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 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 15 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
Ineffective Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
Due to decreased cardiac output, there is decreased preload and stroke volume thus there is decreased blood pumped out from the blood. Decrease in stroke volume decreases perfusion throughout the body.
- Pale conjunctiva, nail beds, and buccal mucosa
- Generalized weakness
- Chest pain
- Difficulty of breathing
- Abnormal pulse rate and rhythm
- Altered BP readings
- With pitting edema on both forearms and hands
- Bipedal pitting edema
- Ineffective tissue perfusion related to decreased cardiac output.
Planning & Desired Outcomes
- Patient will demonstrate behaviors to improve circulation.
- Display vital signs within acceptable limits, dysrhythmias absent/controlled,and no symptoms of failure
|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 minutes.||Assessing response determines effectiveness of medication and whether further interventions are required.|
|Give beta blockers as ordered.||Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.|
|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.|
|Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered.||Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain.|
|Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by physician.||These enzymes elevate in the presence of myocardial infarction at differing times and assist in ruling out a myocardial infarction as the cause of chest pain.|
|Assess cardiac and circulatory status.||Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.|
|Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.||Notes abnormal tracings that would indicate ischemia.|
|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.|
|Reposition the patient every 2 hours||To prevent bedsores|
|Instruct patient on eating a small frequent feedings||To prevent heartburn and acid indigestion|
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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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.Last updated on