Activity intolerance r/t imbalance O2 supply and demand

Assessment Subjective:Napapagod ako kapag konting lakad lang as verbalized by the patient Objective: Patient manifested: orthopnea generalized weakness limited range of motion as observed abnormal pulse rate and rhythm RR- 27 cpm (+) DOB during activities Planning Short Term:After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity intolerance Long Term:After 2-3 days of nursing interventions, the patient will report measurable increase in activity intolerance.. Interventions 1. Assess patients general condition To note for any abnormalities and deformities present within the body 2. Adjust clients daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes To prevent strain and overexertion 3. Instruct client in unfamiliar activities and in alternate ways of conserving energy To conserve energy and promote safety 4. Encourage patient to have adequate bed rest and sleep to relax the body 5. Assist the client in a semi-fowlers position to promote easy breathing 6. Provide the patient with a calm and quiet environment to provide relaxation 7. Assist the client in ambulation to prevent risk for falls that could lead to injury 8. Note presence of factors that could contribute to fatigue fatigue affects both the clients actual and perceived ability to participate in activities 9. Ascertain clients ability to stand and move about and degree of assistance needed or use of equipment to determine current status and needs associated with participation in needed or desired activities 10. Give client information that provides evidence of daily or weekly progress to sustain motivation of client 11. Encourage the client to maintain a positive attitude to enhance sense of well being 12. Assist the client in learning and demonstrating appropriate safety measures to prevent injuries 13. Instruct the SO not to leave the client unattended to avoid risk for falls 14. Provide client with a positive atmosphere to help minimize frustration and rechannel energy 15. Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms to indicate need to alter activity level dependent: Administer supplemental oxygen as indicated. Evaluation Short Term:The patient shall have used identified techniques to improve activity intolerance Long Term:The patient shall have reported measurable increase in activity intolerance.

Excessive Fluid volume r/t decreased cardiac output and sodium and water retention and edema on extremities secondary to CHF
Assessment

Objective: Patient manifested:

y y y y y y

Edema on extremities Abdominal girth- 33 cm Weight: 47 kg Jugular vein distention DOB Harsh breath sound on both lung fields

Planning Short Term: After 3-4 hours of interventions, the patient will verbalized understanding of causative factors and demonstrate behaviors to resolve excess fluid volume. Long Term: After 3-4 days of nursing interventions, the patient will demonstrate adequate fluid balanced, clearing breath sounds, and decreasing edema. Interventions 1. Assess patient s general condition To determine what approach to use in treatment 2. Monitor I&O every 4 hours I&O balance reflects fluid status 3. Weigh patient daily and compare to previous weights. Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess. 4. Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic. Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatis pressure exceeds interstitial pressure, fluids leak out of ht ecpaillaries and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart. 5. Follow low-sodium diet and/or fluid restriction Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess. 6. Encourage or provide oral care q2 The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake. 7. Evaluate urine output in response to diuretic therapy. Focus is on monitoring the response to the diuretics, rather than the actual amount voided 8. Assess the need for an indwelling urinary catheter. 9. Institute/instruct patient regarding fluid restrictions as appropriate. Dependent: Administer diuretics as prescribed (furosemide) and monitor for side effects. R: decreases water retention

Short Term:Pt shall have verbalized understanding of causative factors and demonstrate behaviors to resolve excess fluid volume. Long Term: Pt shall have demonstrated: (-) jugular vein distention decrease edema, weight loses 2 kgs abdominal girth decreases to 31 cm.

Decreased cardiac output r/t impaired contractility

Assessment:
SUBJECTIVE: Putlang putla ang asawa ko, nahihirapan sya huminga, as verbalized by the husband. OBJECTIVE:
y y y y y y y

with pale conjunctiva & nail beds irregular rhythm of pulse bradycardic (40 bpm) prolonged capillary refill (more than 3 seconds) cold clammy skin generalized weakness, DOB dependent edema

Planning Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability. Interventions y y Auscultate apical pulse; assess heart rate, and rhythm. (Tachycardia is usually present even at rest to compensate for decreased ventricular contractility.) Monitor urine output, noting decreasing output and dark or concentrated urine. (Urine output usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent) Note changes in sensorium. (May indicate inadequate cerebral perfusion secondary to decreased cardiac output) Provide quiet environment. Place patient at physical and psychological rest. Encourage activity as tolerated, rest as needed. (Psychological rest help reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate or work.) Elevate the head of the bed to maintain an open airway Adjust clients daily activities and reduce intensity of level which helps to reduce oxygen consumption.

y y

y y

DEPENDENT: y Administer supplemental oxygen as indicated. (Increases available oxygen for myocardial uptake) y Administer diuretics as prescribed. (Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in patients with heart failure).

Evaluation Short Term: After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient was able to display vital signs within acceptable limits (pulse rate- 60 bpm), dysrhythmias controlled and normal capillary refill (2-3 seconds).

When increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular absorption of sodium May include increased fluids or sodium intake, or compromised regulatory mechanisms. Inidicates fluid overload Treatment focuses on diuresis of excess fluid. This helps reduce extracellular volume

1. to reduce work of heart. Provide rest in semi-recumbent position or in arm-chair in air-conditioned environment reduces work of heart, increases heart reserve, decreases work of respiratory muscles and oxygen utilization, improves efficiency of heart contraction. Provide bedside commode to reduce work of getting to bathroom and for defecation. Slowly increase activity level. R: Reduces cardiac workload and minimizes myocardial oxygen consumption.

2. Monitor vital signs during activities. Monitor breathing pattern. Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature of skin, facial pallor, and poor capillary refill of nail beds. Check for signs and symptoms related to decreased cardiac output (chest pain, dyspnea, edema)
3. Instruct the SO not to leave the client unattended R- To ensure safety and reduce risk for falls that may lead to injury