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NANDA - Nursing Diagnosis

Basic Concepts of Nursing Care Plan for CHF

Nursing Assessment - Nursing Care Plan for Congestive Heart Failure

Assessment is an early stage and the foundation of the nursing process. Required careful examination to know the patient's problem, in order to give direction to the nursing actions. The success of the nursing process is highly dependent on the precision and accuracy in the assessment phase (Lismidar, et al., 2005).

1. Identity
The client's identity consists of: name, age, gender, marital status, religion, ethnicity / race, education, occupation and address.
The identity of the person in charge consists of: name, relationship with clients, education, occupation and address.

2. Health history

a. Main complaint
The main complaint client with heart failure are shortness of breath, pain and weakness during the move.

b. Current medical history
Assessment that supports the main complaints made by asking a series of questions about physical weakness by using PQRST ways, namely:
P: Provoking incidents, physical weakness occurs after mild to severe activity, according to the disturbance of the heart.
Q: Quality of pain, such as what the complaints of weakness in an activity that is perceived by the client. Usually every move, clients feel shortness of breath.
R: Region, whether physical weakness localized or affect the entire musculoskeletal system and is accompanied by the inability to perform the movement.
S: Severity (scale) of pain, examine the range of the client's ability to perform daily activities. Usually the client's ability to move decreases the degree of interference experienced organ perfusion.
T: Time, nature of early onset, complaints of weakness activity usually occurs slowly. Old onset of weakness when the move is usually all times, both at rest and during activity.

c. Past medical history
Assessment of the support assessed by asking whether previously been suffering from chest pain, hypertension, myocardial ischemia, diabetes mellitus, and hyperlipidemia.
Ask about drugs commonly taken by the client in the past and are still relevant to current conditions. These drugs include drugs diuretics, nitrates, beta-blockers, and antihypertensives. Note the side effects that occurred in the past. Drug allergies and allergic reactions that arise. Often clients interpret an allergy as a side effect of medications.

d. Family history
The nurse asked about illnesses experienced by the family, the family members who died, especially in the productive age, and cause of death. Ischemic heart disease in the elderly who onset at a young age is a major risk factor for ischemic heart disease in the offspring.


3. Requirement: Biology - Psychology -Sosial -Spiritual, include:

a. Activity / rest
Clients usually complain of fatigue / tiredness constantly throughout the day, insomnia, chest pain on exertion and dyspnea at rest.

b. circulation
Usually the client has a history of hypertension, recent myocardial infarction / acute episodes prior CHF, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.

c. Ego Integrity
Clients say anxiety, worry and fear. Stress related illnesses / financial concerns (job / medical care costs).

d. Elimination
Clients say a decrease in urination, dark colored urine, like urination at night (nocturia), diarrhea / constipation.

e. Food / Fluid
Clients say has no appetite, always nausea / vomiting, weight gain significantly.

f. Hygiene
Client states feel tired / weak, ie the client perceived fatigue during self-care activities.

g. Neurosensory
Client states weakened, like the feel dizzy, and sometimes experience fainting.

h. Pain / comfort
Clients complain of chest pain, acute or chronic angina, upper right abdominal pain and muscle pain.

i. Breathing
Clients expressed dyspnea on exertion, sleep sitting up or with a few pillows, cough with / without the formation of sputum, history of chronic diseases, use of rescue breathing.

j. Security
Clients say experience changes in mental function, loss of strength, muscle tone, skin abrasions.

k. Social interaction
Client states rarely follow the usual social activities.

l. Learning / teaching
Client states use / forget to use heart medications, eg calcium channel blockers.


4. Physical Examination

a. General circumstances:
On examination of the general situation, the client's awareness of heart failure is usually good or composmentis and will change according to the level of perfusion disorders of the central nervous system.

b. Vital signs: blood pressure, pulse, respiration, temperature.


5. Examination Support
Investigations in congestive heart failure, namely:
  • Echocardiography,
  • Thoracic X-rays, and
  • Electrocardiography.

NCP for Activity Intolerance related to Heart Failure


Nursing Care Plan for Heart Failure

Nursing Diagnosis : Activity Intolerance low cardiac output, inability to meet the metabolism of skeletal muscle, pulmonary congestion leading to hypoxia, dyspnea and poor nutritional status during illness.

Activity intolerance related to fatigue.

Definition: Insufficient physiological or psychological energy to continue or complete the requested activity or daily activities.

Defining characteristics:
  • Verbally report the presence of fatigue or weakness.
  • Abnormal response of blood pressure or pulse of activity.
  • ECG changes indicating ischemia or arrhythmias.
  • The presence of dyspnea or discomfort during the move.

Related factors:
  • Bed rest or immobilization.
  • Overall weakness.
  • The imbalance between oxygen supply needs.
  • Lifestyle is maintained.

NOC:
  • Energy conservation.
  • Self Care: ADLs.

Outcomes:
  • Participating in physical activity without an increase in blood pressure, pulse and respiration.
  • Able to perform daily activities (ADLs) independently.

NIC:

Energy Management
  • Observe for client restrictions in activity.
  • Encourage the child to express feelings of limitation.
  • Assess the factors that cause fatigue.
  • Monitor nutrition and adequate sources of energy.
  • Monitor the patient of the existence of physical exhaustion and emotional excess.
  • Monitor cardiovascular response to activity.
  • Monitor sleep patterns and duration of sleep / rest patients.
Activity Therapy
  • Collaborate with the Medical Rehabilitation Workers in planning the program as appropriate therapy.
  • Help clients to identify activity that is able to do.
  • Help to choose appropriate activities consistent with the physical, psychological and social.
  • Help to identify and obtain the necessary resources for the desired activity.
  • Help to get aids such as wheelchairs activity.
  • Help to identify the preferred activity.
  • Help clients to make exercise schedule at leisure.
  • Help the patient / family to identify deficiencies in the move.
  • Provide positive reinforcement for active activities.
  • Help the patient to develop self-motivation and reinforcement.
  • Monitor response to physical, emotional, social and spiritual.

NCP for Ineffective Tissue Perfusion related to Heart Failure


Nursing Diagnosis for Heart Failure : Ineffective Tissue Perfusion related to decrease in cardiac output, tissue hypoxemia, acidosis and possible thrombus or embolism.

Definitions:
Decreased oxygen delivery, the failure to feed the tissue at the capillary level.

Defining characteristics:

Renal :
  • Changes in blood pressure beyond the limits of the parameters.
  • Hematuria.
  • Oliguria / anuria.
  • Elevation / decrease in BUN / creatinine ratio.
Gastrointestinal :
  • Intestinal hypoactive or absent.
  • Nausea.
  • Abdominal distention.
  • Abdominal pain or does not feel soft (tenderness).
Peripheral :
  • Edema.
  • Positive Homan's sign.
  • Changes in skin characteristics (hair, nails, water / moisture).
  • The pulse is weak or non-existent.
  • Discoloration of the skin.
  • Changes in skin temperature.
  • Changes in sensation.
  • Bluish.
  • Changes in blood pressure in the extremities.
  • Bruit.
  • Too late to recover.
  • Reduced arterial pulsation.
  • Pale skin color in elevation, the color does not return to the decrease in the foot.

Cerebral:
  • Abnormalities talk.
  • Limb weakness or paralysis.
  • Changes in mental status.
  • Changes in the motor response.
  • Changes in pupil reaction.
  • Difficulty in swallowing.
  • Changes in habits.
Cardiopulmonary :
  • Changes in the frequency of respiration beyond the limits of the parameters.
  • The use of additional respiratory muscles.
  • Turn over three second capillary (capillary refill).
  • Abnormal arterial blood gases.
  • The feeling of "impending Doom" (Fate threatened).
  • Bronchospasm.
  • Dyspnea.
  • Arrhythmias.
  • Nose redness.
  • Chest retraction.
  • Chest pain.

Related Factors :
  • Hypovolemia.
  • Hypervolaemia.
  • Arterial flow was interrupted.
  • Exchange problems.
  • Venous flow is cut off.
  • Hypoventilation.
  • Mechanical reduction in venous or arterial blood flow.
  • Damage to transport oxygen through the alveolar and capillary membranes.
  • Not comparable between ventilation with blood flow.
  • Poisoning enzyme.
  • Changes in affinity / binding O2 with Hb.
  • The decline in Hb concentration in the blood.

NOC:
  • Circulation status.
  • Tissue Perfusion: cerebral.
Outcomes:
a. Demonstrating circulation status, which is characterized by:
  • Systole and diastole the pressure within the expected range.
  • No orthostatic hypertension.
  • No signs of increased intracranial pressure (no more than 15 mm Hg).
b. Demonstrating cognitive ability, which is characterized by:
  • Communicate clearly and in accordance with ability.
  • Shows attention, concentration and orientation.
  • Process the information.
  • Making the correct decision.
c. Showed intact cranial sensorimotor functions: level of consciousness improved, there is no involuntary movements.


NIC:

Peripheral Sensation Management.
  • Monitor the presence of certain areas only sensitive to heat / cold / sharp / blunt.
  • Monitor the presence of paresthesia.
  • Instruct family to observe the skin, if there are lesions or lacerations.
  • Use gloves for protection.
  • Limit movement of the head, neck and back.
  • Monitor the ability of defecation.
  • Collaboration of analgesic.
  • Monitor the presence of thrombophlebitis.
  • Discuss about the causes of changes in sensation.

NCP Knowledge Deficit related to Cesarean Section

Nursing Care Plan for Cesarean Section

A Caesarean section is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies.

Nursing Diagnosis : Knowledge Deficit : regarding physiological changes, periods of recovery, self-care, and baby care needs related to misinterpretation, did not know the sources.

Goal:
Expressing an understanding of the physiological changes, the needs of the individual, the results expected.
Activities / procedures that need to be done correctly and describes the reasons for the action.

Intervention:

1. Assess the client's readiness and motivation to learn. Help clients / partners in identifying needs.
Rational: the post-partum period can be a positive experience of education when given the opportunity to assist in the development / growth of the mother, malnutrition and competence.

2. Assess the physical state of the client. Plan appropriate groups or individuals after administration of drug or when the client feel comfortable and rest.
Rationale: Allows clients to concentrate more fully and receive counseling.

3. Pay attention to psychological status and response to cesarean birth and the role of motherhood.
Rationale: Anxiety related to the ability to care for themselves and their children, disappointment on the birth experience has a negative impact on learning ability and readiness of the client.

4. Review the need for self-care needs. Encourage participation in self-care if the client can afford.
Rationale: Facilitating autonomy. Help prevent infection and promote recovery.

5. Discuss appropriate exercise program, according to the provisions.
Rationale: progressive exercise program, usually can be started, if abdominal discomfort has diminished.

6. Identify signs / symptoms that require the attention of a health care provider.
Rationale: Evaluation intervene immediately to prevent / limit the development of complications.

7. Demonstrate the techniques of infant care. Observations re demonstration by the client / partner.
Rationale: Helping parents in mastering new tasks.

8. Discuss contraception plan. Give informant about the methods available methods, including advantages and disadvantages.
Rationale: The relationship is re-established as soon as possible when the client starts to feel comfortable and the recovery has progressed.

9. Provide or reinforce information related to post-partum follow-up examination.
Rationale: Evaluation of post-partum cesarean delivery, may be scheduled for the third week of the sixth week because of the increased risk of infection and slowing the recovery.
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