ASSESSMENT Objective data: Shortness of breath Ankle edema Decrease in appetite

GOALS OF CARE MAINTAIN ADEQUATE CARDIAC OUTPUT

NURSING INTERVENTIONS PROMOTIVE/PREVENTIVE Place patient at physical and emotional rest to reduce work of heart. Provide rest in semi-recumbent position or in armchair in air-conditioned environment Provide bedside commode

CORE COMPETENCIES

EVALUATION OUTCOMES y Normal BP and heart rate y Heart rate within normal limits, rests between activities

NURSING DIAGNOSIS: Provide for psychological rest . Decreased Cardiac Output related to impaired contractility and increased preload and after load Promote physical comfort. Avoid situations that tend to promote anxiety and agitation. Offer careful explanations and answers to the patient's questions. Monitor blood pressure to evaluate progression of left sided heart failure Auscultate heart sounds frequently and monitor cardiac rhythm. Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature of skin, facial pallor, poor capillary refill of nailbeds.

Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures

IMPROVE OXYGENATION

Raise head of bed 8 to 10 inches (20 to 25 cm) reduces venous return to heart and lungs; alleviates pulmonary congestion. o Support lower arms with pillows eliminates pull of patient's weight on shoulder muscles. o Sit orthopneic patient on side of bed with feet supported by a chair, head and arms resting on an over-the-bed table, and lumbosacral area supported with pillows. Auscultate lung fields at least every 4 hours for crackles and wheezes in dependent lung fields (fluid accumulates in areas affected by gravity). o Mark with indelible ink the level on the patient's back where adventitious breath sounds are heard. o Use markings for comparative assessment over time and among different care providers. Observe for increased rate of respirations (could be indicative of falling arterial pH). Observe for Cheyne-Stokes respirations (may occur in elderly patients because of a decrease in cerebral perfusion stimulating a neurogenic response). Position the patient every 2 hours (or encourage the patient to

Respiratory rate, 16 to 20 breaths/minute; ABG levels within normal limits; no signs of crackles or wheezes in lung fields

change position frequently) to help prevent atelectasis and pneumonia. Encourage deep-breathing exercises every 1 to 2 hours to avoid atelectasis. Offer small, frequent feedings to avoid excessive gastric filling and abdominal distention with subsequent elevation of diaphragm that causes decrease in lung capacity.

CURATIVE Administer oxygen as directed. Administer pharmacotherapy as directed. Monitor for adverse effects and effect of drug therapy. Monitor clinical response of patient with respect to relief of symptoms (lessening dyspnea and orthopnea, decrease in crackles, relief of peripheral edema).

Excess Fluid Volume related to sodium and water retention

RESTORE FLUID BALANCE

y y

y y

Administer prescribed diuretic as ordered. Give diuretic early in the morning nighttime diuresis disturbs sleep. Keep input and output record patient may lose large volume of fluid after a single dose of diuretic. Watch fluid intake. Weigh patient daily to determine if edema is being controlled; weight loss should not exceed 1 to 2 lb (0.5 to 1 kg)/day. Assess for signs of hypovolemia caused by diuretic therapy thirst, decreased urine output, orthostatic hypotension, weak, thready pulse, increased serum osmolality, and increased urine specific gravity. Be alert for signs of hypokalemia, which may cause weakening of cardiac contractions and may precipitate digoxin toxicity in the form of dysrhythmias, anorexia, nausea, vomiting, abdominal distention, paralytic ileus, paresthesias, muscle weakness and cramps, confusion. Check electrolytes frequently. Give potassium supplements as prescribed. Be aware of disorders that may be worsened by diuretic therapy, including hyperuricemia, gout, volume depletion, hyponatremia, magnesium depletion, hyperglycemia, and diabetes mellitus. Also, note that some patients allergic to sulfa drugs may also be allergic to thiazide diuretics. Watch for signs of bladder

Weight decrease of 2.2 lb (1 kg) daily, no pitting edema of lower extremities and sacral area

distention in elderly male patients with prostatic hyperplasia. Administer I.V. fluids carefully through an intermittent access device to prevent fluid overload. Monitor for pitting edema of lower extremities and sacral area. Use convoluted foam mattress and sheepskin to prevent pressure ulcers (poor blood flow and edema increase susceptibility). Observe for the complications of bed rest pressure ulcers (especially in edematous patients), phlebothrombosis, pulmonary embolism. Be alert to complaints of right upper quadrant abdominal pain, poor appetite, nausea, and abdominal distention (may indicate hepatic and visceral engorgement). Monitor patient's diet. Diet may be limited in sodium to prevent, control, or eliminate edema; may also be limited in calories. Caution patients to avoid added salt in food and foods with high sodium content.

REHABILITAIVE IMPROVE KNOWLEDGE ON DSE PROCESS

y

Instruct family and client about the disease process, complications of disease process, information on medications, need for weighing daily, and when it is appropriate to call doctor. Watch for weight gain and report a gain or loss of more than 2 to 3 lb (1 to 1.4 kg) in a few days. Weigh patient at same time daily to detect any tendency toward fluid retention: swelling of ankles, feet, abdomen; persistent cough; tiredness; loss of appetite; frequent urination at night. Continue to monitor client for exacerbation of heart failure when discharged home. Transition to home can create increased stress and physiological instability related to diagnosis.

Heart rate within normal limits, rests between activities

Review medication regimen. o Medications to control heart rate include digoxin or beta-adrenergic blockers. o Anticoagulation if indicated.

Patient Education and Health Maintenance

Advise patient of symptoms that need to be reported to health care provider. o Breathlessness o Increased shortness of breath o Wheezing o Sleeping upright with pillows Help patient label all medications. o Give written instructions. o Make sure the patient has a check-off system that will show that he has taken medications. o Inform the patient of adverse drug effects. o If the patient is taking oral potassium solution, it may be diluted with juice and taken after a meal. o Tell the patient to weigh self daily and log weight if on diuretic therapy. o Ask whether patient is taking Coenzyme Q10 or other supplements; should discuss with health care provider. Review activity program. Instruct the patient as follows: o Increase walking and other activities gradually, provided they do not cause fatigue and dyspnea. o In general, continue at whatever activity level can be maintained without the

States recurrent symptoms to watch for and knows medications and doses

appearance of symptoms. o Avoid excesses in eating and drinking. o Undertake a weight reduction program until optimal weight is reached. o Avoid extremes in heat and cold, which increase the work of the heart; air conditioning may be essential in a hot, humid environment. o Keep regular appointment with health care provider or clinic. Restrict sodium as directed. o Teach restricted sodium diet and the DASH diet o Give patient a written diet plan with lists of permitted and restricted foods. o Advise patient to look at all labels to ascertain sodium content (antacids, laxatives, cough remedies, and so forth). o Teach the patient to rinse the mouth well after using tooth cleansers and mouthwashes some of these contain large amounts of sodium. Water softeners should be checked for salt content. o Teach the patient that sodium is present in alkalizers, cough remedies, laxatives, pain relievers, estrogens, and other drugs. o Encourage use of

y y

flavorings, spices, herbs, and lemon juice. o Avoid salt substitutes with renal disease. Make sure patient sets up followup appointments. Advise patient on smoking cessation, provide information, if indicated. Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Transition to the home setting can cause risk factors such as inappropriate diet to reemerge. Refer to physical therapy for strengthening exercises if client is not involved in cardiac rehabilitation. Refer to medical social services as necessary for counseling about the impact of severe or chronic cardiac disease. Social workers can assist the client and family with acceptance of life changes.