Nursing Assessment for Congestive Heart Failure
1. Activity / rest
Symptoms: fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
Symptoms: Anxiety, mental status changes such as lethargy, changes in vital signs of activity.
2. Circulation
Symptoms: history of hypertension, acute myocardial infak, previous episodes of Chronic Heart Failure, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
Signs: blood pressure; may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia, apical pulse; PMI may spread and change in an inferior position to the left, heart murmurs; S3 (gallops) is diagnostic, S4 may, occur, S1 and S2 may be weakened, systolic and diastolic murmur, Color: blue, pale gray, cyanotic, nail backs; pale or cyanotic with a filling, capillary slow, Liver; enlargement / can be palpated, breath sounds ; crackles, rhonchi, edema; may be dependent, general or pitting especially on the extremities.
c. Ego integrity
Symptoms: Anxiety, worry and fear. Stress-related illness / financial concerns (job / cost of medical care).
Signs: A variety of behavioral manifestations, such as anxiety, anger, fear and irritability.
d. Elimination
Symptoms: Decreased urination, dark colored urine, nighttime urination (nocturia), constipation / diarrhea.
e. Food / fluid
Symptoms: Loss of appetite, nausea / vomiting, significant weight gain, swelling of the lower extremities, clothes / shoes feel tight, high-salt diet / food that has been processed and the use of diuretics.
Symptoms: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, stress and pitting).
f. Hygiene
Symptoms: fatigue / weakness, fatigue during activities of self care.
Signs: Appearances indicate negligence personal care.
g. Neurosensory
Symptoms: weakness, dizziness, fainting episodes.
Symptoms: Lethargy, tangled thought, oriented, behavioral changes and irritability.
h. Pain / Comfort
Symptoms: Chest pain, acute or chronic angina, upper right abdominal pain and muscle pain.
Signs: No quiet, insecure, narrow focus and behavior to protect themselves.
i. Breathing
Symptoms: Dyspnea on exertion, sleeping, sitting or with several pillows, cough with less / no sputum formation, history of chronic disease, use of rescue breathing.
Signs: Respiratory: tachypnea, shallow breathing, use of accessory respiratory muscles. Cough: Dry / loud / or non productive cough may be continuous with / without sputum formation. Sputum; Perhaps blood Flushed, pink / frothy (pulmonary edema). Breath sounds; may not be heard. Mental function; may decrease, anxiety, lethargy. Skin color; Pallor and cyanosis.
j. Security
Symptoms: Changes in mental function, loss of strength / muscle tone, skin abrasions.
k. Social interaction
Symptoms: Decreased participation in social activities are wont to do.
l. Learning / teaching
Symptoms: use / forgot to use heart medications, such as calcium channel blockers.
Symptoms: Evidence of lack of success to increase.