Nursing care of a patient with heart failure/HF (nurse)

Nursing care



 * Impairment of tissue blood flow and increase in the volume of body fluids as a result of a decrease in srd. excretion and retention of sodium.
 * Risk of impaired gas exchange in the lungs as a result of fluid accumulation in the lungs.
 * Swelling of the limbs due to reduced mobility and less blood supply to peripheral tissues.
 * Reduction of physical performance and limitation of self-care.
 * Anxiety, fear, confusion caused by the symptoms of the disease.
 * Sleep disorders due to nocturia.

Goals of nursing care

 * Monitor the patient's condition and his physiological functions and prevent the deterioration of the condition and the emergence of complications.
 * Improve heart function by correct administration of prescribed drugs.
 * A suitable position to ensure comfort and improvement of respiratory functions.
 * Calm the patient, induce a feeling of security and trust and peaceful sleep.
 * Ensure hygienic care, defecation care and nutrition.

Nursing Care Plan

 * Patient admitted to internment, ICU, ARO according to status.
 * The patient is placed in a high Fowler's position or orthoptic.
 * Room with O2, chair for cardiac patients, near toilet, bell.


 * Peripheral cannula for drug administration, the effect of diuretic and cardiotonic is monitored.
 * Blood sampling according to the doctor's office, EKG, pulse, BP, d, O2, we will teach you about coughing.

We are following

 * VITAL SIGNS – BP, P, D, consciousness, EKG, cough and expectoration, character of cough and appearance of sputum.
 * EMPTYING of urine and faeces, diuresis in 24 hours, FLUID BALANCE.
 * STATUS OF BLOOD PERIP. tissue, skin color – pallor, cyanosis, skin temperature.
 * LAB VALUES. RESULT – minerals, coagulation, astrup.
 * WEIGHT – indicator of changes in the volume of body fluids.
 * SWELLING - sight, palpation, the circumference of the abdomen and ankles with a tape measure.
 * MENTAL STATUS – loss of appetite, moodiness, fatigue, pain, insomnia.
 * DEGREE OF SELF-SUFFICIENCE – prevention of bedsores, bedsores, less effort, hyg. care, care for swollen limbs.
 * DIET - restriction of salt (salt retains fluids in the body).
 * EDUCATION PAC. – no smoking, healthy lifestyle, less salt, eat more often and less, do not exert yourself.

Shortness of breath due to asthma cardiale (pulmonary edema)

 * Aim: To improve gas exchange in the breath. travel, eliminate shortness of breath, improve breathing.
 * Plan:
 * Serve O2.
 * Monitor physiological functions.
 * Orthoptic position for better breathing.
 * Watch for wheezing and wheezing during expiration, expectoration with pink sputum admixture.

Pain induced as a result of cardiac muscle ischemia

 * Goal: To relieve or eliminate pain.
 * Plan:
 * Administer analgesics according to the doctor.
 * Monitor pain and evaluate it verbally or non-verbally, record in documentation.
 * Relief position.

Fear, anxiety

 * Goal: Alleviate fear, eliminate anxiety.
 * Plan:
 * Cooperate with pac.
 * Explain the performed procedures, mediate consultations with the doctor.
 * Support the patient in formulating what he is afraid of.
 * Enough time to talk.