietary/fluid restrictions evidenced by verbalization of at least 3 required dietary changes Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation. Provide small, frequent, easily digestible meals. Measure abdominal girth, as indicated. Encourage verbalization of feelings regarding limitations. Maintain fluid/ sodium restrictions as indicated. Dependent: Administer medications as indicated Consult with dietitian. Assessment Diagnosis Goal of Care Intervention S: Long Term Goal: After 1 month of nursing intervention, the patient will be able to participate in desired activities and meet own self-care needs. 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. Assess for other precipitators/causes of fatigue, e.g., treatments, pain, medications. Evaluate accelerating activity intolerance. Fluid volume excess O: Orthopnea S3 heart sound Oliguria Hypertension abnormal breath sounds Short Term Goal: After 12 hours of nursing intervention, the patient will display understanding of individual dietary/fluid restrictions evidenced by verbalization of at least 3 required dietary changes Activity intolerance related to poor cardiac reserve O: V/S presence of dysrhythmias dyspnea pallor Short Term Goal: After 12 hours of nursing intervention, the patient will achieve measurable increase in activity tolerance evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity. Provide assistance with self- care activities as indicated. Intersperse activity periods with rest periods. Collaborative: Implement graded cardiac rehabilitation/activity program. Assessment Diagnosis Goal of Care Intervention Long Term Goal: After 1 month of nursing intervention, the patient will participate in treatment regimen within level of ability/situation. Independent: Auscultate breath sounds, noting crackles, wheezes. Instruct patient in effective coughing, deep breathing. Encourage frequent position changes. Maintain chair/bedrest, with head of bed elevated 2030 degrees, semi-Fowlers position. Support arms with pillows. Monitor/graph serial ABGs, pulse oximetry. Dependent: Administer supplemental oxygen as indicated. Administer medications as indicated Assessment Diagnosis Goal of Care Intervention Activity intolerance related to poor cardiac reserve O: V/S presence of dysrhythmias dyspnea pallor Short Term Goal: After 12 hours of nursing intervention, the patient will achieve measurable increase in activity tolerance evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity. Risk for impaired gas exchange related to fluid shifts into interstitial space/alveoli Short Term Goal: After 12 hours of nursing intervention, the patient will demonstrate adequate ventilation and oxygenation of tissues evidenced by oximetry within patients normal ranges and free of symptoms of respiratory distress. Long Term Goal: After 1 month of nursing intervention, the patient will maintain skin integrity. Independent: Inspect skin, noting skeletal prominences, presence of edema, areas of altered circulation/pigmentation, or obesity/emaciation. Provide gentle massage around reddened or blanched areas. Encourage frequent position changes in bed/chair, assist with active/passive range of motion (ROM) exercises. Provide frequent skin care; minimize contact with moisture/excretions. Check fit of shoes/slippers and change as needed. Provide alternating pressure/egg-crate mattress, sheep skin elbow/heel protectors. Risk for impaired skin integrity related to decreased tissue perfusion Short Term Goal: After 12 hours of nursing intervention, the patient will demonstrate at least 2 behaviors/ techniques to prevent skin breakdown. Rationale Evaluation Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3and S4), produced as blood flows into noncompliant/ distended chambers. Murmurs may reflect valvular incompetence/ stenosis. Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and posttibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans (strong beat alternating with weak beat) may be present. 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. 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. Goal Met: After 12 hours of nursing intervention: - Patient's breath sounds was clear to auscultation -Patient had no signs of dyspnea -Patient demonstrated an increase in activity tolerance May indicate inadequate cerebral perfusion secondary to decreased cardiac output. 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. 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. Reduced cardiac output, venous pooling /stasis, and enforced bedrest increases risk of thrombophlebitis. Patient is often on multiple medications which can be difficult to manage, thus increasing the likelihood that medications can be missed or incorrectly used Increases available oxygen for myocardial uptake to combat effects of hypoxia /ischemia. A variety of medications may be used to increase stroke volume, improve contractility, and reduce congestion. Goal Met: After 12 hours of nursing intervention: - Patient's breath sounds was clear to auscultation -Patient had no signs of dyspnea -Patient demonstrated an increase in activity tolerance Because of existing elevated left ventricular pressure, patient may not tolerate increased fluid volume (preload). Patients with HF also excrete less sodium, which causes fluid retention and increases myocardial workload. Fluid shifts and use of diuretics can alter electrolytes (especially potassium and chloride), which affect cardiac rhythm and contractility. Patient is often on multiple medications which can be difficult to manage, thus increasing the likelihood that medications can be missed or incorrectly used Rationale Evaluation Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night/ during bedrest. Diuretic therapy may result in sudden/ excessive fluid loss (circulating hypovolemia), even though edema /ascites remains. Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis. Involving patient in therapy regimen may enhance sense of control and cooperation with restrictions. Goal Met: After 12 hours of nursing intervention: - Patient's breath sounds was clear to auscultation -Patient had no signs of dyspnea -Patient demonstrated an increase in activity tolerance Goal Met: After 12 hours of nursing intervention, the patient displayed understanding of individual dietary/fluid restrictions evidenced by verbalization that she should avoid salty and fatty foods and should limit her fluid intake Documents changes in/ resolution of edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in rapid/ excessive fluid shifts and weight loss. Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet/ ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually results in systemic tissue edema. Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility /bedrest are cumulative stressors that affect skin integrity and require close supervision/ preventive interventions. Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute left- sided HF. RHFs respiratory symptoms (dyspnea, cough, orthopnea) may have slower onset but are more difficult to reverse. May indicate development of complications (pulmonary edema/ embolus) and differs from orthopneaparoxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention. Hypertension suggest fluid volume excess and may reflect developing/ increasing pulmonary congestion. Goal Met: After 12 hours of nursing intervention, the patient displayed understanding of individual dietary/fluid restrictions evidenced by verbalization that she should avoid salty and fatty foods and should limit her fluid intake Visceral congestion (occurring in progressive HF) can alter gastric/ intestinal function. Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/ prevent abdominal discomfort. In progressive RHF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites). Expression of feelings/ concerns may decrease stress/ anxiety, which is an energy drain that can contribute to feelings of fatigue. Reduces total body water/ prevents fluid reaccumulation. To help promote wellness. May be necessary to provide diet acceptable to patient that meets caloric needs within sodium restriction. Rationale Evaluation 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., beta-blockers, tranquilizers, and sedatives). Pain and stressful regimens also extract energy and produce fatigue. May denote increasing cardiac decompensation rather than overactivity. Goal Met: After 12 hours of nursing intervention, the patient displayed understanding of individual dietary/fluid restrictions evidenced by verbalization that she should avoid salty and fatty foods and should limit her fluid intake Goal Met: After 12 hours of nursing intervention, the patient achieved measurable increase in activity tolerance evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity. Meets patients personal care needs without undue myocardial stress/excessive oxygen demand. Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption. Rationale Evaluation Reveals presence of pulmonary congestion/collection of secretions, indicating need for further intervention. Clears airways and facilitates oxygen delivery. Helps prevent atelectasis and pneumonia. Reduces oxygen consumption/demands and promotes maximal lung inflation. Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF.Note: In patients with abnormal cardiac index, research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%. Increases alveolar oxygen concentration, which may correct/reduce tissue hypoxemia. To help promote wellness. Rationale Evaluation Goal Met: After 12 hours of nursing intervention, the patient achieved measurable increase in activity tolerance evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity. Goal Met: After 12 hours of nursing intervention, the patient demonstrated adequate ventilation and oxygenation of tissues evidenced by O2 Sat = 95% and free of symptoms of respiratory distress. Skin is at risk because of impaired peripheral circulation, physical immobility, and alterations in nutritional status. Short Term Goal: After 12 hours of nursing intervention, the patient demonstrated 2 behaviors/ techniques to prevent skin breakdown like frequent position changes in bed and active range of motion (ROM) exercises Improves blood flow, minimizing tissue hypoxia.Note: Direct massage of compromised area may cause tissue injury. Reduces pressure on tissues, improving circulation and reducing time any one area is deprived of full blood flow. Excessive dryness or moisture damages skin and hastens breakdown. Dependent edema may cause shoes to fit poorly, increasing risk of pressure and skin breakdown on feet. Reduces pressure to skin, may improve circulation. Drug Name Indications/Contraindications Cefuroxime 750mg IVTT Drug Name Indications/Contraindications Paracetamol 500mg 1 tab q 8h for fever Indications: To relieve mild to moderate pain such as headache, muscle and joint pain, and backache. It is also used to bring down a high temperature. Drug Name Indications/Contraindications Contraindications: - Contraindicated in patients with allergy to acetaminophen. -Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation. Action: Decreases fever by a hypothalamic effect leading to sweating and vasodilation; Inhibits pyrogen effect on the hypothalamic-heat-regulating centers; Inhibits CNS prostaglandin synthesis with minimal effects on peripheral prostaglandin synthesis Indications: It is effective for the treatment of penicillinase-producing Neisseria gonorrhoea (PPNG). Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsillitis, Contraindications: Hypersensitivity to cephalosporins and related antibiotics; pregnancy (category B), lactation. Action: Binds to one or more of the penicillin- binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death. Furosemide 80mg IVTT Inidications: Treatment of edema associated with CHF, cirrhosis of liver, and kidney disease, including nephrotic syndrome. May be used for management of hypertension, alone or in combination with other antihypertensive agents, and for treatment of hypercalcemia. Has been used concomitantly with mannitol for treatment of severe cerebral edema, particularly in meningitis. Drug Name Indications/Contraindications Salbutamol 1 neb q 6 Indications: To relieve bronchospasm associated with acute or chronic asthma, bronchitis, or other reversible obstructive airway diseases. Also used to prevent exercise-induced bronchospasm. Action: Acts relatively selectively at beta2-adrenergic receptors to cause bronchodilation and vasodilation; at higher doses, beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical sympathomimetic Contraindications: Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecholamines); unstable Contraindication: - Severe sodium and water depletion, hypersensitivity to sulphonamides and furosemide, hypokalaemia, hyponatraemia, precomatose states associated with liver cirrhosis, anuria or renal failure. -Addisons disease. Action: Inhibits reabsorption of Na and chloride mainly in the medullary portion of the ascending Loop of Henle. Excretion of potassium and ammonia is also increased while uric acid excretion is reduced. It increases plasma- renin levels and secondary hyperaldosteronism may result. Furosemide reduces BP in hypertensives as well as in normotensives. It also reduces pulmonary oedema before diuresis has set in. Drug Name Indications/Contraindications Aldazide 1 tab BID Indications: Essential hypertension, edema and ascites of CHF, liver cirrhosis, nephritic syndrome, idiopathic edema Action: Competes with aldosterone for receptor sites in the distal renal tubules, increasing sodium chloride and water excretion while conserving potassium and hydrogen ions, may block the effect of aldosterone on arteriolar smooth muscle as well Contraindications: Acute renal insufficiency, rapid deterioration of renal function, anuria, hyperkalaemia or sensitivity to thiazides. Lactating mothers should not receive the combination as thiazides appear in milk. Action: Acts relatively selectively at beta2-adrenergic receptors to cause bronchodilation and vasodilation; at higher doses, beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical sympathomimetic Contraindications: Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecholamines); unstable Side Effects Nursing Responsibilities CNS: headache, dizziness,lethargy, paresthesias Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. GI: nausea,vomiting, diarrhea,anorexia, abdominal pain, flatulence, Inspect IV injection site frequently for signs of phlebitis. GU: nephrotoxicity Report onset of loose stools or diarrhea. Although pseudomembranous colitis rarely occurs, this potentially life- threatening complication should be ruled out as the cause of diarrhea during and after antibiotic therapy. Hematologic: bone marrow depression Side Effects Nursing Responsibilities Check temperatureof patient before giving the medication. Give the medication for temperature >37.5 C Monitor for S&S of: hepatotoxicity, even with moderate doses, especially in individuals with poor nutrition. Ensure patient is not taking other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. Do not use for fever persisting longer than 3 d, fever over 39.5 C (103 F), or recurrent fever. Side Effects Nursing Responsibilities Side effects are rare with paracetamol when it is taken at the recommended doses. Skin rashes, blood disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time. One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed, potential Side effects of aspirin and NSAIDs. Hypersensitivity: ranging from rash to fever to anaphylaxis, serum sickness reaction Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes. Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs. Sudden death from cardiac arrest has been reported. Monitor BP during periods of diuresis and through period of dosage adjustment. Observe patient closely during period of brisk diuresis. Sudden alteration in fluid and electrolyte balance may precipitate significant adverse reactions. Report symptoms to physician. Lab tests: Obtain frequent blood count, serum and urine electrolytes, CO2, BUN, blood sugar, and uric acid values during first few months of therapy and periodically thereafter. Monitor for S&S of hypokalemia. Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive diuresis can result in dehydration and hypovolemia, circulatory collapse, and hypotension. Weigh patient daily under standard conditions. Side Effects Nursing Responsibilities Monitor therapeutic effectiveness which is indicated by significant subjective improvement in pulmonary function within 6090 min after drug administration. Monitor for: S&S of fine tremor in fingers, which may interfere with precision handwork; CNS stimulation (hyperactivity, excitement, nervousness, insomnia), tachycardia, GI symptoms. Report promptly to physician. Body as a Whole: Hypersensitivity reaction. CNS: Tremor, anxiety, nervousness, restlessness, convulsions, weakness, headache, hallucinations. CV: Palpitation, hypertension, hypotension, bradycardia, reflex tachycardia. Special Senses: Blurred vision, dilated pupils. GI: Nausea, vomiting. Other: Muscle cramps, hoarseness. CV: Postural hypotension, dizziness with excessive diuresis, acute hypotensive episodes, circulatory collapse. Metabolic: Hypovolemia, dehydration, hyponatremia hypokalemia, hypochloremia metabolic alkalosis, hypomagnesemia, hypocalcemia (tetany), hyperglycemia, glycosuria, elevated BUN, hyperuricemia. GI: Nausea, vomiting, oral and gastric burning, anorexia, diarrhea, constipation, abdominal cramping, acute pancreatitis, jaundice. Urogenital: Allergic interstitial nephritis, irreversible renal failure, urinary frequency. Hematologic: Anemia, leukopenia, thrombocytopenic purpura; aplastic anemia, agranulocytosis (rare). Special Senses: Tinnitus, vertigo, feeling of fullness in ears, hearing loss (rarely permanent), blurred vision. Skin: Pruritus, urticaria, exfoliative dermatitis, purpura, photosensitivity, porphyria cutanea tarde, necrotizing angiitis (vasculitis). Body as a Whole: Increased perspiration; paresthesias; activation of SLE, muscle spasms, weakness; thrombophlebitis, pain at IM injection site. Lab tests: Periodic ABGs, pulmonary functions, and pulse oximetry. Side Effects Nursing Responsibilities Instruct patient to take medication with meals or milk and avoid excessive ingestion of food high in potassium or use of salt substitutes Diuretic effect may be delayed 2-3 days and maximum hypertensive may be delayed 2-3weeks; monitor I and O ratios and daily weight, BP, serum electrolytes (K, Na) and renal function Body as a Whole: Hypersensitivity reaction. CNS: Tremor, anxiety, nervousness, restlessness, convulsions, weakness, headache, hallucinations. CV: Palpitation, hypertension, hypotension, bradycardia, reflex tachycardia. Special Senses: Blurred vision, dilated pupils. GI: Nausea, vomiting. Other: Muscle cramps, hoarseness. Gynecomastia, GI symptoms, lethargy, headache and thrombocytopenia, leukopenia, agranulocytosis, cutaneous eruptions, pruritus, mental confusion, paresthesia, acute pancreatitis, jaundice, orthostatic hypertension, muscle spasm, weakness, fever, ataxia