ASSESSMENT

S>
O>capillary refill
of 3-4 seconds
- Doppler
Ultrasound:
dilated left atria
with left atrial
volume index of
29 cc/m3, X-ray:
mild
cardiomegaly
- nail beds: pale
- CR: 76 bpm
regular BP:
110/70, with
noticeable S1
and S2
auscultatory
sound,
-urine output for
the shift(7-3):
500 ml, yellowish
clear, patient is
awake, coherent,
oriented to time,
place, person
Nursing

EXPLANATION
OF PROBLEM
Blood is a
connective tissue
composed of a
liquid
extracellular
matrix called
blood plasma
that dissolves
and suspends
various cells and
cell fragments.
Blood transports
oxygen from the
lungs and
nutrients from
the
gastrointestinal
tract. The oxygen
and nutrients
subsequently
diffuse from the
blood into the
interstitial fluid
and then into the
body cells.
Carbon dioxide
and other wastes
move in the
reverse direction,

OBJECTIVES
LTO

STO
After 8 of
nursing
intervention pt
will
a. lessen/
eradicate
stressors that
can help in
reducing the
workload of the
heart participate
in activities that
reduce the
workload of the

INTERVENTION
S

RATIONALE

Auscultate apical pulse;

assess heart rate,
rhythm, and document
dysrhythmia if
telemetry available.

Tachycardia is usually
present, even at rest, to
compensate for
decreased ventricular
contractility. Premature
atrial contractions
(PACs), paroxysmal
atrial tachycardia (PAT),
PVCs, multifocal atrial
tachycardia (MAT), and
AF are common
dysrhythmias
associated with HF,
although others may
also occur. Note:
Intractable ventricular
dysrhythmias
unresponsive to
medication suggest
ventricular aneurysm.

Note heart sounds.

S1 and S2 may be weak
because of diminished
pumping action.
Gallop rhythms are
common (S3 and S4),
produced as blood flows
into noncompliant,
distended chambers.
Murmurs may reflect
valvular incompetence
and stenosis.
Palpate peripheral
pulses.

Decreased cardiac
output may be reflected
in diminished radial,
popliteal, dorsalis pedis,
and post-tibial pulses.
Pulses may be fleeting
or irregular to palpation,

EVALUATION

Diagnosis:
Ineffective
Peripheral Tissue
Perfusion related
to decreased
blood flow

from body cells

to interstitial fluid
to blood. Blood
then transports
the wastes to
various organs
the lungs,
kidneys, and skin
for elimination
form the body.
Circulating blood
helps maintain
homeostasis of
all body fluids.
Blood helps
adjust body
temperature
through the heat
absorbing and
coolant
properties of the
water in blood
plasma and its
variable rate of
flow through the
skin, where
excess heat can
be lost from the
blood to the
environment. In
addition, blood

heart like stress

management,
therapeutic
medication, and
balanced activity
rest pattern.
Obj:
To be able
to decrease
edema
To be able
to promote blood
circulation
To be able
to demonstrate
an increase in
activity

and pulsus alternans

may be present.
Monitor BP.

Inspect skin for pallor

and cyanosis.

Monitor urine output,

noting decreasing
output and dark or
concentrated urine.

In early, moderate, or
chronic HF, BP may be
elevated because of
increased SVR. In
advanced HF, the body
may no longer
be able to compensate,
and profound or
irreversible hypotension
may occur. Note: Many
clients with HF have
consistently low systolic
BP (80 to 100 mm Hg)
due to their disease
process and the
medications they take.
Most tolerate this Bps
without incident
(Wingate, 2007).
Pallor is indicative of
diminished peripheral
perfusion secondary to
inadequate cardiac
output,
vasoconstriction, and
anemia.
Cyanosis may develop
in refractory HF.
Dependent areas are
often blue or mottled as
venous congestion
increases.
Kidneys respond to
reduced cardiac output
by retaining water and
sodium. Urine output is
usually decreased
during the day because

osmotic pressure
influences the
water content of
cells, mainly
through
interactions of
dissolved ions
and proteins.
Blood can clot,
which protects
against its
excessive loss
from the
cardiovascular
system after an
injury. In addition,
its white blood
cells protect
against disease
by carrying on
phagocytosis.
Several types of
blood proteins
including
antibodies,
interferons, and
complement,
help protect
against disease
in a variety of
ways. However,

Note changes in
sensorium, for example,
lethargy, confusion,
disorientation, anxiety,
and depression.
Encourage rest, semi
recumbent in bed or
chair. Assist with
physical care, as
indicated.

Provide quiet
environment, explain
medical and nursing
management, help
client avoid stressful
situations, listen and
respond to expressions
of feelings or fears.
Provide bedside
commode. Have client
avoid activities eliciting
a vasovagal response,
for instance, straining
during defecation and
holding breath during
position changes.

Elevate legs, avoiding

pressure under knee.
Encourage active and
passive exercises.
Increase ambulation
and activity as

of fluid shifts into

tissues but may be
increased at night
because fluid returns to
circulation when client
is recumbent.
May indicate
inadequate cerebral
perfusion secondary to
decreased cardiac
output.

Physical rest should be

maintained during acute
or refractory
HF to improve efficiency
of cardiac contraction
and to decrease
myocardial oxygen
consumption and
workload.
Physical and
psychological rest helps
reduce stress, which
can produce
vasoconstriction,
elevating BP and
increasing heart rate
and work.

Commode use
decreases work of
getting to bathroom or
struggling to use
bedpan. Vasovagal
maneuver causes vagal
stimulation followed by
rebound tachycardia,
which further

conditions such
as conditions
such as
amputation,
cerebrovascular
accident, stroke,
crainiocerebral
trauma, disk
surgery,
myocardial
infarction, sepsis,
thrombophebitis,
deep vein
thrombosis,
upper
gastrointestinal
bleeding and
atherosclerosis
causes.
Reduction in
arterial blood
flow that leads to
deprived
nutrition and
oxygenation at
the cellular level.
Decreased tissue
perfusion can be
transient with
few or minimal
consequences to

tolerated.
Check for calf
tenderness; diminished
pedal pulse; and
swelling, local redness,
or pallor of extremity.

compromises cardiac
function and output.
Decreases venous stasis
and may reduce
incidence of thrombus
and embolus formation.

Reduced cardiac output,

venous pooling and
stasis, and enforced
bedrest increases risk of
thrombophlebitis.

the health of the

patient. If the
decreased
perfusion is acute
and protracted, it
can have
devastating
effects on the
patient.
Diminished tissue
perfusion, which
is chronic in
nature, invariably
results in tissue
or organ damage
or death. Nursing
management is
directed at
following:
removing
vasoconstricting
factor(s),
improving
peripheral blood
flow, reducing
metabolic
demands on the
body, making the
patient
understand
his/her disease

process and its

treatment,
making the
patient
participate in
self-care
program, and
preventing
complications.