A nurse assigned to a client with congestive heart failure (CHF) is providing shift report. Which nursing interventions would be appropriate to include?
The nurse should reduce fluid intake to less than 1,000 ml per shift.
The nurse should keep the client in a supine position as much as possible.
The nurse should encourage alternating activity with rest periods.
The nurse should assess the ankles, legs, and feet for pitting edema.
Numbers 3 and 4 are correct.
Rationale: Inability of the myocardium to pump effectively will reduce the client’s activity tolerance. Alternating activity with rest allows the client to function at her best. Assessment by the nurse is appropriate as pooling of fluid in the lower extremities results if the heart is unable to pump blood throughout the body. While clients with CHF need to be on strict intake and output, fluids do not necessarily need to be limited. Instead, the client’s weight is a better assessment criteria of fluid overload. The client should be kept in a semi-Fowler’s position.
