Congestive Heart Failure-2 Nursing CEs (continued)

NANDA Nursing Diagnosis y 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).
y

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 y

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 Missouri American Medical Network (2007). Acute myocardial infarction. Retrieved on July 5, 2007 at: