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

Nursing care

Symptoms of heart failure

• 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.

Developed nursing diagnoses

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.

Links

References

• ŠAFRÁNKOVÁ, Alena – NEJEDLÁ, Marie. Interní ošetřovatelství I. 1. edition. Grada, 2006. 280 pp. ISBN 80-247-1148-6.