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Congestive Heart Failure-2 Nursing CEs (continued) NANDA Nursing Diagnosis
Decreased cardiac output r/t ventricular damage, ischemia and restriction secondary to fluid overload. The defining characteristics of decreased cardiac output include:
o Dysrhythmias (tachycardia, bradycardia, electrocardiographic changes).
o Altered Preload (jugular vein distention, fatigue, edema, increased/decreased central venous pressure [CVP], increased/decreased pulmonary artery wedge pressure [PAWP]).
o Altered Afterload (cool clammy skin, shortness of breath/dyspnea, oliguria, prolonged capillary refill, decreased peripheral pulses)
o Altered Contractility (crackles at the lung bases, cough, orthopnea/nocturnal dyspnea, cardiac output less than 4 liters/min, cardiac index less that 2.5 liters/min, decreased stroke volume, decreased left ventricular stroke work index (LVSWI), S3 or S4 heart sounds present).
o Behavioral/Emotional (anxiety or restlessness).
Impaired gas exchange r/t increased pulmonary interstitial fluid accumulation. The defining characteristics of impaired gas exchange include:
o Decreased carbon dioxide (hyperventilation) o Dyspnea (difficulty breathing often secondary to fluid overload
and/or pulmonary edema o Abnormal Arterial blood gas levels (respiratory alkalosis) o Hypoxia (oxygen delivery and consumption mismatch) o Tachycardia (increased workload of the myocardium) o Abnormal skin color (pale, dusky)
Altered tissue perfusion (cardiac) r/t imbalance between oxygen
demand and supply. Defining characteristics of altered cardiac tissue perfusion includes:
o Altered respiratory rate (shortness of breath, dyspnea) o Use of accessory muscles to breath o Capillary refill greater than 3 seconds (poor circulation of
oxygenated blood) o Abnormal arterial blood gas levels (low Co2 from
hyperventilation) o Chest pain (increased work load of the heart) o Sense of impending doom (feelings of doom often surface when
a patient is having difficulty breathing)
o Dysrhythmias (due to myocardial work loads)
Ineffective breathing pattern r/t imbalance between oxygen demand and supply. Defining characteristics of ineffective breathing pattern include:
o Decreased inspiratory/expiratory pressure (due to the extra work load of breathing)
o Shortness of breath/dyspnea (fluid overload) o Pursed lip breathing (an attempt to increase the length of
expiration)
Alteration in fluid balance (excess) r/t decreased cardiac output and Aldosterone and ADH compensatory secretion. Defining characteristics of alteration in fluid and electrolytes includes:
o Jugular vein distention (right sided failure) o Decreased hemoglobin (dilutional) o Weight gain (over a short period of time) o Changes in respiratory pattern (dyspnea, shortness of breath) o Pulmonary congestion (crackles, rhonchi, S3 auscultated) o Restless/anxious behavior o Increased CVP o Oliguria, azotemia, specific gravity changes o Positive hepatojugular reflex (due to hepatomegaly)
Fatigue r/t imbalance between oxygen demand and supply. Defining
characteristics of fatigue include:o Inability to restore energy (even after appropriate rest and sleep
periods). o Inability to maintain a level of physical activity (often due to
shortness of breath and discomfort). o Verbalization of unremitting or overwhelming exhaustion. o Increase in physical complaints (unrelated to current medical
condition). o Verbalization of guilt (for not being able to keep up with things)
Anxiety r/t uncertain outcome. Defining characteristics of anxiety
include: o Diminished productivity o Scanning and vigilance o Poor eye contact/glancing around/restless and irritable behavior o Extraneous movement (repetitive movement, foot shuffling) o Insomnia o Regretful/helpless/worried o Quivering of voice when speaking o Elevated pulse/blood pressure
Knowledge deficit r/t new diagnosis/new medication regimen.
Defining characteristics of a knowledge deficit include: o Verbalization of the problem o Inaccurate follow up or follow through o Inappropriate or aggravated behavior o Hysterical, hostile, agitated or apathetic behavior o Ineffective coping r/t health care demands and new diagnosis
References
Ackley, B., J & Ladwig, G., B. (2004). Nursing diagnosis handbook: A guide to planning care. (6th ed.). Mosby; St. Louis MissouriAmerican Medical Network (2007). Acute myocardial infarction. Retrieved on July 5, 2007 at: