Complete NANDA based Nursing care plan for a client with congestive heart failure due to Chronic Renal Failure:
Chronic renal failure is defined as a progressive failure in function of the kidney. The kidneys in this case attempt to reiterate for renal damage through excessive restraining of blood levels (hyperfiltration) in the remaining nephrons that are functional. This goes on to filter different units, which consist of a corresponding tubule and glomerulus). In the long term, hyperfiltration induces further functional loss. The three main symptoms of heart failure (congestive) include exercise intolerance. This is a situation where an individual is unable to cope up with exercise as well as mild physical exertion, which they were able to do previously. It also includes shortness of breath where the individual has some level of difficulty in breathing (dyspnea) which is especially the case when they are still active or at rest). Lastly, it also includes fluid swelling and retention also known as edema of the ankles, feet, and legs).
Assessment for best Nursing practices in Congestive heart failure due to Chronic Renal Failure:
1. Security Symptoms :
Itchy skin
Recurrent infections
Signs:
Fever (dehydration and sepsis)
Pruritus
2. Pain or comfort Symptoms:
Pelvic pain
Headache
Signs:
Anxiety
Distraction/cautious behaviour
3. Stress Symptoms:
Feeling of helpless and hopeless
Signs:
Reject
Anxiety
Personality changes, easily aroused
Fear
Anger
4. Respiratory Symptoms :
Paroxysmal nocturnal
Cough without sputum.
Dyspnea
Shortness of breath
Signs:
Cough (productive) with watery pink sputum also called pulmonary edema
Respiratory Tachypnoea kusmaul
5. Elimination Symptoms:
Abdominal bloating, constipation, Diarrhoea
Signs:
Change of urine colour, the sample cloudy, brown, reddish, thick yellow
6. Neurosensori Symptoms:
Feet soles
weakness and numb/tingling of extremities in the lower peripheral neuropathy
Signs:
Impaired mentality including memory loss, inability to concentrate, confusion, decreased field of attention, decreased degree of consciousness, frequent states of coma and stupor
seizure activity, sudden seizures and muscle fasciculation
Thin and brittle nails as well as thin hair
7. Food/fluid Symptoms:
Weight loss (malnutrition)
Anorexia, heartburn, nausea/vomiting, unpleasant mouth metallic taste (breath of ammonia)
Increased weight fast (edema)
Signs:
Liver enlargement (final stage)abdominal distension/anxiety,
Tongue/bleeding gums, ulceration of gums
Subcutaneous fat loss and no powerful appearance
Decrease in muscle
Edema (depending)
Changes in skin turgor/humidity
8. Activity/rest Symptoms :
Sleep disturbance (somnolen or restless/insomnia)
The weakness malaise
Signs:
Loss of tone
Muscle weakness
Low scope of motion
9. Counselling
Family history of diabetes mellitus (Restichronic renal failure)
Urinary calculus
Polycystic disease
The use of current/recurrent nephrotoxic antibiotics.
Hereditary nephritis
History of exposure to drug samples, toxins and environmental toxins
10. Social interaction Symptoms :
Maintaining the family functions and roles
11. Circulation Symptoms:
chest pain (angina) and Palpitations
severe hypertension or History prolonged
Signs:
Smooth and weak pulse, orthostatic hypotension
The tendency of bleeding
Light socket tissue edema in the feet and palms
Pale skin
Cardiac Dysrhythmias
Friction rub pericardial
12. Activity/rest Symptoms:
Sleep disturbance (restless/insomnia or somnolen)
The weakness malaise
Signs:
Decreased range of motion
Muscle weakness
Loss of tone
13. Sexuality Symptoms :
Amenorrhea
Decreased libido
Infertility
Nursing Diagnosis
Anxiety in relation to change in or threat to health status, which results in inability to address feelings of apprehension and uncertainty relating to the life-style changes
Disturbance in the sleep pattern, which is closely related to illness amounting to interrupted sleep brought about by nocturnal dyspnea
Decreased cardiac performance in relation to structural defect as well as myocardial dysfunction
Ineffective breathing frequencies in relation to pulmonary congestion
Nursing Intervention
Closely monitor crucial signs in intervals of two or four hours. Also, check on capillary refill, apical pulse, peripheral pulses, PAP and CVP if necessary. Put down changes in cardiac status as well as potential for arrhythmias and compromised systemic for a venous flow.
Check on breath sounds and heart sounds. Indicate reduced cardiac output that is caused by pulmonary edema and mechanical failure.
Analyze the electrolyte sodium levels to observe increments as well as decreases in potassium. Diuretic therapy could induce hypokalemia and decrease glomerular filtration rate which causes hypernatremia and potassium imbalances.
Proceed to administer diuretic (furosemide and hydrochlorothiazide) while still monitoring the electrolyte imbalances.
Issue bronchodilator (theophylline) in order to dilate the airways to facilitate proper breathing if the patient is dyspneic
Provide inotropic agents such as digoxin and dopamine while closely checking the hemodynamic status. The two agents increase the cardiac output through increases in cardiac contractility.
Provide oxygen therapy through a cannula as it provides sufficient oxygen if the patient is hypoxic from low cardiac output as well as having ventilation perfusion and mineral imbalance from alveoli fluid.
Provide favourable environment that limits stimuli. Stimuli as well as stress stimulate cardiac workload and catecholamines.
Provide sufficient meals up to six times a day to reduce pressure on the diaphragm while enhancing chest expansion.
Avail enough bed rest with the bed’s head elevated at an angle of 45 degrees to promote proper a decrease in venous return and lung expansion.
Proceed to perform breathing exercises (deep) and incentive spirometry at intervals of two hours to improve breathing as well as oxygen intake.
