congestive heart failure

Congestive Heart FailureDecreased Cardiac OutputS/SxSigns and Symptomslow BPhigh HRlow urine outputdecreaed peripheral pulsescold clammy skindyspneaedemarestlessnessdysrhythmiasextra heart sounds (S3, S4)fatiguePND, orthopneaNICsassess AP, peripheral pulses, BP, S1S2assess lungs sounds, O2 Sat, assess urine output and electrolytes, BNPweigh dailyadminister meds (diuretics, ACE inhibitors, beta blockers,vasodilators, inotropes, antidysrythmics)teach low sodium dietrestrict fluidsRisk for Alteration in Electrolyte ImbalanceRisk FActorsRisk Factorsdecreased renal perfusiondiuretic therapylow sodium dietNICsmonitor serum electrolytesmonitor fluid losses and gainsmonitor digoxin level and effects in presence of hypokalemiaFor Hyponatremiaenc Na restriction as prescribedenc fluid restriction as indicatedadminister prescribed diureticsFor Hypokalemiaadminister oral or IV supplements as prescribedenc daily intake of K-rich foodsfor hypomagnesemiaadminister prescribed magnesium replacement as indicatedFor hypernatremiacarefully replace water orally or IVanticipate reduction in diuretic dosageFor nonacute hyperkalemiaanticipate reduction in potassium supplementprovide diet with potassium restriction as prescribeddiscontinue potassium-sparing diuretics as prescribedinstruct re: avoiding salt substitutes containing potassiumfor acute hyperkalemiaECG monitoringadminister regular IV insulin and hypertonic dextrosesodium bicarbonatecation-exchange resinsIV calcium chloridedialysisActivity ToleranceS/SxSigns/SymptomsPatient Findingsfatigue and weaknessinability to perform ADLsabnormal physical response to activityexertional dyspneaNICsAssess current level of activityobserve response to activitymonitor sleep patternevaluate need for O2 during increased activityuse slow progression of activityteach appropriate environmental aides (BSC, hand rails)teach energy conservation techniquesPT consult for assistance in increasing activityteach to recognize signs of overexertionFluid Volume ExcessS/SxSigns and SymptomsPatient Findingsweight gainedemacracklesJVDelevated CVP & PCWPAscites/hepatojugular refluxDecreased urine outputNICsmonitor weightassess presence of edemamonitor urine outputassess lung sounds, JVD, ascites, abdominal girthrestrict sodium and fluids administer and instruct re: diureticsinstruct re: meds that cause fluid retention