Nursing Diagnosis Activity Intolerance related to Congestive Heart Failure (CHF)

Nursing Diagnosis for Congestive Heart Failure (CHF)

Activity Intolerance

related to imbalance between oxygen supply. General weakness, long bedrest / immobilized.

Characterized by:

• Weakness,
• fatigue,
• changes in vital signs,
• presence of dysrhythmias,
• dyspnea,
• pallor,
• sweating.

Goals / evaluation criteria:

Clients will participate in desired activities, meet self-care, achieve increased tolerance activity can be measured, evidenced by a decrease in weakness and fatigue.

Nursing Interventions Activity Intolerance related to Congestive Heart Failure (CHF) :

1. Check vital signs before and immediately after activity, especially when the client is using vasodilators, diuretics and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), the displacement of fluid (diuretics) or influence cardiac function.

2. Note the cardiopulmonary response to activity, note tachycardia, dysrhythmias, dyspnea sweaty and pale.
Rationale: Decrease / inability of the myocardium to increase the volume of activity during dpat sekuncup cause an immediate increase heart rate and oxygen demand is also increasing fatigue and weakness.

3. Evaluation of increased activity intolerant.
Rational: It can show increased activity of cardiac decompensation rather than excess.

4. Implementation of cardiac rehabilitation programs / activities (collaboration)
Rationale: Increasing gradual to avoid the activity of cardiac work / oxygen consumption is excessive. Strengthening and improvement of cardiac function under stress, if cardiac function can not be improved again.

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Decreased Cardiac Output Congestive Heart Failure Nursing Care Plan

Decreased Cardiac Output NANDA Definition:

Inadequate blood pumped by the heart to meet metabolic demands of the body

Nursing Diagnosis:

Decreased cardiac output related to Altered heart rate and rhythm AEB bradycardia

characterized by:

• with pale conjunctiva, nail beds and buccal mucosa
• irregular rhythm of the pulse
• bradycardic
• pulse rate of 34 beats / min
• generalized weakness

Short-Term Objectives:
the patient Will Participate in activities That Reduced the workload of the heart.

Long-Term Objectives:
Will the patient be Able to display hemodynamic stability.

Nursing Interventions Decreased Cardiac Output Congestive Heart Failure:

1. Auscultation apical pulse; examine the frequency, the heart rhythm.
Rational: Usually tachycardia (even at rest) to compensate for the decrease in ventricular contractility.

2. Record the heart sounds.
Rational: S1 and S2 may be weak due to decreased pumping action. Gallop rhythm common (S3 and S4) is generated as the flow of blood to the porch of distension. Mur-mur may indicate incompetence / stenosis of the valve.

3. Palpation of peripheral pulses.
Rational: The decrease in cardiac output may show decreased radial artery, popliteal, dorsalis, pedis and posttibial. The pulse may disappear fast or irregular pulse to be palpable and alternan.

4. Monitor blood pressure.
Rational: In Congestive Heart Failure early, moderate or chronic blood pressure may increase. In Congestive Heart Failure-up body could no longer compensate and hypotension can not be normal again.

5. Assess against pale skin and cyanosis.
Rational: Pale, indicating reduced peripheral perfusion secondary to cardiac output adekutnya not; vasoconstriction and anemia. Cyanosis may occur as refrakstori Congestive Heart Failure. The area of ​​pain is often colored blue striped atu because of increased venous congestion.

6. Give supplemental oxygen by nasal cannula / mask and drugs as indicated (collaboration).
Rationale: Increased dosage of oxygen to the need to counter the effects of myocardial hypoxia / ischemia.

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