In this nursing care plan guide are 13 NANDA nursing diagnosis for 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.
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 isa progressive and chronic condition that is managed by significant lifestyle changes and adjunct medical therapy to improve quality of life. Heart failure is caused from 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.
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
- Cough that is initially dry and nonproductive
- Frothy sputum that is sometimes blood-tinged
- Inadequate tissue perfusioon
- Weak, thready pulse
Right-Sided Heart Failure
- Congestion of the viscera and peripheral tissues
- Edema of the lower extremities
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 13 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
- Other Nursing Care Plans
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.
Patient may manifest the following:
- rales on BLF
- productive cough
- frothy sputum
- pursed lip breathing
- Ineffective breathing pattern related to fatigue and decreased lung expansion and pulmonary congestion secondary to CHF
Planning & Desired Outcomes
- Patient’s respiratory pattern will be effective without causing fatigue
|Establish rapport||To gain comfort feelings form the pt and pts SO|
|Monitor VS||To gain baseline data|
|Inspect thorax for symmetry of respiratory movement||Determines adequacy of breathing|
|Observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory phase and use of accessory muscles||Identifies increased work of breathing|
|Measure tidal volume and vital capacity||Indicates volume of air moving in and out of lungs|
|Assess emotional response||Detects use of hyperventilation as a causative factor|
|Position patient in optimal body alignment in semi- fowler’s position for breathing|
|Assist patient to use relaxation techniques||Reduces muscle tension, decreases work of breathing|
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