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
As heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the body’s needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries
- Activity Intolerance
- Imbalance between oxygen supply/demand
- Generalized weakness
- Prolonged bed rest/immobility
- Weakness, fatigue
- Changes in vital signs, presence of dysrhythmias
- Pallor, diaphoresis
- Participate in desired activities; meet own self-care needs.
- Achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity.
For Activity Intolerance nursing diagnosis, nursing interventions include monitoring the patient’s response to activity and gradually performing activity.
|Check vital signs before and immediately after activity, especially if patient is receiving vasodilators, diuretics, or beta-blockers.||Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.|
|Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor.||Compromised myocardium and/or inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue.|
|Assess for other causes of fatigue (treatments, pain, medications).||Fatigue is a side effect of some medications (beta-blockers, tranquilizers, and sedatives). Pain and stressful regimens also extract energy and produce fatigue.|
|Assess patient’s general condition||To note for any abnormalities and deformities present within the body|
|Evaluate accelerating activity intolerance.||May denote increasing cardiac decompensation rather than overactivity.|
|Provide assistance with self-care activities as indicated. Intersperse activity periods with rest periods.||Meets patient’s personal care needs without undue myocardial stress and excessive oxygen demand.|
|Implement graded cardiac rehabilitation program.||Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption.|
|Assist patient with ROM exercises. Check regularly for calf pain and tenderness.||To prevent deep vein thrombosis due to vascular congestion.|
|Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes||Prevents straininga nd overexertion which may aggravate symptoms|
|Instruct client in unfamiliar activities and in alternate ways of conserve energy||Conserves energy and promote safety|
|Encourage patient to have adequate bed rest and sleep||Relaxes the body and promotes comfort|
|Provide the patient with a calm and quiet environment||Provides relaxation|
|Assist the client in ambulation||Prevents risk for falls that could lead to injury|
|Note presence of factors that could contribute to fatigue||Fatigue affects both the client’s actual and perceived ability to participate in activities|
|Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment||Determines current status and needs associated with participation in needed or desired activities|
|Give client information that provides evidence of daily or weekly progress||Sustains motivation of client|
|Encourage the client to maintain a positive attitude||Enhances sense of well being|
|Assist the client in a semi-fowlers position||Promotes easy breathing|
|Elevate the head of the bed||Maintains an open airway|
|Assist the client in learning and demonstrating appropriate safety measures||Prevents injuries|
|Instruct the SO not to leave the client unattended||Avoids risk for falls|
|Provide client with a positive atmosphere||Helps minimize frustration and rechannel energy|
|Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms||Indicates need to alter activity level|
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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- 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.