Decease cardiac output r/t Secondary to CHF

Eve- 1 By placing the patient high flower position he will not be in respiratory distress and feel more comfortable.

2 Assessing the skin will permit the patient to have the skin intact and present pulses. Patient presents all pulses and skin is prompt and elastic.

3 - Monitoring EKGs will prevent any further complications for the patient. In addition, the patient maintains adequate blood flow

4 The patient maintain stress by participating in breathing exercises which reduces his anxiety level and decreases cardiac workload.

Activity intolerance related to generalized weakness Secondary to phenomena

NANDA: A state in which an individual has insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Goal - The patient will take rest periods as needed during activities/ ADLs

- 1) Promote balance of rest periods according to the patient’s schedule. Providing rest periods will reduce fatigue which will increase activity tolerance.

(2) Reinforce breathing techniques such pursed-lip breathing to increase activity tolerance. Engaging pursed-lip breathing decreases expiration which will keep the alveoli inflated longer, promoting control of dyspena

(3) Administer oxygen therapy as needed. Providing oxygen increases ventilation, which improves activity tolerance.

(4) Promote high energy nutrition to increase activity. Decreased in nutrition will cause malnutrition declining the strength of the diaphragm.

1. Patient takes adequate rest periods when participating in ADLs and does not feel fatigue.

2Patient is able in participate in pursed lip breathing exercises which helps him to feel relaxed.

3 Patients receives 2L of O2 around the clock to increase energy . In addition, the patient is able to perform activities.

4 For breakfast, lunch and dinner patient receives high energy food that will promote energy. Patent is able participate in more activities without feeling weakness.

Ineffective airway clearance related to retained secretions Secondary to phenomena

Goal - The patient will maintain clear, open airways by having

normal breath sounds

normal rate and depth of respirations

absence of dyspnea.

NANDA: A state in which an individual is unable to clear secretions or obstructions from the respiratory tract to maintain airway patency

(1) Elevate the head of the bed to open the airway. The measures will promote maximal inspiration

(2) Reinforce deep breathing and coughing exercises to mobilize the secretions.

(3) Reinforce fluid intake by at least 2000 mL/day within cardiac tolerance. Hydration will aid in liquefying the secretions to improve with the clearance of them.

4

Reinforce the use of an incentive spirometer. Utilizing the incentive spirometer will expand the lungs and aid in clearing the secretions

Eve :

1 The head of the bed remains elevated and the patient is able to breathe better.

2 Patient coughs and performs deep breathing

exercises. In addition the patient is able to ret rid of the secretions that gave him dyspena.