About
Obstruction of blood flow from the left atrium into the left ventricle causing poor ventricular filling and decreased cardiac output.
Assess
Dyspnea on exertion, dry cough, wheezing, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, palpitations, repeated respiratory infections, irregular weak pulse, atrial dysrhythmias, murmur
Complications
- Respiratory or cardiac arrest- start CPR.
- End stage congestive heart failure
Diagnosis
- Decreased cardiac output related to impaired pumping action of heart.
- Fluid volume excess related to pulmonary and peripheral edema.
- Activity intolerance related to fatigue, weakness and shortness of breath.
- Anxiety related to inadequate oxygenation.
- Impaired airway clearance related to excessive secretions.
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.
- The client will be identify strategies to promote activity tolerance i.e.. Frequent rest periods, clustering of activities, etc.
- The client will describe interventions necessary to assess for exacerbations or worsening of condition ( daily weights, increased shortness of breath).
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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