Congestitive Heart Failure CHF HF Nursing Diagnosis Care Plans
Congestive heart failure (CHF), or simply known as heart failure HF, is a medical condition that involves the decrease in the heart’s capacity to pump blood to the other parts of the body.
As a result, the cells of the body receive less oxygen supply compared to what they need. Aside from Decreased Cardiac Output and Impaired Gas Exchange, nurses can utilize the following care plans to deliver efficient and effective nursing care to a patient with CHF.
- Nursing Diagnosis: Deficient Knowledge related to new diagnosis of Congestive Heart Failure as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”
Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of congestive heart failure and its management.
|Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits)||To address the patient’s cognition and mental status towards the new diagnosis of CHF and to help the patient overcome blocks to learning.|
|Explain what CHF is, its types (specifically whether the CHF of the patient is left-sided, right-sided, or biventricular). Avoid using medical jargons and explain in layman’s terms.||To provide information on CHF and its pathophysiology in the simplest way possible.|
|Educate the patient about lifestyle changes that can help manage CHF. Create a plan for Activities of Daily Living (ADLs) with the patient that involve smoking cessation, increase in physical activity, dietary changes, blood pressure control, stress management, and diabetes management (if patient has diabetes).||Smoking, sedentary lifestyle, poor dietary choices, poor blood pressure control, chronic stress, and unmanaged diabetes are linked to CHF.|
|Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to treat heart failure. Ask the patient to repeat or demonstrate the self-administration details to you.||To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.|
|Refer the patient to a dietitian and physiotherapist.||To enable to patient to receive more information in managing diet and physical activity from specific members of the healthcare team.|
- Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.
|Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels and mental status related to fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.||To gradually increase the patient’s tolerance to physical activity.|
|Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To allow the patient to relax while at rest and to facilitate effective stress management. To allow benough oxygenation in the room.|
|Refer the patient to physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.|
- Nursing Diagnosis: Excess Fluid Volume related to decreased cardiac output and increased glomerular filtration rate (GFR) as evidenced by S3 heart sound, blood pressure level of 190/85, orthopnea, pitting edema of the ankles, and weight gain
Desired Outcome: The patient will demonstrate a balanced input and output, and stabilized fluid volume
|Assess vital signs and auscultate lungs to find any crackles or wheezes.||Heart failure, especially left-sided HF may lead to pulmonary congestion, as evidenced by crackles or wheezes upon auscultation of the lungs.|
|Commence a fluid balance chart, monitoring the input and output of the patient.||To monitor patient’s fluid volume accurately and effectiveness of actions to monitor the progress of excess fluid volume.|
|Restrict fluid intake as instructed by the physician.||To reduce fluid volume and manage edema.|
|Weigh the patient on a daily basis.||Diuretics are needed to manage heart failure, but may put the patient at risk for sudden fluid loss, which is reflected through his/her weight.|
|Monitor patient’s serum electrolytes and renal function to the physician as needed.||The use of diuretics may result to excessive fluid shifts and electrolyte loss.|
4. Nursing Diagnosis: Acute Pain related to decreased myocardial blood flow as evidenced by pain score of 10 out of 10, verbalization of pressure-like/ squeezing chest pain (angina), guarding sign on the chest, blood pressure level of 180/90, respiratory rate of 29 cpm, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
|Administer prescribed medications that alleviate the symptoms of acute chest pain (angina).||Aspirin may be given to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries. Nitrates may be given to relax the blood vessels. Other medications that help treat angina include anti-cholesterol drugs (e.g. statins), beta blockers, calcium channel blockers, and Ranolazine.|
|Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.||To monitor effectiveness of medical treatment for the relief of angina. The time of monitoring of vital signs may depend on the peak time of the drug administered.|
|Elevate the head of the bed if the patient is short of breath. Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value of at least 94%.|
|Place the patient in complete bed rest during angina attacks. Educate patient on stress management, deep breathing exercises, and relaxation techniques.||Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. The effects of stress are likely to increase myocardial workload.|
- Nursing Diagnosis: Ineffective Breathing Pattern related to pulmonary congestion secondary to CHF as evidenced by shortness of breath, SpO2 level of 85%, cough, respiratory rate of 25 cpm, and frothy sputum
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by normal respiratory rate, oxygen saturation within target range, and verbalize ease of breathing.
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range at least 96% (88-92% in a COPD patient)|
|Administer the prescribed bronchodilators, steroids, or combination inhalers / nebulizers, as prescribed.||Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs. Inhalers or nebulizers – To facilitate relaxation of the airway.|
|Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position.||Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
With proper use of the nursing process, a patient can benefit from various nursing interventions to assess, monitor, and manage heart failure and promote client safety and well being.