To fully understand CHF, see the pathophysiology here.
Nursing Care Plans
Fluid Volume Excess
- Body weight will remain within normal limits
- Electrolyte levels will be within normal limits
- Will demonstrate adequate knowledge concerning medical condition.
- Will maintain optimal fluid balance
- Will verbalize less dyspnea and be more comfortable.
- Administer Oxygen as ordered
- Assess for symptoms such as dizziness, weakness/fatigue, nausea/vomiting, confusion, sweatiness, cyanosis. Notify physician as appropriate.
- Assess for presence of edema
- Check breath sounds and assess for labored breathing.
- Check Vital Signs
- Keep head of bed elevated
- Monitor fluid intake, restrict sodium intake as ordered.
- Monitor Lab work; K+, NA, BUN, Creatinine
- Observe for signs and symptoms of malnutrition, Do not force resident to eat. Offer small frequent feedings. Assess food preferences.
- Weigh patient daily
(Potential for) Decreased cardiac output
- Will maintain optimal cardiac output aeb vital signs within acceptable limits, no s/sx of decreased cardiac output.
- Administer medications as ordered by MD and check for side effects.
- Assess and document breath sounds such as dyspnea, cough, extended expiration, wheezing.
- Assess and document heart sounds, apical heart rate, presence of any abnormal heart sounds.
- Check for symptoms related to decreased cardiac output, such as chest pain, dyspnea, orthopnea, dependent edema, JVD, fluid overload.
- Discourage smoking. Discuss avoiding allergens when possible.
- Encourage activity as tolerated, rest as needed.
- Encourage proper posture (stand/sit upright, elevate head as needed) to optimize air exchange and comfort.
- Monitor breathing pattern; include rate, rhythm, depth, pursed lips, nasal flaring, fatigue.
- Obtain lab/diagnostic work as ordered and report results to MD.
Potential for fluid volume overload.
- Will be free from s/sx or complications related to fluid overload.
- Administer diuretics as ordered and monitor for side effects.
- Encourage adequate fluid intake within fluid restrictions as ordered by MD
- Ensure that snacks and beverages offered at activities comply with all ordered diet and fluid restrictions.
- Monitor fluid intake and record
- Monitor for s/sx of fluid overload (edema, shortness of breath, dyspnea, jugular vein distention, bounding pulses) and report to MD
Episodes of dyspnea
- Episodes of dyspnea will decrease to less than [daily/weekly/monthly] by ___
- Administer oxygen at __ L/min as ordered.
- Elevate head of bed as needed to promote comfort
- Monitor and report signs of dyspnea
- Reduce stress and anxiety as much as possible
- Report signs of respiratory distress or infection to MD immediately
- Speak to patient in calm, low voice to help reduce anxiety.
Potential for decreased endurance
NDx: Potential for decreased endurance due to decreased cardiac output
- Allow for periods of rest between activities
- Determine factors that contribute to intolerance (ie sleep disturbance)
- Encourage patient to conserve energy
- If applicable, discourage smoking.
- Monitor food intake to ensure that activity is supported.
- Monitor vital signs during activities.
- Slowly increase activity level. Continue to monitor vitals.