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Nursing Care Plan for Cardiac Decompensation

A. Assessment for Cardiac Decompensation


1. Activity and Rest
  • Symptoms: weakness, fatigue, dizziness, a sense of beat and palpitations, difficulty sleeping (orthopnea, nocturnal dyspnea paroksimal, nocturia, night sweats).
  • Signs: Tachycardia, changes in blood pressure, fainting because of work, tachypnea, dyspnea.
2. Circulation
  • Symptoms: Declare a history of hypertension, rheumatic fever, congenital: arterial septal damage, chest trauma, a history of heart murmurs and palpitations, hoarseness, hemoptysis, cough with / without sputum, history of anemia, a history of shock hipovolema.
  • Signs: Vibration systolic musty, heart sounds: loud S1, opening a hard, tachycardia. Irregular rhythm; arterial fibrillation.
3. Ego integrity
  • Signs: show anxiety: anxious, pale, sweating, trembling. Fear of death, the desire to end life, feel useless, neurotic personality.
4. Food / fluid
  • Symptoms: There is a change of weight, frequent use of diuretics.
  • Signs: general edema, hepatomegaly and ascites, respiratory effort and noisy sounds cracles and wheezing.
5. Neuro-sensory
  • Symptoms: tingling, dizziness
  • Signs: Weakness
6. Respiration
  • Symptoms: Shortness of breath, persistent cough or nocturnal.
  • Signs: Tachypnea, breath sounds; cracles, wheezing, sputum, blood-colored spots, restless.
7. Security
  • Symptoms: The process of infection / sepsis, history of surgery
  • Signs: Weakness of the body
8. Guidance / learning
  • Symptom: Asking about the state of illness.
  • Signs: Indicates lack of information.

Nursing Diagnosis and Interventions for Cardiac Decompensation

1. Impaired Gas Exchange related to pulmonary congestion secondary change in alveolar capillary membrane and fluid retention interstisiil.

Goal:
Maintain adequate ventilation and oxygenation in

Action :
  • Assess the respiratory work (frequency, rhythm, sound and depth)
  • Provide additional Oxygenation 6 liters / minute
  • Monitor saturation (oximetry) PH, BE, HCO3
  • Correction of acid-base balance
  • Give a position that allows clients improve lung expansion. (Semi-Fowler)
  • Prevent atelectasis by exercising effective coughing and deep breathing
  • Perform fluid balance
  • Limit fluid intake
  • Eavluasi radiographic pulmonary congestion through

Rational :
  • To determine the effectiveness of gas exchange function.
  • To increase the concentration of oxygen in the gas exchange process.
  • To determine the level of oxygenation in tissues as a result of the adequacy of gas exchange process.
  • Prevent acidosis which can aggravate respiratory function.
  • Enhance lung expansion
  • Heavy congestion will worsen perukaran process gas so the impact on the onset of hypoxia.
  • Increases contractility of heart muscle that can decimate Odem thus prevents the onset of gas exchange impairment.

2. Decreased cardiac output related to decreased left ventricular filling, increased atrial and venous congestion.

Goal:
Hemodynamic stability can be maintained with the following criteria: (TD> 90/60), normal cardiac frequency.

Actions:
  • Keep the patient to bed rest
  • Measure the hemodynamic parameters
  • Monitor ECG, especially the frequency and rhythm.
  • Monitor heart sound S-3 and S-4
  • Check the BGA and saO2
  • Maintain IV access
  • Limit Sodium and water
Rational
  • Reducing the burden of heart
  • To determine the blood perfusion in vital organs and to determine the PCWP, CVP as an indicator of increased cardiac workload.
  • To find out if there is a decrease in contractility that may affect cardiac output.
  • To determine the level of impairment charge systole or diastole.
  • To know in peripheral tissue perfusion.
  • For maintenance if it occurs during vascular crisis.
  • Preventing an increase in cardiac load
  • Improving perfusion to tissues

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