Risk Factor

Systemic Inflammation of
Coronary Hypertension/ Myocarditis, Stenosis AV Valve
Systemic Factors 
Atherosclerosis Pulmonary Endocarditis, and Semiluron Valve
Hypertension Rheumatism

HEART FAILURE

ECG

Decreased Cardiac Output related Less Volume of The left ventricle fails to pump
Artery Blood
The right ventricle fails to
to decreased ventricular filling blood from the lungs pump blood from the lungs
(preload) as evidence by 
high blood pressure

Pulmonary circulation
Diastolic pressure rises
Offload the pressure Chest X-Ray
Short Tem: Renin release
Sympathetic
- Patient demonstrates adequate cardiac output as
evidenced by blood pressure and pulse rate and
rhythm within normal parameters for patient; strong Angiotensin I is
peripheral pulses; and an ability to tolerate activity Fluid pushed into the alveoli Right atrium dam
Converted to
without symptoms of dyspnea, syncope, or chest pain. vasodilator Angiotensin II
-Patient exhibits warm, dry skin, eupnea with absence therapy 
of pulmonary crackles. Cough
-Patient remains free of side effects from the Systemic vein
medications used to achieve adequate cardiac output. Reduced oxygen dam
supply

Long term: Vasoconstriction of Increased blood

Increased
aldosteron
-Patient explains actions and precautions to take for blood vessels pressure
Secression
cardiac disease. Accumulation of
lactic acid
Dyspnea
Reabsorption Na +
GFR H2O in the extracle
room
Enlarged hepatic
veins

INDEPENDENT NURSING INTERVENTIONS:

The balance of Na
- Record intake and output. If patient is acutely ill, measure hourly urine in blood changes
Hepatomegaly
output and note decreases in output.
Impaired gas exchage related to
- For patients with increased preload, limit fluids and sodium as ordered.
ventilation-perfusion inequality  as
- Place on cardiac monitor; monitor for dysrhythmias, especially atrial Pain acute
fibrillation.
evidenced by cannot catch her
- Position patient in semi-Fowler’s to high-Fowler’s Edema breath Portal vessel
pressure
COLLABORATIVE INTERVENTIONS:
-Examine laboratory data, especially arterial blood gases and electrolytes,
including potassium. Fluid Volume Excess related to Fluid pushed into the
- Monitor laboratory tests such as complete blood count, sodium level, and excessive fluid intake as evidence by abdominal cavity
serum creatinine. generalized edema
- Administer medications as prescribed, noting side effects and toxicity. Diuretic Therapy
- Review results of EKG and chest Xray.
OUTCOME MET: Ascites

Short Tem:
- Patient demonstrates adequate cardiac output as
evidenced by blood pressure and pulse rate and Short Term: Short Term:
rhythm within normal parameters for patient; strong - Patient is normovolemic as evidenced by urine output After 2 hours of nursing intervention the patient will able to : Anxiety related to
peripheral pulses; and an ability to tolerate activity greater than or equal to 30 mL/hr. -maintain optimal gas exchange as evidenced by usual mental status, breathlessness from
without symptoms of dyspnea, syncope, or chest pain. - Patient has balanced intake and output and stable weight. unlabored respirations at 12-20 per minute, oximetry results within normal inadequare oxygenation
-Patient exhibits warm, dry skin, eupnea with absence limits, blood gases with normal range and baseline HR for patient.
- Patient maintains HR 60 to 100 beats/min.
of pulmonary crackles. -Patient maintains clear lung fields and remains free signs of respiratory
-Patient remains free of side effects from the - Patient has clear lung sounds as manifested by absence of
medications used to achieve adequate cardiac output. pulmonary crackles. distress.
- Patient verbalizes awareness of causative factors and Long Term:
Long term: behaviors essential to correct fluid excess. Upon Discharge the patient will be able to: Short Term: After 2 hours of nursing interventions, the
-Patient explains actions and precautions to take for -Participates in procedures to optimize oxygenation and in management patient will be able to:
cardiac disease. Long Term: regimen within level of capability/condition. a. Verbalize awareness of feelings of anxiety
-Patient explains measures that can be taken to treat or -Patient manifests resolution or absence of symptoms of respiratory b. Demonstrate reduced anxiety levels
prevent fluid volume excess. distress.
-Patient describes symptoms that indicate the need to Long Term: Upon discharge, the patient will be able
to:
consult with health care provider.
a. Identify at least 2 healthy ways to deal with
anxiety.

INDEPENDENT NURSING INTERVENTIONS:

OUTCOME MET:
Short Term: -Assess respiratory rate, depth and effort including the use of accessory muscles,
- Patient is normovolemic as evidenced by urine output nasal flaring and abnormal breathing patterns. INDEPENDENT NURSING INTERVENTIONS:
greater than or equal to 30 mL/hr. -Observe for nail beds, cyanosis in skin, especially note the color of the tongue 1. Assess for signs of anxiety:
- Patient has balanced intake and output and stable INDEPENDENT NURSING INTERVENTIONS:
and oral mucous membrane. a. Feelings of panic, fear, and uneasiness.
weight. b. Tachycardia
- Patient maintains HR 60 to 100 beats/min. - Monitor fluid status closely: Auscultate lungs, compare daily body -Monitor oxygen saturation continuously using pulse oximetry.
c. Cold or sweaty hands or feet
- Patient has clear lung sounds as manifested by weights, and monitor intake and output. -Monitor chest x-ray results d. Shortness of breath
absence of pulmonary crackles. - Position patient, or teach patient how to assume a position, that -Position patient with head of the bed elevated, in a semi-fowler’s position as e. Restlessness
- Patient verbalizes awareness of causative factors and facilitates breathing (increase number of pillows, elevate the head of tolerated. Rationale: Dyspnea can become much worse with anxiety since it causes rapid, shallow breathing.
behaviors essential to correct fluid excess. bed), or patient may prefer to sit in a comfortable armchair to sleep.
-Encourage or assist with ambulation as per physician’s order.
- Assess for skin breakdown, and institute preventive measures THERAPEUTIC INTERVENTIONS:
(frequent changes of position, positioning to avoid -Instruct and encourage patient in diaphragmatic breathing and effective
Long Term: 1. Encourage the use of relaxation techniques
pressure, leg exercises). coughing.
-Patient explains measures that can be taken to treat or Rationale: To reduce panic and fear and to consciously produce the body’s relaxed state characterized by
prevent fluid volume excess. -  Teach patient to adhere to a low-sodium diet by reading food labels -Assess home environment for irritants that impair gas exchange. slower breathing, lower blood pressure, and a sense of calmness.
-Patient describes symptoms that indicate the need to and avoiding commercially prepared convenience foods. 2. Administer oxygen during the acute stage
consult with health care provider. - Assist patient to adhere to any fluid restriction by planning the fluid Collaborative Interventions: Rationale: to diminish the work of breathing and to increase comfort
distribution throughout the day while maintaining dietary preferences. -Administer oxygen by the method prescribed
COLLABORATIVE INTERVENTIONS:
- Administer diuretics early in the morning so that diuresis does not
disturb nighttime rest.
- Monitor IV fluids closely; contact physician or pharmacist about the
possibility of double-concentrating any medications.
Outcome Met
Short Term:
After 2 hours of nursing intervention the patient was able to : Outcomes was met
-maintain optimal gas exchange as evidenced by usual mental status, unlabored Short Term: After 2 hours of nursing interventions, the patient will be able to:
a. Verbalize awareness of feelings of anxiety
respirations at 12-20 per minute, oximetry results within normal limits, blood gases b. Demonstrate reduced anxiety levels as evidenced by a calm demeanor
with normal range and baseline HR for patient. and cooperative behavior
-Patient maintains clear lung fields and remains free signs of respiratory distress.
Long Term: Long Term: Upon discharge, the patient will be able to”
Upon Discharge the patient will be able to: a. Identify 2 healthy ways to deal with anxiety such as relaxation
techniques
-Demonstrates diaphragmatic breathing.