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
Hyperthermia: Body temperature elevated above normal range.
Patient may manifest the following:
- Pale palpebral
- Conjunctiva and nail beds
- Warm to touch
- Increased in body temperature
- Fluid or electrolyte imbalance
- Hot flushed skin
- Hyperthermia RT increased metabolic rate secondary to pneumonia
Planning & Desired Outcomes
- Patient’s temperature will be on normal level.
|Assess vital signs, the temperature.||Vital signs provide more accurate indication.|
|Monitor and record all sources of fluid loss such as urine, vomiting and diarrhea.||For potential fluid and electrolyte losses.|
|Performed tepid sponge bath.||To promote heat loss by evaporation and conduction.|
|Maintain bed rest.||To reduce metabolic demands and oxygen consumption.|
|Remove excess clothing and covers.||Decreases warmth and increase evaporative cooling.|
|Increase fluid intake.||To prevent dehydration.|
|Provide adequate nutrition, a high caloric diet.||The meet the metabolic demands.|
|Control environmental temperature.||To prevent an increase in body temperature and prevent shivering of the patient.|
|Adjust cooling measures on the basis of physical response.||Shivering, which burns calories and increases metabolic rate in order to produce heat.|
|Provide information regarding normal temperature and control.||This is especially necessary for patients with conditions at risk for hyperthermia.|
|Explain all treatments.||Patients’ S.O. needs to be oriented.|
|Administer antipyretics as ordered.||To decrease body temperature.|
|Control excessive shivering with medications such as Chlorpromazine and Diazepam if necessary.||Shivering increases metabolic rate and body temperature.|
|Provide ample fluids by mouth or intravenously as ordered.||If the patient is dehydrated or diaphoretic, fluid loss contributes to fever.|
|Provide oxygen therapy in extreme cases as ordered.||Hyperthermia increases metabolism.|
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