This nursing care plan guide contains 18 NANDA nursing diagnosis and some priority aspects of clinical care for patients with heart failure. Learn about the nursing interventions and assessment cues for heart failure including the goals, defining characteristics, and related factors for each nursing diagnosis.
What is Heart Failure?
Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which the heart cannot pump enough blood to meet the metabolic needs of the body following any structural or functional impairment of ventricular filling or ejection of blood.
Heart failure results from changes in the 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 a progressive and chronic condition that is managed by significant lifestyle changes and adjunct medical therapy to improve quality of life. Heart failure is caused by a variety of cardiovascular conditions such as chronic hypertension, coronary artery disease, and valvular disease.
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.
Heart failure can affect the heart’s left side, right side, or both sides. Though, it usually affects the left side first. The signs and symptoms of heart failure are defined based on which ventricle is affected—left-sided heart failure causes a different set of manifestations than right-sided heart failure.
Left-Sided Heart Failure
- Dyspnea on exertion
- Pulmonary congestion, pulmonary crackles
- Cough that is initially dry and nonproductive
- Frothy sputum that is sometimes blood-tinged
- Inadequate tissue perfusion
- Weak, thready pulse
- Oliguria, nocturia
Right-Sided Heart Failure
- Congestion of the viscera and peripheral tissues
- Edema of the lower extremities
- Enlargement of the liver (hepatomegaly)
- Anorexia, nausea
- Weight gain (fluid retention)
Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer uses this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency, and ventricular failure.
Nursing care plan goals for patients with heart failure includes support to improve heart pump function by various nursing interventions, prevention, and identification of complications, and providing a teaching plan for lifestyle modifications. Nursing interventions include promoting activity and reducing fatigue to relieve the symptoms of fluid overload.
Here are 18 nursing care plans (NCP) and nursing diagnosis for patients with Heart Failure:
- Decreased Cardiac Output
- Activity Intolerance
- Excess Fluid Volume
- Risk for Impaired Gas Exchange
- Risk for Impaired Skin Integrity
- Deficient Knowledge
- Acute Pain
- Ineffective Tissue Perfusion
- Ineffective Breathing Pattern
- Ineffective Airway Clearance
- Impaired Gas Exchange
- Risk for Decreased Cardiac Output
- Other Nursing Care Plans
Decreased Cardiac Output
The heart 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.
- Altered myocardial contractility/inotropic changes
- Alterations in rate, rhythm, electrical conduction
- Structural changes (e.g., valvular defects, ventricular aneurysm)
- Poor cardiac reserve
- Side effects of medication
- Generalized weakness.
- Increased heart rate (tachycardia), dysrhythmias, ECG changes
- Changes in BP (hypotension/hypertension)
- Extra heart sounds (S3, S4)
- Decreased urine output
- Diminished peripheral pulses
- Cool, ashen skin; diaphoresis
- Orthopnea, crackles, JVD, liver engorgement, edema
- Chest pain
- Patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable limits, dysrhythmias absent/controlled, and no symptoms of failure (e.g., hemodynamic parameters within acceptable limits, urinary output adequate).
- Patient will report decreased episodes of dyspnea, angina.
- Patient will participate in activities that reduce cardiac workload.
|Auscultate apical pulse, assess heart rate, rhythm. Document dysrhythmia if telemetry is available.||Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and atrial fibrillation (AF) are common dysrhythmias associated with HF, although others may also occur.
Note: Intractable ventricular dysrhythmias unresponsive to medication suggest ventricular aneurysm.
|Note heart sounds.||S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3and S4), produced as blood flows into noncompliant chambers. Murmurs may reflect valvular incompetence.|
|Palpate peripheral pulses.||Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post tibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans (strong beat alternating with weak beat) may be present.|
|Monitor BP.||In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate, and profound hypotension may occur.|
|Inspect skin for pallor, cyanosis.||Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases.|
|Monitor urine output, noting decreasing output and concentrated urine.||Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent.|
|Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression.||May indicate inadequate cerebral perfusion secondary to decreased cardiac output.|
|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 renin-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|
|Encourage rest, semirecumbent in bed or chair. Assist with physical care as indicated.||Physical rest should be maintained during acute or refractory HF to improve efficiency of cardiac contraction and to decrease myocardial oxygen demand/ consumption and workload.|
|Provide quiet environment: explain therapeutic management, help patient avoid stressful situations, listen and respond to expressions of feelings.||Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate.|
|Provide bedside commode. Have patient avoid activities eliciting a vasovagal response (straining during defecation, holding breath during position changes).||Commode use decreases work of getting to bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function.|
|Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase activity as tolerated.||Decreases venous stasis, and may reduce incidence of thrombus or embolus formation.|
|Check for calf tenderness, diminished pedal pulses, swelling, local redness, or pallor of extremity.||Reduced cardiac output, venous pooling, and enforced bed rest increases risk of thrombophlebitis.|
|Withhold digitalis preparation as indicated, and notify physician if marked changes occur in cardiac rate or rhythm or signs of digitalis toxicity occur.||Incidence of toxicity is high (20%) because of narrow margin between therapeutic and toxic ranges. Digoxin may have to be discontinued in the presence of toxic drug levels, a slow heart rate, or low potassium level.|
|Administer supplemental oxygen as indicated.||Increases available oxygen for myocardial uptake to combat effects of hypoxia.|
|Administer medications as indicated:|
||Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in patients with stages I and II HF. In general, type and dosage of diuretic depend on cause and degree of HF and state of renal function. Preload reduction is most useful in treating patients with a relatively normal cardiac output accompanied by congestive symptoms. Loop diuretics block chloride reabsorption, thus interfering with the reabsorption of sodium and water.|
||Vasodilators are the mainstay of treatment in HF and are used to increase cardiac output, reducing circulating volume (venodilators) and decreasing SVR, thereby reducing ventricular workload. Note: Parenteral vasodilators (Nitroprusside) are reserved for patients with severe HF or those unable to take oral medications.|
||ACE inhibitors represent first-line therapy to control heart failure by decreasing ventricular filling pressures and SVR while increasing cardiac output with little or no change in BP and heart rate.|
||Antihypertensive and cardioprotective effects are attributable to selective blockade of AT1(angiotensin II) receptors and angiotensin II synthesis.|
||Increases force of myocardial contraction when diminished contractility is the cause of HF, and slows heart rate by decreasing conduction velocity and prolonging refractory period of the atrioventricular (AV) junction to increase cardiac efficiency /output.|
||These medications are useful for short-term treatment of HF unresponsive to cardiac glycosides, vasodilators, and diuretics in order to increase myocardial contractility and produce vasodilation. Positive inotropic properties have reduced mortality rates 50% and improved quality of life.|
||Useful in the treatment of HF by blocking the cardiac effects of chronic adrenergic stimulation. Many patients experience improved activity tolerance and ejection fraction.|
||Decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety.|
||Promote rest, reducing oxygen demand and myocardial workload.|
||May be used prophylactically to prevent thrombus and embolus formation in presence of risk factors such as venous stasis, enforced bed rest, cardiac dysrhythmias, and history of previous thrombotic episodes.|
|Administer IV solutions, restricting total amount as indicated. Avoid saline solutions.||Because of existing elevated left ventricular pressure, patient may not tolerate increased fluid volume (preload). Patients with HF also excrete less sodium, which causes fluid retention and increases myocardial workload.|
|Monitor and replace electrolytes.||Fluid shifts and use of diuretics can alter electrolytes (especially potassium and chloride), which affect cardiac rhythm and contractility.|
|Monitor serial ECG and chest x-ray changes.||ST segment depression and T wave flattening can develop because of increased myocardial oxygen demand, even if no coronary artery disease is present. Chest x-ray may show enlarged heart and changes of pulmonary congestion.|
|Measure cardiac output and other functional parameters as indicated.||Cardiac index, preload, afterload, contractility, and cardiac work can be measured noninvasively by using thoracic electrical bioimpedance (TEB) technique. Useful in determining effectiveness of therapeutic interventions and response to activity.|
|Monitor laboratory studies:|
||Elevation of BUN or creatinine reflects kidney hypoperfusion.|
||May be elevated because of liver congestion and indicate need for smaller dosages of medications that are detoxified by the liver.|
||Measures changes in coagulation processes or effectiveness of anticoagulant therapy.|
||May be necessary to correct bradydysrhythmias unresponsive to drug intervention, which can aggravate congestive failure and/or produce pulmonary edema.|
|Prepare for surgery as indicated:|
||Heart failure due to ventricular aneurysm or valvular dysfunction may require aneurysmectomy or valve replacement to improve myocardial contractility/ function. Revascularization of cardiac muscle by CABG may be done to improve cardiac function.|
||Cardiomyoplasty, an experimental procedure in which the latissimus dorsi muscle is wrapped around the heart and electrically stimulated to contract with each heartbeat, may be done to augment ventricular function while the patient is awaiting cardiac transplantation or when transplantation is not an option.|
||Other new surgical techniques include transmyocardial revascularization (percutaneous [PTMR]) using CO2 laser technology, in which a laser is used to create multiple 1-mm diameter channels in viable but underperfused cardiac muscle.|
|Assist with mechanical circulatory support system, such as IABP or VAD, when indicated.||An intra-aortic balloon pump (IABP) may be inserted as a temporary support to the failing heart in the critically ill patient with potentially reversible HF. A battery-powered ventricular assist device (VAD) may also be used, positioned between the cardiac apex and the descending thoracic or abdominal aorta. This device receives blood from the left ventricle (LV) and ejects it into the systemic circulation, often allowing patient to resume a nearly normal lifestyle while awaiting heart transplantation. With end-stage HF, cardiac transplantation may be indicated.|
References and Sources
Recommended references and sources for heart failure nursing care plan:
- Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier. [Link]
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis. [Link]
- Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. [Link]
- Jaarsma, T., Strömberg, A., De Geest, S., Fridlund, B., Heikkila, J., Mårtensson, J., … & Thompson, D. R. (2006). Heart failure management programmes in Europe. European Journal of Cardiovascular Nursing, 5(3), 197-205. [Link]
- Scott, L. D., Setter-Kline, K., & Britton, A. S. (2004). The effects of nursing interventions to enhance mental health and quality of life among individuals with heart failure. Applied Nursing Research, 17(4), 248-256. [Link]
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Cardiac Care Plans
Nursing care plans about the different diseases of the cardiovascular system:
- Angina Pectoris (Coronary Artery Disease) | 4 Care Plans
- Cardiac Arrhythmia (Digitalis Toxicity) | 3 Care Plans
- Cardiac Catheterization | 4 Care Plans
- Cardiogenic Shock | 5 Care Plans
- Congenital Heart Disease | 5 Care Plans
- Heart Failure | 16+ Care Plans
- Hypertension | 6 Care Plans
- Hypovolemic Shock | 4 Care Plans
- Myocardial Infarction | 7 Care Plans
- Pacemaker Therapy | 7 Care Plans
Originally published on July 14, 2013.