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Tagged as: CHF. heart failure. congestive heart failure. med surg. cardiac. nursing school. memory notebook. nursing student. nclex. mneumonic. student nurse.

Focused Assessment of the patient:

The nurse looks for evidence of worsening of the heart failure: including increasing dyspnea, tachypnea, tachycardia, fatigue and exercise intolerance. Dysrhythmias such as ventricular ecotopy or atrial fibrillation may exist in the presence of worsening disease. Atrial fibrillation in the setting of a low ejection fraction can precipitously drop a patients cardiac output. Atrial kick which may supply as much as nearly 20% of the volume entering the ventricle  may contribute to a lessening of ventricular volume. 

Left sided symptoms (decreased CO and pulmonary congestion)

    • Fatigue, weakness, lethargy exercise intolerance
    • Orthopnea; rhonchi, crackles, wheezes, dyspnea, frothy pink sputum, tachypnea, hacking cough worse at night, hypoxia, respiratory acidosis
    • Tachycardia with exertion, dizziness, palpitations, irregular rhythm, s3,s4, cardiomegaly, ^PCWP, PADP, CVP, angina, 
    • Oliguric during the day
    • Skin cool, moist; cyanosis; pallor; decreased cap refill, mild to moderate edema

Right sided failure symptoms(systemic congestion)

  • Easily fatigued
  • Dyspnea present but not as prominent
  • Palpitations; irregular rhythm, JVD, ^ CVP, PCWP, PADP, 
  • Anorexia, nausea, hepatosplenomegaly, distended abdomen; constipation
  • Polyuria @ night; weight gain
  • Moderate to severe edema
302 | reblog