Heart-Failure-Care-Plans

Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body. Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself, instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.

Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure.

For the updated version of this care plan, see: 6 Heart Failure Nursing Care Plans

Nursing Care Plans

Here are 10 nursing care plans for patients with Congestive Heart Failure. 

1. Decreased Cardiac Output


The heat 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

Assessment

The patient may manifest the following:

  • Pale conjunctiva, nail beds, and buccal mucosa
  • irregular rhythm of pulse
  • bradycardia
  • generalized weakness

Diagnosis

  • Decreased cardiac output r/t [altered heart rate and rhythm] AEB [bradycardia]

Planning

  • Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.
  • Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

Nursing Interventions

Nursing Interventions Rationale
Assess for abnormal heart and lung sounds. Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.
Monitor blood pressure and pulse. Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.
Assess mental status and level of consciousness. The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
Assess patient’s skin temperature and peripheral pulses. Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
Monitor results of laboratory and diagnostic tests. Results of the test provide clues to the status of the disease and response to treatments.
Monitor oxygen saturation and ABGs. Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs. Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
Implement strategies to treat fluid and electrolyte imbalances. Decreases the risk for development of cardiac output due to imbalances.
Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity. Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
Encourage periods of rest and assist with all activities. Reduces cardiac workload and minimizes myocardial oxygen consumption.
Assist the patient in assuming a high Fowler’s position. Allows for better chest expansion, thereby improving pulmonary capacity.
Teach patient the pathophysiology of disease, medications Provides the patient with needed information for management of disease and for compliance.
Reposition patient every 2 hours To prevent occurrence of bed sores
Instruct patient to get adequate bed rest and sleep To promote relaxation to the body
Instruct the SO not to leave the client unattended To ensure safety and reduce risk for falls that may lead to injury

Evaluation

  • After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.
  • After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

2. Excess Fluid Volume


When blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and renin is released into the bloodstream. Renin interacts with angiotensinogen to produce angiotensin I. When angiotensin I contacts ACE, it is converted to angiotensin II, a potent vasoconstrictor. Angiotensin II increases arterial vasoconstriction, promote release of norepinephrine from sympathetic nerve endings, and stimulates the adrenal medulla to secrete aldosterone, which enhances sodium and water absorption. Stimulation of the renin-angiotensin system causes plasma volume to expand and preload to increase.

Assessment

The patient may manifest the following:

  • Edema of extremities
  • Difficulty of breathing
  • Crackles
  • Change in mental status
  • Restlessness and anxiety

Diagnosis

  • Excessive Fluid volume related to decreased cardiac output and sodium and water retention

Planning & Desired Outcomes

  • Patient will verbalize understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.
  • Patient will demonstrate adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema.
Nursing Interventions Rationale
Establish rapport To gain patient’s trust and cooperation
Monitor and record VS To obtain baseline data
Assess patient’s general condition To determine what approach to use in treatment
Monitor I&O every 4 hours I&O balance reflects fluid status
Weigh patient daily and compare to previous weights. Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess.
Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production When increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema
Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic. Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular absorption of sodium Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.
Follow low-sodium diet and/or fluid restriction The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.
Encourage or provide oral care q2 Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatis pressure exceeds interstitial pressure, fluids leak out of ht ecpaillaries and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart.
Obtain patient history to ascertain the probable cause of the fluid disturbance. May include increased fluids or sodium intake, or compromised regulatory mechanisms.
Monitor  for distended neck veins and ascites Indicates fluid overload
Evaluate urine output in response to diuretic therapy. Focus is on monitoring the response to the diuretics, rather than the actual amount voided
Assess the need for an indwelling urinary catheter. Treatment focuses on diuresis of excess fluid.
Institute/instruct patient regarding fluid restrictions as appropriate. This helps reduce extracellular volume.

3. Acute Pain


In ischemic heart disease, atherosclerosis develops in the coronary arteries, causing them to become narrowed or blocked. 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.

Assessment

Patient may manifest the following

  • Difficulty of breathing
  • Chest pain
  • Restlessness

Diagnosis

  • Acute Pain

Planning & Desired Outcomes

  • Patient’s pain will be decreased.
  • Patient will demonstrate activities and behaviors that will prevent the recurrence of pain.
Nursing Interventions Rationale
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Administer or assist with self-administration of vasodilators, as ordered. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
Assess the response to medications every 5 minutes Assessing response determines effectiveness of medication and whether further interventions are required.
Provide comfort measures. To provide nonpharmacological pain management.
Establish a quiet environment. A quiet environment reduces the energy demands on the patient.
Elevate head of bed. Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Teach patient relaxation techniques and how to use them to reduce stress. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction. In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.

4. Ineffective Tissue Perfusion


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.

Assessment

  • Pale conjunctiva, nail beds, and buccal mucosa
  • Generalized weakness
  • Chest pain
  • Difficulty of breathing
  • Abnormal pulse rate and rhythm
  • Bradycardia
  • Altered BP readings
  • With pitting edema on both forearms and hands
  • Bipedal pitting edema

Diagnosis

  • Ineffective tissue perfusion related to decreased cardiac output.

Planning & Desired Outcomes

  • Patient will demonstrate behaviors to improve circulation.
  • Display vital signs within acceptable limits, dysrhythmias absent/controlled,and no symptoms of failure
Nursing Interventions Rationale
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Administer or assist with self administration of vasodilators, as ordered. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
Assess the response to medications every 5 minutes. Assessing response determines effectiveness of medication and whether further interventions are required.
Give beta blockers as ordered. Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.
Establish a quiet environment. A quiet environment reduces the energy demands on the patient.
Elevate head of bed. Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered. Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain.
Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by physician. These enzymes elevate in the presence of myocardial infarction at differing times and assist in ruling out a myocardial infarction as the cause of chest pain.
Assess cardiac and circulatory status. Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.
Monitor cardiac rhythms on patient monitor and results of 12 lead ECG. Notes abnormal tracings that would indicate ischemia.
Teach patient relaxation techniques and how to use them to reduce stress. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction. In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.
Reposition the patient every 2 hours To prevent bedsores
Instruct patient on eating a small frequent feedings To prevent heartburn and acid indigestion

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