Nursing Diagnoses and related interventions

Below are a helpful list of potential nursing diagnoses commonly used when caring for a patient with Heart Failure.  The relevant nursing interventions follow.  The below list is not exhaustive, but a guide to help the student nurse in providing care to the patient with Heart Failure.

Decreased Cardiac Output

  • Auscultate heart and lung sounds, assess for abnormalities.
  • Assess and monitor blood pressure and pulse
  • Assess and monitor mental status and level of consciousness
  • Assess and monitor laboratory tests
  • Assess and monitor oxygen saturation
  • Assess need for oxygen and apply as needed per patient symptoms
  • Administer cardiac medications
  • Assess peripheral pulses
  • Assist with all activities
  • Encourage rest
  • Position to high Fowler’s position and reposition as needed.

Fluid volume excess

  • Assess and monitor vital signs
  • Monitor intake and output
  • Weigh daily, assess for 2lb. weight gain in 24 hours (goal is decrease weight)
  • Auscultate lung sounds
  • Assess for peripheral edema
  • Assess for jugular vein distention
  • Assess for ascites
  • Follow low sodium diet as ordered by MD
  • Follow fluid restriction as ordered by MD
  • Administer diuretics as ordered and monitor urine output

Activity Intolerance

  • Monitor, assess and document vital signs
  • Provide for periods of rest
  • Assist with all activities
  • Provide calm, quiet environment
  • Assist with walking
  • Assess for need of adaptive device
  • Assess  need for physical and or occupational therapy

Ineffective Tissue Perfusion

  • Administer vasodilators and beta blockers as ordered by MD
  • Assess for changes and monitor vital signs
  • Administer oxygen as needed per patient indications
  • Assess and monitor laboratory results
  • Elevate head of bed
  • Assess circulatory status

Ineffective airway clearance

  • Assess, monitor and record vital signs
  • Assess respiratory rate, rhythm
  • Assess lung sounds
  • Elevate head of bed
  • Auscultate lung sounds
  • Assess and monitor for dyspnea
  • Administer oxygen as needed
  • Assist patient with coughing and deep breathing
  • Administer bronchodilators as ordered/needed

Anxiety

  • Assess for signs/symptoms of anxiety:  dyspnea, poor eye contact, restlessness
  • Assess for insomnia
  • Assess for elevated blood pressure and pulse
  • Assess client’s support system
  • Provide comfort and reassurance
  • Teach deep breathing exercises, biofeedback, guided imagery to decrease anxiety

Impaired gas exchange

  • Assess, monitor, record vital signs
  • Assess for cyanosis of nail beds, mucous membranes, skin
  • Elevate head of bed
  • Encourage rest periods
  • Administer oxygen as needed

 

 

 

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