NURSING CARE PLAN Nursing Diagnosis: Excess fluid volume r/t decrease cardiac output Cause Analysis: As cardiac

output falls, compensatory mechanisms cause salt and water retention increasing blood volume. This increased fluid volume places additional stressed on an already failing ventricles, making them harder to move the fluid load. References: Medical Surgical Nursing by: Lemone and Burke vol.1 p.883 Cues Objectives Nursing interventions Rationale Outcomes Subjective findings: Short Term Objectives: -Assess respiratory status - decliningrespiratory status Client may verbalize -after 6 hours of nursing and auscultate lung sounds indicates worsening left complaints of abdominal interventions, the client will be at least every 4hours. ventricle. discomfort. able to: Demonstrate weight loss -monitor intake and output. - Careful monitoring of fluid Decreases edema, jugular Notify the physician if urine volume is important during is less than 30 ml/hr. treatment of Hf. A fall in UO vein distension and may indicate reduced CO and abdominal distension renal ischemia. Objectives findings: -weigh daily. - Weight is an objective Presence of edema measure of fluid status. noted in the lower Long Term Objectives: extremities -after 2 days of nursing -record abdominal girth -venous congestion can lead to Weight gain interventions, the client will be every shift. Note any ascites and may affect able to: Nausea abdominal discomfort or gastrointestinal function and Achieve his/her normal weight. Jugular vein distension nausea. nutritional status. Abdominal distension -restrict fluids as ordered. Allow choices of fluid type and timing of intake and scheduling most of fluid intake during morning and afternoon - Offer ice chips and frequent mouth care -providing choices to the client allow clients sense of control.

-Ice chips an hard candies and mouth care relieves mouth dry thirst and promote comfort.

NURSING CARE PLAN Nursing Diagnosis: Activity intolerance r/t imbalance between O2 demand and supply Cause Analysis: Clients w/ heart failure have little or no cardiac reserve to meet increased O2 demand. As the disease progresses and cardiac function is further compromised, activity intolerance increases. Reference: Medical Surgical Nursing by: Lemone and Burke Vol.2 P.883 Cues Objectives Nursing Intervention Rationale Outcomes STO: 1. Organize nursing care to -grouping activities together After 8 hours of nursing allow rest periods. allow adequate time to interventions patient will be recharge able to participate in desired 2. Assist w/ ADL as needed. activities related to self-care Encourage - assisting with ADLs helps within her capacity independence within ensure that care needs are prescribe limit. met while reducing workload. OBJECTIVE: Involving the client promote LTO: a sense of control and After 2 days of duty, patient reduces helplessness. Decreased performance will achieve measurable 3. Plan and implements on ADLs increase in activity tolerance progressive activities. Inability to maintain as evidenced by reduced Use passive ROM -progressive activity slowly usual routine weakness and fatigue exercises as appropriate. increase capacity by Patient prefers lying on Consult physical strengthening and improving bed and sitting. therapist on activity Cardiac function without Patient appears drowsy plan. strain. Activity also helps and exhausted prevent complication. 4. Provide written and verbal information -written information provides about the activity after a reference of important discharge. information. Verbal information allows clarification and validation of material.

NURSING CARE PLAN Nursing Diagnosis: Imbalance Nutrition related to Anorexia and nausea secondary to right sided heart failure Cause Analysis: The loss of appetite contributes to improper / inadequate intake of food thus resulting to imbalance nutrition Reference: Medical Surgical Nursing by: Lemone and Burke Vol.2 Cues Objectives Nursing Intervention Rationale STO: 1. Encourage rest period of - Helps reduce fatigue during After 4 hours of implementing one hour before and after mealtime, and provide nursing interventions, patient meals. Provide frequent opportunity to increase total will be able to improve his small feedings. caloric intake. appetite. 2. Make selective menu available, and allow patient to control choices as much as possible. - Patient who gains confidence in self and feels in control of environment is more likely to eat preferred foods.

Outcomes

OBJECTIVES: * Weakness * Pallor * Minimal amount of food consumed per meal

LTO:
After 2 days of implementing nursing interventions, patient will be able to note increase in weight after improved appetite and will maintain optimal nutritional status.

3. Take into consideration patients lifestyle, cultural -helps the patient to increase background, activity level, food intake and food preferences. 4. Elicit patients explanation of why he is unable to eat more.

- His explanation may present easily corrected practices