15 Heart Failure Nursing Care Plans

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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.

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 perfusioon
  • 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
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Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

In ischemic heart disease, atherosclerosis develops in the coronary arteries, causing them to become narrowed or blocked. When a coronary artery is blocked, blood flow to the area of the heart supplied by that artery is reduced. If the remaining blood flow is inadequate to meet the oxygen demands of the heart, the area may become ischemic and injured and myocardial infarction may result. Neural pain receptors are stimulated by local mechanical stress resulting from abnormal myocardial contraction.

Assessment

Patient may manifest the following

  • Difficulty of breathing
  • Chest pain
  • Restlessness

Diagnosis

  • Acute Pain

Planning & Desired Outcomes

  • Patient’s pain will be decreased.
  • Patient will demonstrate activities and behaviors that will prevent the recurrence of pain.

Nursing Interventions

Nursing InterventionsRationale
Nursing Assessment
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Administer or assist with self-administration of vasodilators, as ordered.The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
Assess the response to medications every 5 minutesAssessing response determines effectiveness of medication and whether further interventions are required.
Provide comfort measures.To provide non pharmacological pain management.
Establish a quiet environment.A quiet environment reduces the energy demands on the patient.
Elevate head of bed.Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Teach patient relaxation techniques and how to use them to reduce stress.Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.
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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

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