Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.
A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
B. Activity intolerance related to increased cardiac output.
C. Decreased cardiac output related to structural and functional changes.
D. Impaired gas exchange related to decreased sympathetic nervous system activity.
E. Acute pain related to inability to meet the oxygen demands.
Correct Answer: A, C & E.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity.
Option A: Due to decreased cardiac output, there is decreased preload and stroke volume thus there is decreased blood pumped out from the blood. Decrease in stroke volume decreases perfusion throughout the body.
Option B: Activity intolerance is related to a decrease, not increase, in cardiac output. 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. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries
Option C: The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased therefore decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness, and paleness.
Option D: Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity. 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 E: When a coronary artery is blocked, blood flow to the area of the heart supplied by that artery is reduced. If the remaining blood flow is inadequate to meet the oxygen demands of the heart, the area may become ischemic and injured and myocardial infarction may result. Neural pain receptors are stimulated by local mechanical stress resulting from abnormal myocardial contraction.
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