About
Failure of the heart to adequately perfuse the tissues with resulting back-up of fluids into the lungs, peripheral tissues, and increased workload of the heart.
Assess
Fatigue, weakness, dyspnea, orthopnea, pulmonary congestion, cool, pale, tachycardia, anxiety, restless, pulse oximetry
Complications
End stage congestive heart failure
Respiratory or cardiac arrest- start CPR.
Multisystem organ failure, end stage disease
Diagnosis
- Decreased cardiac output related to abnormal cardiac rhythm.
- Knowledge deficit related to procedure and treatment of arrhythmias.
- Impaired gas exchange related to pulmonary congestion
- Decreased cardiac output related to pump failure of ventricle
- Activity intolerance related to oxygen supply/ demand imbalances
- Excess fluid volume related to mechanical factors
Goals
- The client will have adequate oxygenation.
- The client will identify symptoms that may necessitate a change in treatment protocol.
- The client will have clear breath sounds upon auscultation.
Interventions
- Monitor extremity including edema, redness, pulses, pallor, pain, and decreased sensation.
- Assess lung sounds, vital signs, and pulse oximetry.
- Monitor intake and output, monitor daily weights ( a 2.2 pound weight gain = 1 liter of fluid gain).
- Administer diuretics, as ordered.
- Administer other cardiac drugs to manage cardiac disease ( cardiac glycosides, antihypertensives, nitrates, etc.).
- Implement fluid restrictions as ordered.
- Teach the client to maintain a low sodium diet.
- Teach client to monitor for signs of worsening; increase in daily weights, increase in shortness of breath, orthopnea, nocturia, etc.).
- Monitor for signs/ symptoms of complications.
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