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.
- 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.
