Nursing Assessment for Cardiac Decompensation

Cardiac Decompensation

Cardiac Decompensation is a condition of congestive heart failure in which the heart is unable to ensure adequate cellular perfusion in all parts of the body without assistance. Causes may include myocardial infarction, increased workload, infection, toxins, or defective heart valves.


Nursing Assessment for Cardiac Decompensation

Activity and Rest
  • Symptoms: Complaining weak, tired, dizzy, feeling throbbing and pounding. Complain of difficulty sleeping (ortopneu, paroksimal nocturnal dyspnoea, nocturia, night sweats).
  • Signs: tachycardia, changes in blood pressure, fainting because of work, takpineu, dyspnoea.
Circulation
  • Symptoms: Having a history of rheumatic fever, hypertension, congenital: arteial septal damage, chest trauma, a history of heart murmurs and palpitations, hoarse, hemoptisisi, cough with / without sputum, history of anemia, a history of shock hipovolema.
  • Signs: Vibration systolic musty, heart sounds; loud S1, opening a hard, tachycardia. Irregular rhythm; arterial fibrillation.
Ego integrity
  • Signs : indicates anxiety; restless, pale, sweating, trembling. Fear of death, the desire to end life, feeling useless, neurotic personality.
Food / Fluids
  • Symptoms: Complaining weight changes, frequent use of diuretics.
  • Signs: general edema, hepatomegaly and asistes, respiratory effort and noisy sounds cracles, and wheezing.
Neuro Sensory
  • Symptoms: Complaining tingling, dizziness
  • Signs: Weakness
Breathing
  • Symptoms: Complaining tightness, persistent cough or nocturnal.
  • Signs: Takipneu, breath sounds; cracles, wheezing, sputum, blood-colored spots, restless.
Security
  • Symptoms: The process of infection / sepsis, history of surgery
  • Signs: Weakness of the body
Guidance / learning
  • Symptoms: Asking about the state of illness.
  • Signs: Showing the uninformed.
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