Assessment

  1. Gather the patient’s medical history, including any previous cardiac conditions, medications, and lifestyle habits.
  2. Perform a thorough physical examination, focusing on cardiovascular and respiratory systems.
  3. Monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation.
  4. Assess the patient’s level of dyspnea, activity tolerance, and fluid status.
  5. Evaluate the patient’s nutritional status and assess for any signs of fluid retention.

Nursing Diagnosis

  1. Impaired gas exchange related to decreased oxygenation secondary to heart failure.
  2. Decreased cardiac output related to impaired pumping ability of the heart.
  3. Excess fluid volume related to fluid retention secondary to heart failure.
  4. Activity intolerance related to decreased cardiac function.
  5. Knowledge deficit regarding heart failure management.

Planning

  1. Improve gas exchange and oxygenation.
  2. Optimize cardiac output and improve heart function.
  3. Reduce fluid retention and manage edema.
  4. Increase activity tolerance and exercise capacity.
  5. Educate the patient and family about heart failure management and lifestyle modifications.

Implementation

  1. Administer oxygen therapy as prescribed to improve oxygenation.
  2. Monitor fluid intake and output; implement a fluid restriction plan if necessary.
  3. Administer medications as prescribed (e.g., diuretics, ACE inhibitors, beta-blockers) to manage heart failure symptoms and improve cardiac function.
  4. Monitor electrolyte levels, especially potassium, due to diuretic use.
  5. Educate the patient about a low-sodium diet and fluid management.
  6. Encourage regular exercise as tolerated and provide a structured exercise program if needed.
  7. Assist with activities of daily living to conserve the patient’s energy.
  8. Monitor the patient’s weight regularly to detect fluid retention.
  9. Implement measures to reduce anxiety and stress.
  10. Educate the patient and family about heart failure management, warning signs, and when to seek medical help.

Evaluation

  1. Regularly assess the patient’s response to interventions and adjust the care plan as needed.
  2. Monitor vital signs, oxygen saturation, and fluid status.
  3. Evaluate improvements in activity tolerance and exercise capacity.
  4. Review the patient’s understanding of heart failure management and provide additional education if necessary.
  5. Collaborate with the healthcare team to ensure comprehensive care and address any complications or changes in the patient’s condition.

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