Question

A patient with heart failure has inadequate tissue perfusion. Which nursing interventions are included in the plan of care for this patient? (Select all that apply.)

a. Monitor respiratory rate, rhythm, and quality every 1 to 4 hours.
b. Auscultate breath sounds every 4 to 8 hours.
c. Provide supplemental oxygen to maintain oxygen saturation at 90% or greater.
d. Place the patient in a supine position with pillows under each leg.
e. Assist the patient in performing coughing and deep-breathing exercises every 2 hours.

Answer 1

For a patient with heart failure, nursing interventions to improve tissue perfusion include monitoring respiratory rate, auscultating breath sounds, providing supplemental oxygen, positioning the patient correctly, and assisting with coughing and deep-breathing exercises.

Step-by-step explanation:

For a patient with heart failure and inadequate tissue perfusion, several nursing interventions can be included in the plan of care. Among the options provided:

• Monitor respiratory rate, rhythm, and quality every 1 to 4 hours to ensure that any changes can be quickly identified and addressed.
• Auscultate breath sounds every 4 to 8 hours to detect any abnormalities such as crackles which could indicate fluid buildup or pneumonia.
• Provide supplemental oxygen to maintain oxygen saturation at 90% or greater, ensuring the tissues receive an adequate supply of oxygen.
• Place the patient in a position that helps with breathing, typically semi-Fowler's or Fowler's, rather than a supine position with pillows under each leg, which could actually worsen the heart failure symptoms.
• Assist the patient in performing coughing and deep-breathing exercises every 2 hours to help clear the airways and improve lung expansion.

These interventions are designed to enhance respiratory function, improve oxygenation, and monitor the patient's condition for any sign of deterioration or complications.