Chf Care Plan

1406 WordsDec 1, 20116 Pages
Congestive Heart Failure (CHF) Congestive Heart Failure or CHF is a severe circulatory congestion due to decreased myocardial contractility, which results in the heart’s inability to pump sufficient blood to meet the body’s needs. In general, causes can be classified according to the following: a. Volume overload may cause the right ventricle to hypertrophy to compensate for added volume. b. Pressure overload usually results from an obstructive lesion, such as COA c. Decrease contractility can result from problems such as sever anemia, asphyxia, heart block and acidemia. d. High cardiac output demands occur when the body’s need for oxygen exceeds the heart’s output s seen in sepsis and hyperthyroidism. Clinical manifestations: It is clinically difficult to differentiate right from left ventricular failure. Failure of one chamber causes reciprocal changes in the opposite chamber; Weakness and fatigue; Poor feeding, resulting in weight loss; Developmental delays; Irritability; Pallor and cyanosis; Dyspnea, tachypnea, orthopnea, wheezing, cough, weak cry, grunting, mild cyanosis and coastal retractions; Tachycardia; Hepatomegaly; Weight gain from edema, ascites and pleural effusion; Distended neck and peripheral veins; Sweating Nursing Diagnosis: Activity intolerance r/t generalized weakness; imbalance between oxygen supply and demand Goal: Participates in prescribed physical activity with appropriate increases in heart rate, blood pressure, and breathing rate Nursing Interventions and Rationales: • Determine cause of activity intolerance and determine whether cause is physical, psychological, or motivational. Determining the cause of a disease can help direct appropriate interventions. • Assess client daily for appropriateness of activity and bed rest orders.

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