Mind Map Gallery congestive heart failure
- 641
- 2
congestive heart failure
A mind map about congestive heart failure.
Edited at 2020-09-08 01:18:24
- Recommended to you
- Outline
Congestive Heart Failure
Decreased Cardiac Output
S/Sx
Signs and Symptoms
low BP
high HR
low urine output
decreaed peripheral pulses
cold clammy skin
dyspnea
edema
restlessness
dysrhythmias
extra heart sounds (S3, S4)
fatigue
PND, orthopnea
NICs
assess AP, peripheral pulses, BP, S1S2
assess lungs sounds, O2 Sat,
assess urine output and electrolytes, BNP
weigh daily
administer meds (diuretics, ACE inhibitors, beta blockers,vasodilators, inotropes, antidysrythmics)
teach low sodium diet
restrict fluids
Risk for Alteration in Electrolyte Imbalance
Risk FActors
Risk Factors
decreased renal perfusion
diuretic therapy
low sodium diet
NICs
monitor serum electrolytes
monitor fluid losses and gains
monitor digoxin level and effects in presence of hypokalemia
For Hyponatremia
enc Na restriction as prescribed
enc fluid restriction as indicated
administer prescribed diuretics
For Hypokalemia
administer oral or IV supplements as prescribed
enc daily intake of K-rich foods
for hypomagnesemia
administer prescribed magnesium replacement as indicated
For hypernatremia
carefully replace water orally or IV
anticipate reduction in diuretic dosage
For nonacute hyperkalemia
anticipate reduction in potassium supplement
provide diet with potassium restriction as prescribed
discontinue potassium-sparing diuretics as prescribed
instruct re: avoiding salt substitutes containing potassium
for acute hyperkalemia
ECG monitoring
administer regular IV insulin and hypertonic dextrose
sodium bicarbonate
cation-exchange resins
IV calcium chloride
dialysis
Activity Tolerance
S/Sx
Signs/Symptoms
Patient Findings
fatigue and weakness
inability to perform ADLs
abnormal physical response to activity
exertional dyspnea
NICs
Assess current level of activity
observe response to activity
monitor sleep pattern
evaluate need for O2 during increased activity
use slow progression of activity
teach appropriate environmental aides (BSC, hand rails)
teach energy conservation techniques
PT consult for assistance in increasing activity
teach to recognize signs of overexertion
Fluid Volume Excess
S/Sx
Signs and Symptoms
Patient Findings
weight gain
edema
crackles
JVD
elevated CVP & PCWP
Ascites/hepatojugular reflux
Decreased urine output
NICs
monitor weight
assess presence of edema
monitor urine output
assess lung sounds, JVD, ascites, abdominal girth
restrict sodium and fluids
administer and instruct re: diuretics
instruct re: meds that cause fluid retention