Congestive Heart Failure ( CHF) – Nursing Care Plan

Congestive Heart Failure ( CHF)

Congestive heart failure (CHF) occurs when the myocardium can not pump effectively enough to meet the body’s needs. Heart failure usually occurs in the damaged left ventricle, however, it may also occur in the right ventricle. In any event, damage to the left ventricle usually occurs first.

Signs and Symptoms may include:

  • Fatigue
  • Jugular vein distention (JVD)
  • Dyspnea
  • Palpitations
  • Frothy – blood tinged sputum
  • Chest tightness
  • Steady weight gain
  • Slowed mental response
  • Anorexia
  • Crackles
  • Decreased peripheral pulses
  • Nausea
  • Tachypnea
  • Dependent edema
  • Decreased urine output

Diagnostic Tests:

  • Chest X-Ray – Cardiomegaly
  • EKG – ischemia, tachycardia
  • Echo-cardiogram – reveals type and severity of the heart failure
  • PAP monitoring – elevated PAP, PAWP

 


Excess Fluid Volume r/t compromised regulatory mechanisms occurring with decreased cardiac output.

Goals:

  • Body weight will remain within normal limits

 

  • Electrolyte levels will be within normal limits

 

  • Will demonstrate adequate knowledge concerning medical condition.

 

  • Will maintain optimal fluid balance

 

  • Will verbalize less dyspnea and be more comfortable.

 

 Interventions:

  • Administer Oxygen as ordered

 

  • Assess for presence of edema

 

  • Assess for symptoms such as dizziness, weaknes/fatigue, nausea/vomiting, confusion, sweatiness, cyanosis. Notify physician as appropriate.

 

  • Check breath sounds and assess for labored breathing.

 

  • Check Vital Signs q ____

 

  • Keep head of bed elevated

 

  • Monitor fluid intake, restrict sodium intake as ordered.

 

  • Monitor Lab work; K+, NA, BUN, Creatinine

 

  • Observe for signs and symptoms of malnutrition, Do not force resident to eat. Offer small frequent feedings. Assess food preferences.

 

  • Weigh patient/resident in relation to nutritional status q ________

 


 

 

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Anna C. RN-BC, BSN, PHN, CMSRN Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process. She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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