Nursing Care Plan for CHF
Chronic heart failure (CHF) occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body. The terms congestive heart failure (CHF) or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure. Symptoms commonly include shortness of breath, excessive tiredness, and leg swelling. The shortness of breath is usually worse with exercise, when lying down, and at night while sleeping. There is often a limitation on the amount of exercise people can perform, even when well treated.
A study of healthy adults in the United States found the following risk factors:
- Ischaemic heart disease 62%
- Cigarette smoking 16%
- Hypertension (high blood pressure) 10%
- Obesity 8%
- Diabetes 3%
- Valvular heart disease 2% (much higher in older populations)
Rarer causes of heart failure include:
- Viral myocarditis (an infection of the heart muscle)
- Infiltrations of the muscle such as amyloidosis
- HIV cardiomyopathy (caused by human immunodeficiency virus)
- Connective tissue diseases such as systemic lupus erythematosus
- Abuse of drugs such as alcohol and cocaine
- Pharmaceutical drugs such as chemotherapeutic agents
- Arrhythmias.
Nursing Diagnosis and Nursing Intervention for CHF
1. Activity intolerance related to imbalance between supply and demand of oxygen
NOC:
Perform daily activities well
Outcome:
- Participating in physical activity with blood pressure, respiratory rate appropriate
- Normal skin color, warm and dry
- Verbalizing the importance of activity gradually
- Expressing understanding of the importance of balancing exercise and rest
- Improved activity tolerance
Interventions :
- Determining the cause of activity intolerance and determine whether the cause of physical, psychological / motivational
- Assess suitability and activities of daily recess
- Increase activity gradually, let it participate in the change of position, movement and personal care
- Make sure the client to change position gradually. Monitor symptoms of activity intolerance
- When helping clients stand, observation intolerance symptoms such as nausea, pale, headache, impaired consciousness and vital signs
- Perform ROM exercises if the client is unable to tolerate activity
- Determining the cause can help determine intolerance
Rational :
- Prolonged bedrest can contribute to activity intolerance
- Increased activity helps maintain muscle strength, tone
- Inactivity contributes to muscle strength and joint structure
2. Decreased cardiac output related to myocardial infarction
NOC:
- Having a heart pump effectively,
- Status of the circulation, tissue perfusion & vital signs normal status.
- Cardiac output is adequate, as indicated by blood pressure, pulse, normal rhythm, strong peripheral pulse, perform the activity without dipsnea and pain.
- Free from side effects of drugs used.
- Cardiac care: acute
- Evaluation of chest pain
- Auscultation of heart sounds
- Evaluation of crackels
- Monitor the status of neurology
- Monitor intake / output, urine output
- Create an environment that is conducive to rest
Circulatory Care:
- Evaluation of pulse and peripheral edema
- Monitor your skin and extremities
- Monitor vital signs
- Move the position of the client every 2 hours if necessary
- Teach ROM during bedrest
- Monitor compliance with liquid
Rational:
- The presence of pain indicates ketidakadekuatan blood supply to the heart
- Still the rhythm Gallop, crackels, tachycardia indicates heart failure
- Disturbance in the central nervous system may be associated with decreased cardiac output
- Expenditures urine less than 30 ml / h showed decreased cardiac output
- The emergence of signs of heart failure showed decreased cardiac output