Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?
A. Risk for infection related to stasis of alveolar secretions.
B. Impaired skin integrity related to pressure.
C. Activity intolerance related to pump failure.
D. Constipation related to immobility.
Correct Answer: C. Activity intolerance related to pump failure
Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. As heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the body’s needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain.
Option A: The client could be at risk for infection related to stasis of secretions but it is not the priority. The exchange in oxygenation and carbon dioxide gases is impeded due to the obstruction caused by the accumulation of bronchial secretions in the alveoli. Oxygen cannot diffuse easily.
Option B: Impaired skin integrity related to pressure is not a priority. Skin is at risk because of impaired peripheral circulation, physical immobility, and alterations in nutritional status. Provide gentle massage around reddened or blanched areas. Improves blood flow, minimizing tissue hypoxia. Note: Direct massage of compromised areas may cause tissue injury.
Option D: This is not the priority nursing diagnosis for the client with HF and pulmonary edema. Implement a graded cardiac rehabilitation program. Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption.
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