Name of Patient: M.
E
Age: 28
Medical Diagnosis: CHF
Nursing Diagnosis: Activity intolerance r/t reduced cardiac output
Short Term Goal: After 8 hours of nursing intervention the patient will verbalize confidence with progressive activity.
Long Term Goal: After the period of hospitalization, the patient will continue to verbalize confidence with progressive activity at home.
CUES PROBLEM SCIENTIFIC REASON
Subjective: Activity Heart failure, also called
intolerance congestive heart failure
Ø , occurs when cardiac output
is inadequate to meet the
Objective: metabolic demands of the
body. The heart rate
- Pallor increases as a compensatory
- Weak looking mechanism to increase
- V/S taken: cardiac output, and
BP: 90/70 vasoconstriction occurs to try
PR: 42 to maintain blood pressure.
Eventually, the chronic
increase in preload and
afterload contribute to
chamber dilation and
hyperthrophy, worsening
heart failure. Underlying
causes of heart failure
include congenital heart
disease, rheumatic heart
NURSING
INTERVENTIONS
Independent:
- Assess patients readiness to
increase activity
- For in patients monitor
oxygen saturation
- Encourage verbalization of
feelings regarding exercise
or need to increase activity
- Inform patient about health
benefits and physical effects
of activity or exercise
RATIONALE EVALUATION
- Older patients with CHF can GOAL MET. The
be quite fearful of overexerting patient verbalized
their hearts or causing confidence with
discomfort. progressive activity.
- A saturation of greater than
90mmHg recommended.
Lower values require
supplemental oxygen during
activity and slower activity
progression.
- An honest relationship
facilitates problem solving and
successful coping.
- Activity prevents
complications related to
immobilization, improves
feelings of well being and may
improve mortality(w/ long
disease, endocarditis, term exercise)
myocarditis, and - Instruct patient regarding - Information enables patient
noncardiovascular causes whom to call if any abnormal to take control of situation.
such as, chronic pulmonary response to exercise is noted
disease, various metabolic
diseases, and anemia. - Teach patient to self - HR is a guide for monitoring
Complications of heart monitor their pulse rate if intensity or duration of
failure include pneumonia, appropriate exercise.
pulmonary edema,
pulmonary emboli, refractory
heart failure, and myocardial
failure.
Name of Patient: M.E
Age: 28
Medical Diagnosis: CHF
Nursing Diagnosis: Impaired gas exchange r/t altered oxygen-carrying capacity of blood
Short Term Goal: After 8 hours of nursing intervention the patient will maintain optimal gas exchange as evidenced by normal rate, pattern, depth, and breathing effort
Long Term Goal: After the period of hospitalization, the patient will continue to maintain optimal gas exchange as evidenced by normal rate, pattern, depth, and breathing
effort

CUES PROBLEM SCIENTIFIC REASON NURSING RATIONALE EVALUATION

INTERVENTIONS

Subjective: Heart failure, also called Independent:

Impaired Gas congestive heart failure
Ø Exchange , occurs when cardiac output
is inadequate to meet the
Objective: metabolic demands of the
body. The heart rate
- Pallor increases as a compensatory
- Difficulty of mechanism to increase
breathing cardiac output, and
- Weak looking vasoconstriction occurs to try
- V/S taken: to maintain blood pressure.
BP: 90/70 Eventually, the chronic
RR: 35 increase in preload and
afterload contribute to
chamber dilation and
hyperthrophy, worsening
heart failure. Underlying
causes of heart failure
- Position with proper body
alignment for optimal
respiratory excursion
- Routinely check the
patient’s position so that he
or she does not slide down in
bed
- Pace activities and schedule - Even simple activities such as
rest periods to prevent
fatigue
- Change patient’s position
every 2 hours
- This promotes lung GOAL MET. The
expansion and improves air patient slightly
exchange maintain optimal gas
exchange as evidenced
- This would cause the by normal rate,
abdomen to compress the pattern, depth, and
diaphragm, which would cause breathing effort
respiratory embarrassment
bathing during bed rest can
cause fatigue and increase
oxygen consumption
- This facilitates secretion
movement and drainage
include congenital heart
disease, rheumatic heart
disease, endocarditis,
myocarditis, and
noncardiovascular causes
such as, chronic pulmonary
disease, various metabolic
diseases, and anemia.
Complications of heart
failure include pneumonia,
pulmonary edema,
pulmonary emboli, refractory
heart failure, and myocardial
failure.
- Encourage deep breathing
exercises
Dependent:
- Maintain oxygen
administration device as
ordered, attempting to
maintain oxygen saturation
at 90% or greater
- Administer medications as
prescribed
- This reduces alveolar
collapse
- This provides for adequate
oxygenation
- To relieve uneasy feeling of
the patient