nursing interventions with rationale of CHF

Expert Solution

Auscultate apical pulse, assess heart rate, rhythm. Document dysrhythmia if telemetry is 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 atrial fibrillation (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 (S3and S4), produced as blood flows into noncompliant chambers. Murmurs may reflect valvular incompetence.
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, and pulsus alternans (strong beat alternating with weak beat) may be present.
Monitor BP. 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 hypotension may occur.
Inspect skin for pallor, cyanosis.   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.
Monitor urine output, noting decreasing output and concentrated urine. Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent.
Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression.   May indicate inadequate cerebral perfusion secondary to decreased cardiac output.
Assess for abnormal heart and lung sounds.   Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.
Monitor blood pressure and pulse. Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the renin-angiotensin mechanism.
Assess mental status and level of consciousness. The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
Assess patient’s skin temperature and peripheral pulses. Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
Monitor results of laboratory and diagnostic tests. Results of the test provide clues to the status of the disease and response to treatments.
Monitor oxygen saturation and ABGs. Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood

Nightingale answered 1 year ago

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