Congestive heart failure (CHF) occurs when the heart isn't able to pump blood normally. As a result, there is not enough blood flow to provide the body's organs with oxygen and nutrients. The term "heart failure" does not mean that the heart stops beating completely, but that the heart is not working as efficiently.
There are two basic problems in congestive heart failure:
- systolic dysfunction occurs when the heart can't pump enough blood to supply all the body's needs
- diastolic dysfunction occurs when the heart cannot accept all the blood being sent to it
Nursng Diagnosis for CHF : Activity Intolerance related to
- Imbalance between oxygen supply.
- General weakness.
- Prolonged bed rest / immobilization.
Characterized by:
- weakness
- fatigue
- changes in vital signs
- presence of dysrhythmias, dyspnea, pallor, sweating.
Goals / expected outcomes:
Client will:
- participate in desired activities,
- meet self-care,
- achieve increased tolerance activity can be measured
evidenced by the decrease in weakness and fatigue.
Nursing Intervention
1. Check vital signs before and immediately after the activity, especially if the client is using vasodilators, diuretics and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), displacement fluid (diuretics) or influence cardiac function.
2. Note the cardiopulmonary response to activity, noted tachycardia, dysrhythmias, dyspnea, sweating and pale.
Rationale: Decrease / inability of the myocardium to increase the volume, as long as the activity can lead to an immediate increase in heart rate and oxygen demand is also increasing fatigue and weakness.
3. Evaluation of increased activity intolerance.
Rational: It can show an increase in cardiac decompensation rather than excess activity.
4. Implementation of cardiac rehabilitation programs / activities (collaboration).
Rational: gradual increase in activity, avoiding cardiac work / oxygen consumption is excessive. Strengthening and improvement of cardiac function under stress, when the heart is unable to function better again.
Nursng Diagnosis for CHF : Fluid Volume Excess related to
- Decline in glomerular filtration rate (decreased cardiac output)
- Increased ADH production and retention of sodium / water
characterized by: Orthopnea, S3 heart sound, oliguria, edema, weight gain, hypertension, respiratory distress, abnormal heart sounds.
Goals / expected outcomes:
Client will:
- demonstrate stable fluid volume with the balance of inputs and outputs,
- breath sounds clean / clear,
- vital signs within acceptable range,
- stable weight and no edema,
- expressed an understanding of individual fluid restriction.
1. Monitor urine output, record the number and color of the time in which diuresis occurs.
Rational: urine output may be few and concentrated, due to decreased renal perfusion. Supine position so that helps diuresis of urine may be increased during bed rest.
2. Monitor / count balance input and output for 24 hours.
Rational: diuretic therapy may be caused by a sudden loss of fluid / redundant (hypovolemia) although edema / ascites is still there.
3. Keep sitting or bed rest with semifowler position during the acute phase.
Rational: The position is increasing kidney filtration and reduce the production of ADH to increase diuresis.
4. Monitor BP and CVP (if any)
Rationale: Hypertension and increased CVP showed excess fluid and may indicate an increase in pulmonary congestion, heart failure.
5. Assess bowel sounds. Record complaints anorexia, nausea, abdominal distension and constipation.
Rational: visceral congestion (occurring in chronic heart failure) can interfere with the function of gastric / intestinal.
6. Administration of drugs as indicated (collaboration)
7. Consult with a dietitian.
Rationale: The need to provide an acceptable diet that meets the client's needs calories in sodium restriction.
