15 Heart Failure Nursing Care Plans

6

In this nursing care plan guide are 15 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.

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.

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.

Clinical Manifestations

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 perfusion
  • Weak, thready pulse
  • Fatigue

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 Plans

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 15 nursing care plans (NCP) and nursing diagnosis for patients with Heart Failure:

  1. Decreased Cardiac Output
  2. Activity Intolerance
  3. Excess Fluid Volume
  4. Risk for Impaired Gas Exchange
  5. Risk for Impaired Skin Integrity
  6. Deficient Knowledge
  7. Acute Pain
  8. Ineffective Tissue Perfusion
  9. Hyperthermia
  10. Ineffective Breathing Pattern
  11. Ineffective Airway Clearance
  12. Impaired Gas Exchange
  13. Fatigue
  14. Risk for Decreased Cardiac Output
  15. Fear
  16. Other Nursing Care Plans
Back
Next

Risk for Decreased Cardiac Tissue Perfusion

Alteration of tissue perfusion is related with dilation, constriction, and occlusion of the blood vessels of the heart.

Nursing Diagnosis

Ineffective Tissue PerfusionDecrease in oxygen, resulting in failure to nourish tissues at capillary level.

Risk factors may include

  • Atherosclerosis
  • Pulmonary congestion
  • Presence of edema

Desired Outcomes

  • Maintained adequate tissue perfusion as evidenced by blood pressure, pulse rate and rhythm, respiratory rate, and capillary refill within normal limits.
  • Demonstrate improvement in mental status.

Nursing Interventions

Nursing InterventionsRationale
Nursing Assessment
Assess changes in mental status such as anxiety, memory loss, confusion, depression, restlessness, lethargy, stupor, and coma.This may signal reduced cerebral perfusion and decreased oxygen level.
Monitor blood pressure every 15 minutes or more frequently if unstable. Watch out for any reduction greater than 20 mm Hg over patient’s baseline or related changes such as dizziness and changes in mental status.A major side effect of the medical management of heart failure is hypotension which can also be a result of the disease.
Monitor heart rate. Monitor for any changes such as tachycardia, arrhythmia.Indicate decompensation and reduced function of the heart.
Assess the extremities for color, temperature, capillary refill, pulse presence and amplitude.Signs of peripheral vasoconstriction due to sympathetic nervous system compensation includes pallor, coolness, delayed capillary refill time (more than 2 seconds), and decreased pulse amplitude. The presence of edema in the extremities may be observed due to fluid overload
Therapeutic Interventions
Administer inotropic, vasodilators as ordered. Watch out for adverse effects that include hypotension, arrhythmia.
  • Dopamine, dobutamine, milrinone
These inotropic drugs enhances the strength of contractions and are kept in case for use in Acute decompensated heart failure (ADHF) related to low-cardiac output and cardiogenic shock until the patient is stabilized. They may be utilized in a long period during advanced-stage HF as a bridge to transplantation or for palliation of symptoms. Use may be associated with increased mortality and ventricular dysrhythmias. Transfer to the coronary care unit may be required for closed monitoring during the administration of these inotropic medications.
  • Nitroglycerin, nitroprusside, nesiritide
These vasodilators are given in Acute decompensated heart failure (ADHF) to reduce cardiac workload by decreasing ventricular filling pressures and systemic vascular resistance. These medications are not recommended for patients with systemic blood pressure less than 90 mm Hg, low-output HF, and cardiogenic shock.
Back
Next

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 Nursing5(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 Research17(4), 248-256. [Link]

See Also

You may also like the following posts and care plans:

Cardiac Care Plans

Nursing care plans about the different diseases of the cardiovascular system:

Originally published on July 14, 2013. 

Last updated on

6 COMMENTS

LEAVE A REPLY

Please enter your comment!
Please enter your name here