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
Excess Fluid Volume
When blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and renin is released into the bloodstream. Renin interacts with angiotensinogen to produce angiotensin I. When angiotensin I contacts ACE, it is converted to angiotensin II, a potent vasoconstrictor. Angiotensin II increases arterial vasoconstriction, promote release of norepinephrine from sympathetic nerve endings, and stimulates the adrenal medulla to secrete aldosterone, which enhances sodium and water absorption. Stimulation of the renin-angiotensin system causes plasma volume to expand and preload to increase.
- Excess Fluid Volume: Increased isotonic fluid retention
- Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention.
- Changes in glomerular filtration rate
- Use of diuretics
- Fluid intake or sodium intake
- Orthopnea, S3 heart sound
- Oliguria, edema, JVD, positive hepatojugular reflex
- Weight gain
- Respiratory distress, abnormal breath sounds
- Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, vital signs within acceptable range, stable weight, and absence of edema.
- Verbalize understanding of individual dietary/fluid restrictions.
|Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.||Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night and/or during bed rest.|
|Monitor and calculate 24-hour intake and output (I&O) balance.||Diuretic therapy may result in sudden increase in fluid loss (circulating hypovolemia), even though edema or ascites remains.|
|Maintain chair or bed rest in semi-Fowler’s position during acute phase.||Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis.|
|Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care. Ice chips can be part of fluid allotment.||Involving patient in therapy regimen may enhance sense of control and cooperation with restrictions.|
|Weigh daily. Frequently monitor blood urea nitrogen, creatinine, and serum potassium, sodium, chloride, and magnesium levels.||Documents changes edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in excessive fluid shifts and weight loss.|
|Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema (check for pitting); note presence of generalized body edema (anasarca).||Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet and ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually results in systemic tissue edema.|
|Auscultate breath sounds, noting decreased and/or adventitious sounds (crackles, wheezes). Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough.||Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute left-sided HF. RHF’s respiratory symptoms (dyspnea, cough, orthopnea) may have slower onset but are more difficult to reverse.|
|Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom.||May indicate development of complications (pulmonary edema and/or embolus) and differs from orthopnea paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention.|
|Monitor BP and central venous pressure (CVP)||Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, HF.|
|Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation.||Visceral congestion (occurring in progressive HF) can alter intestinal function.|
|Obtain patient history to ascertain the probable cause of the fluid disturbance.||May include increased fluids or sodium intake, or compromised regulatory mechanisms.|
|Monitor for distended neck veins and ascites||Indicates fluid overload|
|Evaluate urine output in response to diuretic therapy.||Focus is on monitoring the response to the diuretics, rather than the actual amount voided|
|Assess the need for an indwelling urinary catheter.||Treatment focuses on diuresis of excess fluid.|
|Institute/instruct patient regarding fluid restrictions as appropriate.||This helps reduce extracellular volume.|
|Weigh patient daily and compare to previous weights.||Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess.|
|Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production||When increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema|
|Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic.||Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular reabsorption of sodium Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.|
|Follow low-sodium diet and/or fluid restriction||The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.|
|Encourage or provide oral care q2||Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatic pressure exceeds interstitial pressure, fluids leak out of the capillaries and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart.|
|Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated.||Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility (including bed rest) are cumulative stressors that affect skin integrity and require close supervision/ preventive interventions.|
|Provide small, frequent, easily digestible meals.||Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/ prevent abdominal discomfort.|
|Measure abdominal girth, as indicated.||In progressive RHF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites).|
|Encourage verbalization of feelings regarding limitations.||Expression of feelings may decrease anxiety, which is an energy drain that can contribute to feelings of fatigue.|
|Palpate abdomen. Note reports of right upper quadrant pain and tenderness.||Advancing HF leads to venous congestion, resulting in abdominal distension, liver engorgement (hepatomegaly), and pain. This can alter liver function and prolong drug metabolism.|
|Administer medications as indicated:|
|Signs of potassium and sodium deficits that may occur because of fluid shifts and diuretic therapy. Increases rate of urine flow and may inhibit reabsorption of sodium/ chloride in the renal tubules.|
|Promotes diuresis without excessive potassium losses.|
|Replaces potassium that is lost as a common side effect of diuretic therapy, which can adversely affect cardiac function.|
|Maintain fluid and sodium restrictions as indicated.||Reduces total body water and prevent fluid reaccumulation.|
|Consult with dietitian.||May be necessary to provide diet acceptable to patient that meets caloric needs within sodium restriction.|
|Monitor chest x-ray.||Reveals changes indicative of resolution of pulmonary congestion.|
|Assist with rotating tourniquets and/or phlebotomy, dialysis, or ultrafiltration as indicated.||Although not frequently used, mechanical fluid removal rapidly reduces circulating volume, especially in pulmonary edema refractory to other therapies|
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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