OUTLINE.OF.NURSING.

MANAGEMENT

Rheumatic Heart disease, Cardiomegaly, CHF Class III-C

Decreased Cardiac Output

GOAL: Patient will be able to maintain optimal cardiac output (as evidenced by normal BP & HR, clear breath sounds, Urine output >30ml/hr, No shortness of breath)

NURSING INTERVENTION :

*Monitor vital signs *Weight daily & keep record of intake &ouput *Assess for signs & symptoms of decreasing cardiac output

*provide O2 as indicated by patients condition & saturation levels

*administer the ff meds as ordered: Diuretics Inotropes Vasodilators *attach patient to a pulse oximeter

FLUID VOLUME EXCESS

GOAL: Patient will be able to maintain optimal fluid balance (as evidenced by maintenance of normal weight, no edema, clear breath sounds)

NURSING INTERVENTION

*Monitor v/s *Assess weight daily and consistently *Monitor for significant weight change in 1 day or trend over several days *Assess for presence of edema by palpating area over tibia, ankles, feet & sacrum

*Restrict fluid & sodium as prescribed *Give diuretics as prescribed *In preparation for discharge, instruct the patient on how to weight self daily & monitor intake & output at home.

Activity Intolerance

GOAL: Patient will maintain activity level within capabilities & would verbalize & utilize energy conservation technique.

NURSING INTERVENTION :

*Assess pt's level of mobility

*Encourage adequate rest periods, especially after ambulation, diagnostic procedures and meals

*Refrain from performing nonessential procedures

*Assist in ADL as indicated

*provide bedside commode as indicated *progress activity gradually *teach energy conservation techniques. They reduce O2 consumption, allowing more prolonged activity.