10 Congestive Heart Failure Nursing Care Plans

Assessment

Planning

Nursing Interventions

Rationale

Evaluation

Objectives:

The patient manifested the following:

• with pale conjunctiva, nail beds and buccal mucosa
• irregular rhythm of pulse
• bradycardic
• pulse rate of 34 beats/min
• generalized weakness

Long Term:

After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

1. Assess for abnormal heart and lung sounds.
2. Monitor blood pressure and pulse
3. Assess mental status and level of consciousness.
4. Assess patient’s skin temperature and peripheral pulses.
5. Monitor results of laboratory and diagnostic tests.
6. Monitor oxygen saturation and ABGs.
7. Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
8. Implement strategies to treat fluid and electrolyte imbalances.
9. Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.
10. Encourage periods of rest and assist with all activities.
11. Assist the patient in assuming a high Fowler’s position.
12. Teach patient the pathophysiology of disease, medications
13. Reposition patient every 2 hours
14. Instruct patient to get adequate bed rest and sleep
15. Instruct the SO not to leave the client unattended
16. 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.

1. Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.
2. 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.
3. 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.
4. Results of the test provide clues to the status of the disease and response to treatments.
5. Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
6. Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
7. Decreases the risk for development of cardiac output due to imbalances.
8. Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
9. Reduces cardiac workload and minimizes myocardial oxygen consumption.
10. Allows for better chest expansion, thereby improving pulmonary capacity.
11. Provides the patient with needed information for management of disease and for compliance.
12. To prevent occurrence of bed sores
13. To promote relaxation to the body
14. To ensure safety and reduce risk for falls that may lead to injury

Long Term:

After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.