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
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.
- Impaired Gas Exchange
- Productive cough
- Rales on auscultation
- Difficulty of breathing
- Pale conjunctiva, nail beds and buccal mucosa
- Metabolic acidosis
- Circumoral cyanosis
Planning & Desired Outcomes
- Patient will be able to demonstrate improvement in gas exchange as evidenced by normal breath sounds, and skin color, presence of eupnea, heart rate 100 bpm or less, Pa02 mm
|Assess respiratory rate, use of accessory muscles, signs of air hunger, lung excursion, cyanosis, and significant changes in vital signs.||These are warning signs of increasing respiratory distress that requires immediate attention.|
|Auscultate lung fields for presence of crackles.||Decreased breath sound can be a sign of fluid overload or altered ventilation. Crackles signify alveolar fluid congestion and systolic dysfunctional heart failure. On the other hand, wheezing may indicate asthma or related bronchitis.|
|Monitor oxygen saturation and ABG findings.||A pulse oximetry value of 92% or less, decreased PaO2, and increased PaCO2 are signs of decreasing oxygenation.|
|Observe color of skin, mucous membranes and nail beds, noting presence of peripheral cyanosis.||Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/ chills.|
|Monitor potassium levels.||A possibility of hypokalemia is evident in patients taking diuretics.|
|Position the patient in a High Fowler’s position with head of the bed elevated up to 90°.||Promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation.|
|Keep back dry.||To avoid coughing|
|Promote adequate rest periods||Rest will prevent fatigue and decrease oxygen demands for metabolic demands|
|Keep environment allergen free||To reduce irritant effects on airways|
|Suction secretions PRN||To clear airway when secretions are blocking the airway.|
|Administer oxygen therapy as ordered.||Patients with ADHF, high-flow oxygen is given via non non rebreathing mask, positive airway pressure devices, or endotracheal intubation and mechanical intubation. If improves, oxygen is titrated to maintain pulse oximetry readings greater than 92%.|
|Administer diuretics as ordered.||Diuretics promotes normovolemia by decreasing fluid accumulation and blood volume. Fluid overload reduces lung perfusion leading to hypoxemia.|
|Administer vasodilatiors as ordered.||These medications increase venous dilation and decrease pulmonary congestion, that will enhance gas exchange.|
||Suppresses the effects of the renin-angiotensin system by decreasing angiotensin II and causing reduced secretion of aldosterone. These medications lower blood pressure and decrease preload and afterload, reducing work of the left ventricle.|
||These are given for patients with intolerance to ACE inhibitors due to cough secondary to the release of bradykinin.|
||Used in conjunction with nitrates in patients who cannot tolerate medications suchs as ACE inhibitor/ARB due to renal dysfunction.|
||Acts as a coronary vasodilators and used in combination with hydralazing.|
|Have an airway emergency equipment available at the bedside.||A likelihood of cardiac arrest for patients with severe decompensated heart failure.|
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]
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
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.