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Student Nurses Community NURSING CARE PLAN Congenital Heart Failure ASSESSMENT SUBJECTIVE: Putlang putla a ng anak ko,

, nahihirapan sya huminga (My baby looks very pale and she finds it difficult to breath) DIAGNOSIS Decreased cardiac output related to altered myocardial contractility / inotropic changes. INFERENCE Heart failure, also called congestive heart failure, occurs when cardi ac output is inadequate to meet the metabolic demands of the body. The heart rat e increases as a compensatory mechanism to increase cardiac output, and vasocons triction occurs to try to maintain blood pressure. Eventually, the chronic incre ase in preload and afterload contribute to chamber dilation and hyperthrophy, wo rsening heart failure. Underlying causes of heart failure include congenital hea rt disease, rheumatic heart PLANNING After 8 hours of nursing intervention the patient will display vital si gns within acceptable limits, dysrhythmias controlled and no symptoms of failure . INTERVENTION INDEPENDENT: Auscultate apical pulse; assess heart rate, and rhythm . RATIONALE Tachycardia is usually present even at rest to compensate for decrease d ventricular contractility. Pallor is an indicative of diminished peripheral pe rfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cy anosis may develop in refractory heart failure. Dependent areas are often blue o r mottled as venous congestion increases. Urine output is usually decreased duri ng the day because of fluid shifts into tissues but may be increased at night be cause fluid returns to circulation when patient is recumbent. EVALUATION After 8 hours of nursing intervention the patient was able to display vital signs within acceptable limits, dysrhythmias controlled and no symptoms o f failure. as verbalize by the mother. Inspect skin for pallor, cyanosis. OBJECTIVE: Cool, ashen skin. Orthopnea Crackles V/S taken as follows T: 36.2 C P: 130 R: 45 Monitor urine output, noting decreasing output and dark or concentrated urine.

Student Nurses Community disease, endocarditis, myocarditis, and noncardiovascul ar causes such as, chron ic pulmonary disease, various metabolic diseases, and anemia. Complications of h eart failure include pneumonia, pulmonary edema, pulmonary emboli, refractory he art failure, and myocardial failure. Note changes in sensorium. May indicate ina dequate cerebral perfusion secondary to decreased cardiac output. Psychological rest help reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate or work. Provide quiet environment. DEPENDENT: Administer supplemental oxygen as indicated. Administer diuretics as prescribed. Increases available oxygen for myocardial uptake to combat effects of hypoxia or ischemia. Diuretics, in conjunction with restriction of dietary sodium and flui ds, often lead to clinical improvement in patients with heart failure.