10 Congestive Heart Failure Nursing Care Plans

Assessment

Planning

Interventions

Rationale

Evaluation

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

• Monitor and record vital signs

• Observe color of skin, mucous membranes and nail beds, noting presence of peripheral cyanosis.

• Elevate head of bed and encourage frequent position changes.

• Keep back dry.

• Promote adequate rest periods

• Change position q 2 hrs.

• Keep environment allergen free

• Suction secretions PRN

• Administer oxygen therapy as ordered.

• To obtain baseline data

• Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/ chills

• To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation
• To avoid coughing

• Rest will prevent fatigue and decrease oxygen demands for metabolic demands

• To promote drainage of secretions

• To reduce irritant effects on airways

• To clear airway when secretions are blocking the airway.

• O2 therapy is indicated to increase oxygen saturation