Nursing 211

N211: Health Differences Across the Lifespan I Nursing Assessment: left sided heart failure or pulmonary edema (left ventricular failure) results in pulmonary congestion due to the inability of the left ventricle to pump blood to the periphery. Signs and symptoms include SOB, dyspnea, and a moist cough, crackles, and gallop rhythm: S3 and S4. Clients will also have fatigue, tachycardia, anxiety, restlessness and confusion. Right-sided heart failure also known as Cor Pulmonale, causes peripheral edema (right sided ventricular failure). This results in peripheral congestion due to the inability of the right ventricle to pump blood out to the lungs. This often results from left sided failure or pulmonary disease. Symptoms include peripheral edema, swelling, dependent edema, jugular vein distention, hepatomegaly and weight gain. Causes include atherosclerosis, conduction defects, COPD, fluid overload, hypertension, MI, pulmonary hypertension, valvular insufficiency or stenosis. Enlargement of the ventricles is demonstrated on chest x-ray. Chest x-ray shows increased pulmonary congestion and left ventricular hypertrophy. Right sided failure shows pulmonary congestion, cardiomegaly and pleural effusions on chest x-ray. Nursing Diagnosis • Activity intolerance related to decreased cardiac output • Fluid volume excess related to pump failure and fluid retention • Ineffective tissue perfusion related to increased preload and pump failure Nursing Interventions Interventions include keeping the patient in semi-fowler’s position to increase chest expansion and improve ventilation. Administer O 2 to enhance arterial oxygenation. Monitor patient for fluid gain. Plan periods of relaxation for patients with cardiac failure. Restrict fluid intake after two consecutive days of weight gain. Monitor vital signs every four hours for changes, monitor apical heart rate to detect arrhythmias and S3 or S4. Assess for hypoxia (restlessness, tachycardia, and angina). Auscultate lung sounds for crackles. Observe for signs of edema by weighing daily, monitoring I&O and measuring abdominal girth. Limit sodium intake. Elevate lower extremities while sitting. Check apical heart rate prior to administration of digitalis; withhold medication and call physician if rate is <60 bpm. Diet Low-sodium diet, fluid restriction. Medical Interventions ACE inhibitors (Captopril, Lisinopril), Morphine Sulfate, Digoxin, Inotropic agents (Dopamine), Diuretics (Lasix), Nitrates, and vasodilators.


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