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.

Nursing Care Plans

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

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

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.

Excess Fluid Volume

When blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and rennin 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 rennin-angiotensin system causes plasma volume to expand and preload to increase.

NDx: Excessive Fluid volume  r/t decreased cardiac output and sodium and water retention AEB crackles on both lung field and edema on extremities secondary to CHF and IHD

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:(none)Objective:Patient manifested:

  • Edema on extremities
  • DOB
  • Crackles heard on both lung fields

Patient may manifest:

  • Change in mental status (lethargy or confusion)
  • Restlessness and anxiety

 

Short Term:After 3-4 hours of interventions, the patient will verbalize understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.Long Term:After 3-4 days of nursing interventions, the patient will demonstrate adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema.
  1. Establish rapport
  2. Monitor and record VS
  3. Assess patient’s general condition
  4. Monitor I&O every 4 hours
  5. Weigh patient daily and compare to previous weights.
  6. Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production
  7. Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic.
  8. Follow low-sodium diet and/or fluid restriction
  9. Encourage or provide oral care q2
  10. Obtain patient history to ascertain the probable cause of the fluid disturbance.
  11. Monitor  for distended neck veins and ascites
  12. Evaluate urine output in response to diuretic therapy.
  13. Assess the need for an indwelling urinary catheter.
  14. Institute/instruct patient regarding fluid restrictions as appropriate.

 

  1. To gain patient’s trust and cooperation
  2. To obtain baseline data
  3. To determine what approach to use in treatment
  4. I&O balance reflects fluid status
  5. Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess.
  6. 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
  7. 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.
  8. The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.
  9. 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.
  10. May include increased fluids or sodium intake, or compromised regulatory mechanisms.
  11. Inidicates fluid overload
  12. Focus is on monitoring the response to the diuretics, rather than the actual amount voided
  13. Treatment focuses on diuresis of excess fluid.
  14. This helps reduce extracellular volume.
Short Term:Pt shall have verbalized understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.Long Term:Pt shall have demonstrated adequate fluid balance AEB output equal to exceeding intake, clearing breath sounds and decreasing edema.

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

Planning

Interventions

Rationale

Evaluation

Subjective:PainObjective:Patient manifested:

  • (+) DOB
  • with a rate of 7 out of 10
  • with complaints of chest pain unprovoked

Patient may manifest:

  • Restlessness

 

Short Term:After 3-4 hours of nursing interventions, the patient’s pain will decrease from 7 to 3 as verbalized by the patient.Long Term:After 2-3 days of nursing interventions, the patient will demonstrate activities and behaviors that will prevent the recurrence of pain.
  1. Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
  2. Administer or assist with self-administration of vasodilators, as ordered.
  3. Assess the response to medications every 5 minutes
  4. Provide comfort measures.
  5. Establish a quiet environment.
  6. Elevate head of bed.
  7. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
  8. Teach patient relaxation techniques and how to use them to reduce stress.
  9. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.

 

  1. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
  2. 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.
  3. Assessing response determines effectiveness of medication and whether further interventions are required.
  4. To provide nonpharmacological pain management.
  5. A quiet environment reduces the energy demands on the patient.
  6. Elevation improves chest expansion and oxygenation.
  7. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
  8. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
  9. 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.

 

Short Term:Patient shall have verbalized a decrease in pain from a scale of 7 to 3.Long Term:The patient shall have demonstrated activities and behaviors that will prevent the recurrence of pain.

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.

NDx: Ineffective tissue perfusion r/t decreased cardiac output.

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:Objective:Patient manifested:

  • with pale conjunctiva, nail beds and buccal mucosa
  • (+)chest pain
  • (+) DOB
  • Generalized weakness
  • Abnormal pulse rate and rhythm
  • Bradycardic
  • Altered BP readings.
  • With pitting edema on both forearms and hands
  • Bipedal pitting edema
Short Term:After 6 hours of nursing interventions the patient will demonstrate behaviors to improve circulation.Long Term:After 3-4 days of nursing interventions the patient will demonstrate increased perfusion as individually appropriate.
  1. Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
  2. Administer or assist with self administration of vasodilators, as ordered.
  3. Assess the response to medications every 5 minutes.
  4. Give beta blockers as ordered.
  5. Establish a quiet environment.
  6. Elevate head of bed.
  7. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
  8. Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered.
  9. Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by physician.
  10. Assess cardiac and circulatory status.
  11. Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.
  12. Teach patient relaxation techniques and how to use them to reduce stress.
  13. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
  14. Reposition the patient every 2 hours
  15. Instruct patient on eating a small frequent feedings
  1. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
  2. 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.
  3. Assessing response determines effectiveness of medication and whether further interventions are required.
  4. Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.
  5. A quiet environment reduces the energy demands on the patient.
  6. Elevation improves chest expansion and oxygenation.
  7. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
  8. 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.
  9. 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.
  10. Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.
  11. Notes abnormal tracings that would indicate ischemia.
  12. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
  13. 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.
  14. To prevent bed sores
  15. To prevent heartburn and acid indigestion
Short Term:The patient shall have demonstrated behaviors to improve circulation.Long Term:The patient shall have demonstrated increased perfusion as individually appropriate

Hyperthermia

Presence of microorganisms stimulates the release of pyrogen from the leukocytes resetting the body’s thermostat to febrile level and then there would be activation of the hypothalamus, which will result in increase in epinephrine and norepinephrine, vasoconstriction of cutaneous vessels. The heat will be produced as peripheral vasodilation results in skin flushing and skin is warm to touch.

NDx: Hyperthermia RT increased metabolic rate secondary to pneumonia

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:(none)Objective:Patient manifested:

  • Pale palpebral
  • Conjunctiva and nail beds
  • Warm to touch
  • Weakness
  • Temperature of 38.9 oC

Patient may manifest:

  • Fluid or electrolyte imbalance
  • Diaphoresis
  • Hot flushed
  • skin

 

Short Term:After 3- 4 hours of nursing interventions the patient will have demonstrate body temperature from 38.9˚C to37.5˚CLong Term:After 3 days of nursing interventions the patient will have maintain a core temperature that is within the normal range.
  1. Assess vital signs, the temperature.
  2. Monitor and record all sources of fluid loss such as urine, vomiting and diarrhea.
  3. Performed tepid sponge bath.
  4. Maintain bed rest.
  5. Remove excess clothing and covers.
  6. Increase fluid intake.
  7. Provide adequate nutrition, a high caloric diet.
  8. Control environmental temperature.
  9. Adjust cooling measures on the basis of physical response.
  10. Provide information regarding normal temperature and control.
  11. Explain all treatments.
  12. Administer antipyretics as ordered.
  13. Control excessive shivering with medications such as Chlorpromazine and Diazepam if necessary.
  14. Provide ample fluids by mouth or intravenously as ordered.
  15. Provide oxygen therapy in extreme cases as ordered.
  1. Vital signs provide more accurate indication.
  2. For potential fluid and electrolyte losses.
  3. To promote heat loss by evaporation and conduction.
  4. To reduce metabolic demands and oxygen consumption.
  5. Decreases warmth and increase evaporative cooling.
  6. To prevent dehydration.
  7. The meet the metabolic demands.
  8. To prevent an increase in body temperature and prevent shivering of the patient.
  9. Shivering, which burns calories and increases metabolic rate in order to produce heat.
  10. This is especially necessary for patients with conditions at risk for hyperthermia.
  11. Patients’ S.O. needs to be oriented.
  12. To decrease body temperature.
  13. Shivering increases metabolic rate and body temperature.
  14. If the patient is dehydrated or diaphoretic, fluid loss contributes to fever.
  15. Hyperthermia increases metabolism.
Short Term:The patient shall have demonstrated body temperature from 38.9˚C to37.5˚CLong Term:The patient shall have maintained a core temperature that is within the normal range.

Ineffective Breathing Pattern

Ineffective Breathing Pattern occurs when there is presence of spasm and inflammation of the lung tissue and parenchyma , these results in inability of the pt to move air in and out of the lungs as needed to maintain adequate tissue oxygenation and perfusion.

NDx: Ineffective breathing pattern r/t fatigue and decreased lung expansion and pulmonary congestion secondary to CHF

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:(none)Objective:Patient manifested:

  • weakness
  • rales on BLF
  • productive cough
  • frothy sputum

Patient may manifest:

  • pursed lip breathing
  • tachypnea
Short Term:After 3- 4 hours of nursing interventions, the patient and patient’s SO will verbalized understanding of pts conditionLong Term:After 3-4 days of nursing interventions, the pts respiratory pattern will be effective without causing fatigue
  1. establish rapport
  2. monitor VS
  3. inspect thorax for symmetry of respiratory movement
  4. observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory phase and use of accessory muscles
  5. measure tidal volume and vital capacity
  6. assess emotional response
  7. position patient in optimal body alignment in semi- fowler’s position for breathing
  8. assist patient to use relaxation techniques

 

  1. to gain comfort feelings form the pt and pts SO
  2. to gain baseline data
  3. determines adequacy of breathing
  4. identifies increased work of breathing
  5. indicates volume of air moving in and out of lungs
  6. detects use of hyperventilation as a causative factor
  7. optimizes diaphragmatic contraction
  8. reduces muscle tension, decreases work of breathing
  9. facilitates deep breathing
Short Term:The patient and patient’s SO shall have verbalized understanding of patient’s condition]Long Term:The patient’ s respiratory pattern shall have been effective without causing fatigue

Activity Intolerance

As heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the body’s needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries

NDx: Activity intolerance r/t imbalance O2 supply and demand AEB limited ROM, generalized weakness and DOB

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:Objective:Patient manifested:

  • generalized weakness
  • limited range of motion as observed
  • abnormal pulse rate and rhythm
  • (+) DOB
Short Term:After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity intoleranceLong Term:After 2-3 days of nursing interventions, the patient will report measurable increase in activity intolerance..
  1. Establish Rapport
  2. Monitor and record Vital Signs
  3. Assess patient’s general condition
  4. Adjust client’s daily activities and reduce intensity of level. Discontinue  activities that cause undesired psychological changes
  5. Instruct client in unfamiliar activities and in alternate ways of conserve energy
  6. Encourage patient to have adequate bed rest and sleep
  7. Provide the patient with a calm and quiet environment
  8. Assist the client in ambulation
  9. Note presence of factors that could contribute to fatigue
  10. Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
  11. Give client information that provides evidence of daily or weekly progress
  12. Encourage the client to maintain a positive attitude
  13. Assist the client in a semi-fowlers position
  14. Elevate the head of the bed
  15. Assist the client in learning and demonstrating appropriate safety measures
  16. Instruct the SO not to leave the client unattended
  17. Provide client with a positive atmosphere
  18. Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms
  1. To gain clients participation and cooperation in the nurse patient interaction
  2. To obtain baseline data
  3. To note for any abnormalities and deformities present within the body
  4. To prevent strain and overexertion
  5. To conserve energy and promote safety
  6. to relax the body
  7. to provide relaxation
  8. to prevent risk for falls that could lead to injury
  9. fatigue affects both the client’s actual and perceived ability to participate in activities
  10. to determine current status and needs associated with participation in needed or desired activities
  11. to sustain motivation of client
  12. to enhance sense of well being
  13. to promote easy breathing
  14. to maintain an open airway
  15. to prevent injuries
  16. to avoid risk for falls
  17. to help minimize frustration and rechannel energy
  18. to indicate need to alter activity level
Short Term:The patient shall have used identified techniques to improve activity intoleranceLong Term:The patient shall have reported measurable increase in activity intolerance.

Ineffective Airway Clearance

Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increased in RR will also be expected as a compensatory mechanism of the body due to obstructed airways.

NDx: Ineffective airway clearance RT retained secretions AEB presence of rales on both lung fields.

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:Objective:Patient manifested:

  • with productive cough yellowish in color
  • presence of rales upon auscultation
  • (+) DOB
  • with pale conjunctiva, nail beds and buccal mucosa
Short Term:After 3-4 hours of nursing interventions, the patient will be able to establish and maintain airway patency AEB absence of signs of respiratory distress.Long Term:After 2-3 days of NI, the patient will be able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and improved RR.
  1. Monitor and record vital signs.
  2. Assess patient’s condition.
  3. Monitor respirations and breath sounds, noting rate and sounds.
  4. Position head properly
  5. Position appropriately and discourage use of oil-based products around nose.
  6. Auscultate breath sounds and assess air movement.
  7. Encourage deep breathing and coughing exercises
  8. Elevate head of bed and encourage frequent position changes.
  9. Keep back dry and loosen clothing
  10. Observed for signs and symptoms of infection.
  11. Instruct patient have adequate rest periods and limit activities to level of activity intolerance.
  12. Give expectorants and bronchodilators as ordered.
  13. Suction secretions PRN
  14. Administer oxygen therapy and other medications as ordered.

 

  1. To obtain baseline data
  2. To know the patient’s general condition
  3. To determine respiratory distress and accumulation of secretions.
  4. To open or maintain open airway.
  5. To prevent vomiting with aspiration into lungs.
  6. To ascertain status and note progress.
  7. To maxixmize effort
  8. To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation
  9. To promote comfort and adequate ventilation
  10. To identify infectious process and promote timely intervention.
  11. Rest will prevent fatigue and decrease oxygen demands for metabolic demands
  12. To further mobilize secretions
  13. To clear airway when secretions are blocking the airway
  14. Indicated to increase oxygen saturation.
Short Term:The patient shall have been able to establish and maintain airway patency AEB absence of respiratory distress.Long Term:The patient shall have been able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and improved RR.

Impaired Gas Exchange

The exchange in oxygenation and carbon dioxide gases is impeded due to the obstruction caused by the accumulation of bronchial secretions in the alveoli. Oxygen cannot diffuse easily.

NDx: Impaired gas exchange related to inflammation of airways and accumulation of fluid in the alveoli

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:Objective:Patient manifested:

  • productive cough yellowish in color
  • presence of rales upon auscultation
  • (+) DOB
  • Tachypnic AEB RR= 27bpm
  • with pale conjunctiva, nail beds and buccal mucosa
  • fatigue

Patient may manifest:

  • Metabolic acidosis
  • Circum-oral cyanosis

 

Short Term:After 6 hours of nursing interventions, the patient will be able to demonstrate improvement in gas exchange AEB a decrease in respiratory rate to normal, and absence of pallorLong Term:After 3-4 days of nursing interventions, the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress
  1. Monitor and record vital signs
  2. Observe color of skin, mucous membranes and nail beds, noting presence of peripheral cyanosis.
  3. Elevate head of bed and encourage frequent position changes.
  4. Keep back dry.
  5. Promote adequate rest periods
  6. Change position q 2 hrs.
  7. Keep environment allergen free
  8. Suction secretions PRN
  9. Administer oxygen therapy as ordered.

 

  1. To obtain baseline data
  2. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/ chills
  3. To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation
  4. To avoid coughing
  5. Rest will prevent fatigue and decrease oxygen demands for metabolic demands
  6. To promote drainage of secretions
  7. To reduce irritant effects on airways
  8. To clear airway when secretions are blocking the airway.
  9. O2 therapy is indicated to increase oxygen saturation
Short Term:The patient shall have been able to demonstrate improvement in gas exchange AEB a decrease in respiratory rate to normalLong Term:The patient shall have been able to demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress

Fatigue

Heart failure is a physiologic state in which the heart cannot pump enough blood to meet the metabolic demands of the body. Since the patient has inadequate cardiac output, it can lead to hypoxic tissue and slowed removal of metabolic wastes, which in turn cause the patient to tire easily.

Assessment

Planning

Interventions

Rationale

Evaluation

Subjective:(none)Objective:Patient manifested:

  • Generalized weakness
  • (+) DOB
  • Limited range of motion
Short Term:After 6 hours of nursing interventions the patient will identify basis of fatigue and individual areas of control.Long Term:After 3-4 days of nursing interventions, the patient will report improved sense of energy
  1. Review medication regimen.
  2. Assess vital signs.
  3. Determine presence or degree of sleep disturbances.
  4. Obtain client descriptions of fatigue.
  5. Ask client to rate fatigue.
  6. Note daily energy patterns.
  7. Establish realistic activity goals with client and encourage forward movement.
  8. Plan interventions to allow individually adequate rest periods.
  9. Assist with self-care needs and ambulation.
  10. Avoid exposure to temperature and humidity extremes
  11. Instruct client in ways to monitor responses to activity and significant signs or symptoms.
  12. Promote overall health measures
  13. Provide supplemental oxygen, as indicated.
  14. Assist client to identify appropriate coping behaviors.
  1. Certain medications are known to cause or exacerbate fatigue.
  2. To evaluate fluid status and cardiopulmonary response to activity.
  3. Fatigue can be a consequence of sleep deprivation.
  4. To assist in evaluating impact on client’s life.
  5. To determine degree of fatigability.
  6. Helpful in determining pattern or timing of activity.
  7. Enhances commitment to promoting optimal outcomes.
  8. To maximize participation.
  9. To conserve energy for other tasks.
  10. Has negative impact on energy level.
  11. Indicate the need to alter activity level
  12. To promote energy
  13. Presence of hypoxemia reduces oxygen available for cellular uptakes and contributes to fatigue.
  14. Promote sense of control and improves self-esteem.
Short Term:The patient shall have identified basis of fatigue and individual areas of control.Long Term:The patient shall have reported improved sense of energy

More CHF Nursing Care Plans

You may also read more at Congestive Heart Failure Nursing Care Plans.

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