Nursing Diagnosis and Interventions for Heart Failure

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Nursing Diagnosis and Interventions for Heart Failure

Nursing Diagnosis for Heart Failure 1.

Decreased cardiac output related to changes in myocardial contractility.

Goal: show vital signs within acceptable limits, decreased dyspnea episodes of angina (report).

Nursing Interventions :

a. Auscultation apical pulse, assess the frequency and rhythm of the heart
b. Record the heart sounds
c. Palpation of peripheral pulses
d. Assess the skin of cyanosis and pallor
e. Provide a comfortable and quiet environment

Nursing Diagnosis for Heart Failure 2.

Activity intolerance related to imbalance between supply oxygenation needs.

Goal : Participate in a desired activity, meets the needs of self-tolerance achieving increased activity can be measured, evidenced by a decrease in fatigue and weakness and vital signs during exercise.

Nursing Interventions :

a. Check vital signs before and after the activity, particularly when patients using vasodilator, diuretic.
b. Note the cardiopulmonary response to activity, note tachycardia, distrimia, dyspnea, sweating, pale.
c. Assess the precipitator / causes weakness example: treatment, pain, medication.
d. Evaluation of an increase in activity intolerance.
e. Provide assistance in self-care activities in accordance with the indication.

Nursing Diagnosis for Heart Failure 3.

Excess fluid volume related to decreased glomerular filtration rate (GFR).

Goal : The balance of inputs and outputs, clean breath sounds, vital signs within acceptable range, stable weight, no edema. Stating an understanding of individual fluid restriction.

Nursing Interventions :

a. Monitor urine output
b. Monitor / calculate the balance of income and output 24 hours.
c. Maintain a sitting / semi-Fowler position during the acute phase.
d. Auscultation of breath sounds, or sound record and an additional reduction.
e. Monitor blood pressure.

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