Nanda Nursing Diagnosis

In case of heart failure, the body has several adaptations, both in the heart and systemically. If both ventricular stroke volume is reduced, therefore the emphasis contractility or afterload was increased, the volume and end-diastolic pressure in the two chambers of the heart increased. This will increase the length of myocardial fibers end-diastolic, systolic rise time becomes shorter. If this condition persists, ventricular dilatation occurs. Cardiac output at rest can still be good, but the increase in diastolic pressure that lasts longer / chronicle will spread to both the atrium and the pulmonary circulation and the systemic circulation. Finally, capillary pressure will increase which will lead to transudation of fluid and edema arising systemic or pulmonary edema. Decrease in cardiac output, especially if associated with a reduction in arterial pressure or decreased renal perfusion, will activate several neural and humoral systems. Increased activity of the sympathetic nervous s...

Nursing Diagnosis for CHF - Congestive Heart Failure 1 Decreased Cardiac Output related to changes in left ventricular contractility, rhythm frequency changes, electrical conduction 2. Ineffective Tissue Perfusion related to decrease in cardiac output tissue hypoxemia, acidosis and, the possibility of thrombus or emboli. 3. Ineffective Airway Clearance related to decrease in lung volume, hepatomegaly, splenomegaly 4. Activity Intolerance related to imbalance between myocardial oxygen supply and demand of the body, the ischemic / necrotic myocardial tissue 5. Excess Fluid Volume related to Systemic fluid overload, interstitial fluid permeation in the systemic secondary to decreased cardiac output, right heart failure 6. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, dyspnoea, nausea, vomiting, side effects of drugs, sputum production 7. Sleep pattern disturbance related to paroxysmal nocturnal disease, hospitalization, crowded 8. Anxiety related to fear of death,...

Nursing Assessment for Congestive Heart Failure 1. Activity / rest Symptoms: fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest. Symptoms: Anxiety, mental status changes such as lethargy, changes in vital signs of activity. 2. Circulation Symptoms: history of hypertension, acute myocardial infak, previous episodes of Chronic Heart Failure , heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen. Signs: blood pressure; may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia, apical pulse; PMI may spread and change in an inferior position to the left, heart murmurs; S3 (gallops) is diagnostic, S4 may, occur, S1 and S2 may be weakened, systolic and diastolic murmur, Color: blue, pale gray, cyanotic, nail backs; pale or cyanotic with a filling, capillary slow, Liver; enlargement / can be palpated, breath sounds ; crackles, rhonchi, edema; ma...

Diagnostic Examination for CHF 1. Thoracic X-ray: may reveal an enlarged heart, edema or pleural effusion which confirmed the diagnosis of CHF. 2. ECG: reveals tachycardia, ventricular hypertrophy and ischemia, an echocardiogram. 3. Laboratory examination: includes electrolytes, serum sodium levels revealed a low blood hemodilution that results from the presence of excess water retention, potassium, sodium, chloride, urea and blood sugar. 4. Sonogram (echocardiogram) to indicate the dimensions of ventricular enlargement, changes in the function / structure of the valve or area decreased ventricular contractility. 5. Cardiac catheterization: an indication of abnormal pressure and helps to distinguish right and left heart failure and valvular stenosis or insufficiency. Also assess patency of coronary arteries. Contrast agent is injected into the ventricles show abnormal size and ejection fraction / change in contractility. 6. Ultrasonography (USG): get an overview of free fluid in the ab...

Nursing Care Plan for Heart Failure    Nursing Diagnosis : 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 rhyt...

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 / in...