Definition

Congestive Heart Failure (CHF) or heart failure is a condition in which the heart can’t pump enough blood to the body’s other organs.

To fully understand CHF, see the pathophysiology here.

Nursing Care Plans

Fluid Volume Excess

Goals:

  • 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.

Interventions:

  • 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

Goal:

  • Will maintain optimal cardiac output aeb vital signs within acceptable limits, no s/sx of decreased cardiac output.

Interventions:

  • 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.

Goals:

  • Will be free from s/sx or complications related to fluid overload.

Interventions:

  • 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

Goal(s)

  • Episodes of dyspnea will decrease to less than [daily/weekly/monthly] by ___

Intervention(s)

  • 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

Intervention(s)

  • 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.

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