Nursing Diagnosis of CHF: A Comprehensive Guide for Heart Failure Care

Heart failure (HF), often known as congestive heart failure (CHF), is a chronic, progressive condition where the heart is unable to pump enough blood to meet the body’s needs. This inadequacy in blood circulation can stem from issues in the left ventricle, the heart’s primary pumping chamber. In left-sided heart failure, the left ventricle may lose its contractile strength, hindering normal pumping, or it may stiffen, preventing proper relaxation and blood filling between heartbeats.

Left-sided heart failure frequently progresses to right-sided heart failure. In right-sided heart failure, the right ventricle’s pumping inefficiency causes blood to back up in the veins, leading to systemic congestion and the characteristic signs of congestive heart failure (CHF). When the heart fails to effectively circulate blood, every organ system in the body is affected, underscoring the critical need for prompt and effective nursing care.

The Crucial Role of Nursing in CHF Management

Nurses are at the forefront of patient care for individuals with heart failure. Their role extends beyond treatment administration to encompass patient education on vital lifestyle adjustments. These modifications are essential to slow disease progression and minimize complications, highlighting the importance of skilled nursing in CHF management.

A deep understanding of cardiac mechanics and the pathophysiology of heart failure is paramount for nurses. This knowledge base enables them to deliver effective care, vigilantly monitor for subtle changes indicating patient deterioration, and proactively prevent adverse effects across all body systems impacted by CHF. The nursing process is the foundation for this comprehensive care, beginning with a thorough assessment.

Nursing Assessment: Identifying CHF Through Data Collection

The initial phase of nursing care is a comprehensive nursing assessment. This involves gathering a broad spectrum of patient data – physical, psychosocial, emotional, and diagnostic. This section will delve into both subjective and objective data collection pertinent to heart failure, essential for formulating accurate nursing diagnoses of CHF.

Reviewing Health History for CHF Indicators

1. Eliciting General Symptoms: A detailed patient history begins with documenting the patient’s chief complaints and general symptoms. Common symptoms indicative of heart failure include:

• Dyspnea on exertion: Shortness of breath triggered by physical activity.
• Orthopnea: Breathlessness when lying down, often relieved by sitting upright.
• Fatigue and weakness: Persistent tiredness and reduced physical strength.
• Edema in lower extremities: Swelling in ankles, feet, and legs due to fluid retention.
• Tachycardia: An abnormally rapid heart rate.
• Irregular heartbeat: Arrhythmias or palpitations.
• Exercise intolerance: Reduced ability to perform physical activities.
• Persistent cough: A cough that may be dry or productive, sometimes with white or pink-tinged sputum.
• Wheezing: A whistling sound during breathing, indicating airway narrowing.
• Abdominal swelling: Ascites, or fluid accumulation in the abdominal cavity.
• Rapid weight gain: Sudden increase in weight due to fluid retention.
• Nausea: Feeling sick to the stomach.
• Lack of appetite: Anorexia or reduced desire to eat.
• Decreased alertness: Confusion or reduced level of consciousness.
• Chest pain: Angina, or discomfort in the chest area, although not always present in CHF.

2. Investigating Underlying Causes of Heart Failure: Heart failure rarely arises spontaneously; it’s typically a consequence of another condition, disease, or even medication that damages the heart muscle. Identifying these underlying causes is crucial for effective management. Conditions frequently associated with heart failure include:

• Coronary artery disease (CAD): Narrowing or blockage of coronary arteries, reducing blood flow to the heart muscle.
• Myocardial infarction (MI): Heart attack, causing damage to the heart muscle.
• Hypertension: Chronic high blood pressure, leading to increased workload on the heart.
• Heart valve disease: Conditions affecting the heart valves, impairing their function and heart efficiency.
• Myocarditis: Inflammation of the heart muscle, often due to viral infection.
• Congenital heart defects: Structural abnormalities present at birth.
• Cardiac arrhythmias: Irregular heart rhythms that can weaken the heart over time.
• Chronic conditions: Poorly managed long-term illnesses like diabetes mellitus, HIV, hyperthyroidism, or hypothyroidism can all contribute to heart failure.

3. Determining Heart Failure Stage: Classifying heart failure severity is essential for guiding treatment and prognosis. The New York Heart Association (NYHA) functional classification is commonly used:

Stages of Heart Failure:

1. Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
2. Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
3. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
4. Class IV: Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest can be present. If any physical activity is undertaken, discomfort increases.

4. Recognizing Risk Factors for Heart Failure: Understanding risk factors helps in prevention and early identification. These factors are categorized as non-modifiable and modifiable.

Non-modifiable risk factors:

• Age: The heart muscle naturally changes with age, becoming stiffer and less efficient. Risk significantly increases after 65 years old.
• Gender: Men are statistically more likely to develop heart failure than women.
• Family history of ischemic heart disease: Genetic predisposition plays a role. A strong family history significantly elevates risk.
• Race/ethnicity: Certain ethnic groups, such as African Americans and Latinos, have a higher incidence of heart failure.

Modifiable risk factors:

• Hypertension: Controlling high blood pressure is paramount in preventing heart failure.
• Hyperlipidemia/hypercholesterolemia/coronary artery disease: Managing cholesterol levels and preventing atherosclerosis reduces heart failure risk.
• Diabetes or insulin resistance: Effective diabetes management is crucial to minimize heart damage.
• Heart valve disease: Early detection and treatment of valve disorders can prevent progression to heart failure.
• Tobacco use: Smoking cessation is a critical modifiable risk factor.
• Obesity: Weight management significantly reduces the risk of heart failure and associated conditions.
• Physical inactivity: Regular physical activity strengthens the heart and reduces risk.
• Diet: A heart-healthy diet, low in sodium, saturated and trans fats, and processed foods, is essential.
• Stress: Chronic stress management is important for cardiovascular health.
• Alcohol use: Limiting alcohol consumption is advised.
• Lack of sleep: Adequate sleep promotes overall health and reduces cardiovascular strain.
• Bacterial and viral infections: Prevention and prompt treatment of infections can reduce heart failure risk. Examples include influenza, pneumonia, urinary tract infections, bacteremia, Covid-19, HIV, and endocarditis.

5. Reviewing Treatment Records and Medications: Certain medications and past medical treatments can impact heart health and contribute to heart failure. These include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Can cause fluid retention and worsen heart failure.
• Diabetes medications rosiglitazone (Avandia) and pioglitazone (Actos): Associated with increased risk of heart failure.
• Antihypertensive medications: While treating hypertension, some can have side effects impacting heart function in susceptible individuals.
• Medications for various conditions: Cancer, blood disorders, arrhythmias, nervous system disorders, mental health issues, lung and urinary issues, inflammatory diseases, and infections – some medications for these conditions can have cardiac side effects.

Physical Assessment: Objective Signs of CHF

1. Assessing Vital Signs: Vital sign monitoring is fundamental. Changes in pulse rate and blood pressure are expected due to the heart’s compromised ability to deliver oxygenated blood. Specifically monitor:

• Blood pressure: May be elevated or decreased depending on the stage and type of heart failure.
• Heart rate: Tachycardia is common as the heart attempts to compensate for reduced output.
• Respiratory rate: Tachypnea (rapid breathing) may be present due to pulmonary congestion.
• Oxygen saturation (SpO2): Decreased SpO2 indicates impaired oxygenation.

2. Systemic Physical Examination: A thorough head-to-toe assessment is crucial to identify objective signs of heart failure:

• Neck: Jugular vein distention (JVD) indicates increased central venous pressure due to fluid overload.
• Central Nervous System (CNS): Decreased alertness, confusion, or restlessness can result from reduced cerebral perfusion.
• Cardiovascular:
  • Tachycardia and arrhythmias upon auscultation.
  • Chest pain (angina).
  • Abnormal heart sounds, particularly a pathological S3 gallop, indicative of ventricular dysfunction.
• Circulatory:
  • Decreased peripheral pulses, indicating reduced cardiac output.
  • Narrow pulse pressure (less than 25 mmHg), also a sign of reduced cardiac output.
• Respiratory:
  • Dyspnea on exertion or at rest.
  • Tachypnea.
  • Orthopnea.
  • Persistent or nocturnal cough.
  • Crackles or rhonchi in the lung bases upon auscultation, indicating pulmonary edema.
• Gastrointestinal:
  • Nausea and vomiting.
  • Lack of appetite.
  • Abdominal swelling (ascites) due to hepatic congestion and fluid accumulation.
• Lymphatic: Edema, particularly in the lower extremities (pitting or non-pitting).
• Musculoskeletal:
  • Fatigue and muscle weakness.
  • Activity intolerance.
  • Rapid weight gain from fluid retention.
  • Pain in neck, arm, back, jaw, or upper body (may be associated with underlying CAD).
• Integumentary:
  • Cyanotic or pale skin, indicating poor perfusion.
  • Excessive sweating (diaphoresis).

Diagnostic Procedures for CHF Confirmation

1. Electrocardiogram (ECG): An ECG is often the first diagnostic test. In heart failure, ECG findings may show:

• P wave changes indicative of left atrial hypertrophy (enlargement), a common adaptation to increased pressure in the left atrium.
• May also reveal underlying causes like previous myocardial infarction or arrhythmias.

2. B-type Natriuretic Peptide (BNP) Lab Test: BNP is a hormone released by the heart in response to ventricular stretching and stress. Elevated BNP levels are a key indicator of heart failure.

• BNP levels rise significantly in heart failure, making it a valuable diagnostic marker.

3. Other Blood Tests: Additional blood tests provide a broader picture of the patient’s condition:

• Complete blood count with differential: Evaluates for infection (WBC count), blood clotting ability (platelets), and anemia (RBC levels), which can exacerbate heart failure.
• Cholesterol levels: Assesses risk for coronary artery disease, a major contributor to heart failure.
• Thyroid levels: Thyroid disorders can trigger arrhythmias and contribute to heart failure.

4. Chest X-ray: A chest X-ray provides visual information about the heart and lungs:

• Reveals heart size, which may be enlarged in heart failure (cardiomegaly).
• Detects pulmonary congestion and pleural effusions (fluid around the lungs), common in CHF.

5. Echocardiogram: An echocardiogram (ultrasound of the heart) is a crucial test to assess heart structure and function:

• Measures ejection fraction (EF), the percentage of blood pumped out of the left ventricle with each beat. EF is a key indicator of heart failure severity.
  • Normal EF: 55-70%
  • Slightly below normal: 40-54%
  • Mild heart failure: 35-39%
  • Moderate to severe heart failure: EF less than 35%

6. Further Investigations: More specialized tests may be indicated depending on the clinical picture:

• Exercise treadmill test: Assesses heart function during exercise, suitable for patients capable of physical exertion and with a normal resting ECG.
• Nuclear stress test: Uses a radioactive tracer to visualize blood flow to the heart muscle, often combined with exercise or medication to simulate stress.
• Stress imaging: Used for patients unable to exercise or with ECGs difficult to interpret; provides images of heart function under stress.
• Cardiac CT scan: Detects calcium deposits and blockages in coronary arteries.
• Cardiac catheterization: Invasive procedure to visualize coronary arteries and assess for blockages or coronary artery disease.
• CT coronary angiogram: Detailed imaging of coronary arteries using contrast dye, similar to cardiac CT but with enhanced visualization.
• Myocardial biopsy: Used to investigate specific heart muscle diseases that may be causing heart failure.

Nursing Interventions: Managing CHF and Improving Patient Outcomes

Nursing interventions are vital for managing heart failure, alleviating symptoms, and improving patient quality of life. These interventions focus on promoting perfusion, cardiac rehabilitation, and reducing the risk of complications.

Promoting Perfusion in CHF Patients

1. Vasodilators: Medications that relax blood vessels are essential to improve blood flow and reduce cardiac workload.

• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are commonly used to dilate blood vessels, lower blood pressure, and reduce strain on the heart muscle.

2. Beta-blockers: These medications reduce heart rate and blood pressure, improving heart function and reducing oxygen demand.

• Administer beta-blockers as prescribed to slow heart rate and lower blood pressure, enhancing cardiac efficiency.

3. Diuretics: These medications promote fluid excretion, reducing fluid overload, a hallmark of CHF.

• Induce diuresis with loop diuretics (e.g., furosemide) to remove excess fluid and alleviate congestion.

4. Potassium-sparing diuretics: These diuretics help manage fluid volume while conserving potassium.

• Aldosterone antagonists (e.g., spironolactone) are potassium-sparing diuretics beneficial in systolic heart failure.

5. Inotropic Agents: These medications strengthen heart contractions, particularly useful in acute heart failure exacerbations.

• Inotropes (e.g., dobutamine, milrinone) are typically administered intravenously in hospital settings to enhance heart pumping strength and maintain blood pressure.
• Digoxin, an oral inotrope, can be used to increase the force of heart contractions; requires careful monitoring for digoxin toxicity.

6. Treating Underlying Conditions: Addressing the root cause of heart failure is crucial for long-term management.

• Coronary artery bypass graft surgery (CABG): Surgical revascularization to bypass blocked coronary arteries, improving blood supply to the heart.
• Heart valve repair or replacement: Surgical correction of defective heart valves to restore proper function.
• Cardiac resynchronization therapy (CRT): Implantation of a biventricular pacemaker to coordinate heart contractions in patients with conduction delays.
• Ventricular assist devices (VADs): Mechanical pumps that support heart function in severe heart failure, serving as a bridge to transplant or destination therapy.
• Heart transplant: Considered for end-stage heart failure when other treatments are ineffective.

Cardiac Rehabilitation: Restoring Function and Quality of Life

1. Multidisciplinary Team Approach: Cardiac rehabilitation is a comprehensive program involving various healthcare professionals.

• Collaborate with cardiologists, cardiac rehab nurse specialists, dietitians, social workers, and physical and occupational therapists to provide holistic patient care.

2. Improving Activity Tolerance: Gradual exercise and activity progression are key components of cardiac rehab.

• Improve activity tolerance through structured exercise programs tailored to the patient’s functional capacity.

3. Enhancing Overall Health: Cardiac rehabilitation aims to improve physical and emotional well-being and prevent future cardiac events.

• Strengthen patient’s health and quality of life by promoting physical recovery, education, and lifestyle modifications.

Reducing the Risk of CHF Complications

1. Implantable Cardioverter-Defibrillators (ICDs): These devices prevent life-threatening arrhythmias.

• Regulate heart rhythm with ICDs, which detect and correct dangerous arrhythmias, reducing the risk of sudden cardiac death.

2. Lifestyle Modifications: Patient education on sustainable lifestyle changes is paramount.

• Reinforce the importance of lifestyle modifications to manage symptoms and prevent disease progression:
  • Regular exercise
  • Heart-healthy diets
  • Smoking cessation
  • Avoiding secondhand smoke
  • Stress management
  • Vaccinations (influenza, pneumococcal)
  • Limiting alcohol consumption
  • Restful sleep

3. Activity Recommendations: Individualized exercise advice is essential.

• Advise on appropriate activity levels, starting with short durations of moderate exercise and gradually increasing as tolerated.

4. Weight Management: Maintaining a healthy weight reduces cardiac strain.

• Keep a healthy weight through diet and exercise, limiting saturated and trans fats.

5. Treatment Adherence: Promoting adherence to medications and lifestyle changes is crucial for effective management.

• Promote patient adherence to treatment plans through education, support, and addressing barriers to adherence.

6. Stress Reduction Techniques: Managing stress is important for cardiovascular health.

• Decrease stress through techniques like guided imagery, yoga, deep breathing, muscle relaxation, and meditation.

7. Fluid Management: Preventing fluid overload is a key aspect of CHF management.

• Prevent fluid accumulation by monitoring for edema, instructing on daily weight monitoring, and limiting sodium intake.

8. Recognizing Warning Signs: Patient education on when to seek prompt medical attention is vital.

• Teach patients when to seek medical attention for worsening symptoms:
  • Chest pain
  • Sudden weight gain
  • Fainting (syncope)
  • Dyspnea at rest or worsening dyspnea
  • Sudden productive cough with white or pink, foamy secretions

9. Cardiology Follow-up: Regular follow-up appointments are necessary for ongoing management.

• Follow up with the cardiologist regularly for monitoring and adjustments to the treatment plan.

10. Medical Identification: Ensuring patients have medical identification is important for emergencies.

• Emphasize the use of medical identification (bracelet, necklace, or ID tag) to alert emergency responders to their heart failure history.

Nursing Care Plans for Heart Failure: Addressing Key Nursing Diagnoses

Nursing care plans are essential tools for organizing and prioritizing nursing care based on identified nursing diagnoses. For heart failure, common nursing diagnoses include Activity Intolerance, Decreased Cardiac Output, Decreased Cardiac Tissue Perfusion, Excess Fluid Volume, Impaired Gas Exchange, Ineffective Health Maintenance, and Risk for Unstable Blood Pressure. These care plans guide both short-term and long-term goals of care.

Activity Intolerance related to Heart Failure

Activity intolerance is a prevalent nursing diagnosis in CHF, significantly impacting a patient’s quality of life.

Nursing Diagnosis: Activity Intolerance

Alt text: Elderly man sitting on the edge of his bed, catching his breath, experiencing activity intolerance due to heart failure.

Related to:

• Imbalance between oxygen supply and demand
• Weakness/deconditioning secondary to heart failure
• Sedentary lifestyle

As evidenced by:

• Fatigue, disproportionate to activity level
• Dyspnea on exertion
• Immobility or reduced mobility
• Abnormal vital sign responses to activity (tachycardia, increased respiratory rate, blood pressure changes)
• Chest pain on exertion
• Diaphoresis (excessive sweating)

Expected outcomes:

• Patient will participate in activities within their physical limitations without experiencing excessive cardiac workload.
• Patient will manage activity levels by alternating periods of activity and rest to complete Activities of Daily Living (ADLs).
• Patient will demonstrate stable vital signs and heart rhythm within acceptable limits during activity.

Assessment:

1. Cardiopulmonary Response to Activity:

Monitor heart rate, oxygen saturation, and cardiac rhythm before, during, and after activity. Abnormal responses like significant heart rate increase, desaturation, or arrhythmias indicate overexertion and need for activity modification.

2. Patient’s Perception of Activity Limitations:

Assess the patient’s understanding of their condition and their perceived limitations. Balance patient motivation for independence with the need to avoid overexertion.

3. Degree of Debility:

Evaluate the patient’s level of fatigue, weakness, and dyspnea in relation to activity. Tailor interventions to the severity of symptoms and provide assistance with ADLs as needed.

Interventions:

1. Calm Environment:

Provide a restful and quiet environment to minimize anxiety and restlessness associated with dyspnea. Ensure the space is cool, dimly lit, and free of clutter. Encourage slow, controlled breathing and provide emotional support.

2. Encourage Participation in Self-Care:

Encourage patient participation in care to the extent possible to promote independence and prevent complications of immobility. Provide bedside toiletries and encourage self-care activities within their tolerance.

3. Energy Conservation Techniques:

Teach energy conservation strategies: grouping tasks, sitting during ADLs, planning rest periods, promoting restful sleep, avoiding rushing, and avoiding activities in extreme temperatures.

4. Cardiac Rehabilitation Referral:

Recommend cardiac rehabilitation for a structured, supervised program to improve activity tolerance, strength, and overall cardiovascular health.

Decreased Cardiac Output related to Heart Failure

Decreased cardiac output is a critical nursing diagnosis in heart failure, directly affecting systemic perfusion.

Nursing Diagnosis: Decreased Cardiac Output

Alt text: Nurse carefully auscultating heart sounds of a patient to assess for indicators of decreased cardiac output due to heart failure.

Related to:

• Altered heart rate or rhythm (arrhythmias)
• Altered contractility of the heart muscle
• Structural changes in the heart (e.g., aneurysm, rupture)

As evidenced by:

• Increased heart rate (tachycardia, palpitations)
• Dysrhythmias (abnormal heart rhythms)
• Fatigue and weakness
• Shortness of breath, orthopnea
• Anxiety and restlessness
• Jugular vein distention (JVD), peripheral edema
• Central venous pressure (CVP) changes
• Heart murmurs
• Decreased peripheral pulses (weak or thready)
• Decreased urine output (oliguria)
• Skin pallor, mottling, or cyanosis (indicating poor perfusion)

Expected outcomes:

• Patient will demonstrate hemodynamic stability, with vital signs, cardiac output, and renal perfusion within normal limits for their baseline.
• Patient will participate in activities that reduce cardiac workload.
• Patient will report absence or reduction of chest pain and shortness of breath.

Assessment:

1. Vital Signs, Cardiac Rhythm, and Hemodynamics:

Continuously monitor vital signs, cardiac rhythm (telemetry), and hemodynamic parameters. Promptly identify and address dysrhythmias. Unstable patients may require invasive hemodynamic monitoring.

2. Skin and Peripheral Pulses:

Assess skin color, temperature, and peripheral pulses. Mottling, pallor, cyanosis, cool/clammy skin, and weak pulses indicate impaired tissue perfusion due to decreased cardiac output.

3. Mental Status Changes:

Monitor for subtle changes in mental status, such as confusion, restlessness, or decreased alertness, which can indicate reduced cerebral perfusion. Assess for cognitive impairment or memory issues.

Interventions:

1. Oxygen Administration:

Administer supplemental oxygen to maintain adequate oxygen saturation, especially if SpO2 is low. Patients with chronic CHF may require home oxygen therapy.

2. Medication Administration:

*Administer prescribed medications to improve cardiac output and reduce workload.

• Vasodilators: Reduce vascular resistance, increasing cardiac output and reducing ventricular workload.
• Morphine and anti-anxiety medications: Promote relaxation and reduce cardiac workload.
• Angiotensin receptor blockers (ARBs): Lower blood pressure and ease heart pumping.*

3. Reduce Cardiac Workload:

Instruct patients on strategies to reduce cardiac workload: activity modification, assistance with ADLs, rest periods, and avoiding strenuous activities.

4. Patient Education on Risk Factors and Lifestyle Modifications:

Educate patients on modifiable risk factors (hypertension, diabetes, smoking, obesity, sedentary lifestyle, high-fat diet) and the importance of lifestyle modifications for CHF prevention and management.

Decreased Cardiac Tissue Perfusion related to Heart Failure

Decreased cardiac tissue perfusion is a direct consequence of impaired cardiac function in heart failure.

Nursing Diagnosis: Decreased Cardiac Tissue Perfusion

Alt text: Illustration of a cardiac catheterization procedure used to diagnose decreased cardiac tissue perfusion in a patient with heart failure.

Related to:

• Structural impairment of the heart
• Malfunctions of heart structures (valves, chambers)
• Difficulty of the heart muscle to pump effectively
• Increased cardiac workload
• Inadequate blood supply to the heart muscle
• Inability of the heart to contract and relax effectively
• Erratic electrical signals causing irregular heart contractions

As evidenced by:

• Decreased cardiac output
• Decreased blood pressure (hypotension)
• Decreased peripheral pulses
• Increased central venous pressure (CVP)
• Increased pulmonary artery pressure (PAP)
• Tachycardia and dysrhythmias
• Ejection fraction less than 40%
• Decreased oxygen saturation
• Presence of abnormal S3 and S4 heart sounds upon auscultation
• Chest pain (angina)

Expected outcomes:

• Patient will exhibit pulse rate and rhythm within normal limits.
• Patient will demonstrate ejection fraction greater than 40% (or improved from baseline).
• Patient will maintain palpable peripheral pulses.

Assessment:

1. Auscultation for Abnormal Heart Sounds:

Auscultate the apex of the heart for abnormal S3 or S4 heart sounds. S3 in adults with heart failure is pathological, while S4 indicates a stiff ventricle.

2. Myocardial Perfusion Testing:

Assist with myocardial perfusion imaging (nuclear stress test) to assess blood flow to the heart muscle and heart pumping efficiency.

3. BNP/NT-proBNP Levels:

Check BNP or NT-proBNP levels, which are elevated in heart failure and support the diagnosis.

4. Electrocardiogram (EKG):

Obtain EKG to rule out heart failure and identify potential causes (e.g., previous MI) or therapeutic needs (e.g., anticoagulation for atrial fibrillation).

5. Transthoracic Echocardiography (TEE):

Assist with TEE to determine ejection fraction, left atrial pressure, and cardiac output.

6. Cardiac Catheterization/Coronary Angiography Preparation:

Prepare patient for left heart catheterization or coronary angiography to identify blockages or abnormalities in coronary arteries.

Interventions:

1. Goal Setting:

Collaborate with the patient to establish treatment goals focused on improving survival, symptom management, reducing hospitalizations, preventing organ damage, and symptom suppression in asymptomatic patients.

2. Medication Administration:

Administer medications as prescribed, which may include:

• Diuretics
• Angiotensin system blockers (ACE inhibitors, ARBs, or ARNIs)
• Hydralazine with nitrate (alternative to angiotensin system blockers)
• Beta-blockers

3. Lifestyle Modification Education:

Instruct on lifestyle modifications:

• Dietary and nutritional consultation
• Sodium restriction (2-3 g/day)
• Fluid restriction (2 L/day)
• Daily weight monitoring
• Aerobic exercise training
• Control of risk factors (DM, lipid disorders)
• Smoking/alcohol/illicit drug cessation

4. Device Therapy Consideration:

Consider device therapies like cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillators (ICD) as appropriate, often after a trial of medications.

5. Surgical Intervention Anticipation:

Anticipate potential surgical interventions (heart transplant, valve replacement, catheter ablation) when medications are insufficient.

Excess Fluid Volume related to Heart Failure

Fluid overload is a common and significant complication of heart failure, requiring careful nursing management.

Nursing Diagnosis: Excess Fluid Volume

Alt text: Visible edema in the lower extremities, a key indicator of excess fluid volume in a patient with congestive heart failure.

Related to:

• Excessive fluid intake or sodium intake
• Reduced glomerular filtration rate (kidney dysfunction)
• Increased secretion of antidiuretic hormone (ADH)

As evidenced by:

• Shortness of breath (dyspnea)
• Weight gain (rapid)
• Edema in extremities (peripheral edema)
• Jugular vein distention (JVD)
• Adventitious breath sounds (crackles, rales)
• Elevated blood pressure
• Oliguria (decreased urine output)
• Tachycardia
• Pulmonary congestion (on chest X-ray)
• Cough, potentially with frothy sputum
• S3 heart sound

Expected outcomes:

• Patient will achieve stable fluid volume, evidenced by balanced intake and output, stable baseline weight, and absence of peripheral edema.
• Patient will verbalize understanding of signs and symptoms of fluid overload and when to seek medical help.
• Patient will verbalize dietary recommendations and fluid restrictions necessary for fluid management.

Assessment:

1. Peripheral Edema, Anasarca, and JVD:

Assess for peripheral edema (lower legs, feet), generalized edema (anasarca), and jugular vein distention (JVD), reliable indicators of fluid overload.

2. Breath and Heart Sounds:

Monitor breath sounds for crackles (rales) and heart sounds for an S3 gallop, both indicative of congestive heart failure. Assess for cough and sputum production.

3. Urine Output and Intake & Output (I&Os):

Strictly monitor urine output and document intake and output to assess fluid balance. Monitor response to diuretic therapy.

Interventions:

1. Upright Positioning:

Maintain patient in semi-Fowler’s or Fowler’s position to ease breathing and improve comfort.

2. Diuretic Administration:

Administer prescribed diuretics to promote fluid excretion and reduce edema and dyspnea. Monitor for side effects like hypokalemia and hypotension.

3. Sodium and Fluid Restriction Education:

Educate patient on sodium and fluid restrictions, including hidden sodium sources and strategies for managing fluid intake. Provide guidance on reading food labels and meal planning.

4. Fluid Overload Monitoring Education:

Teach patients how to monitor for fluid overload at home, including daily weight monitoring, recognizing edema, and reporting significant weight gain or worsening symptoms to their healthcare provider.

Impaired Gas Exchange related to Heart Failure

Impaired gas exchange is a significant respiratory complication of heart failure, often due to pulmonary congestion.

Nursing Diagnosis: Impaired Gas Exchange

Alt text: Nurse using pulse oximetry to monitor a patient’s oxygen saturation, assessing for impaired gas exchange due to heart failure.

Related to:

• Ventilation-perfusion imbalance due to altered blood flow in pulmonary circulation
• Changes in alveolar-capillary membrane permeability
• Pulmonary congestion resulting from fluid retention

As evidenced by:

• Dyspnea (shortness of breath)
• Changes in mental status (restlessness, confusion)
• Anxiety and apprehension
• Abnormal arterial blood gases (ABGs)
• Changes in respiratory rate, depth, or rhythm (tachypnea, shallow breathing)
• Tachycardia

Expected outcomes:

• Patient will maintain adequate ventilation and perfusion, as evidenced by ABGs within normal limits for their baseline.
• Patient will demonstrate improved ventilation, with oxygen saturation above 95% (or patient’s baseline).
• Patient will participate in ambulation and ADLs as tolerated by respiratory status.

Assessment:

1. Breath Sounds Auscultation:

Auscultate breath sounds for crackles, wheezes, or diminished sounds, indicating pulmonary congestion or airway obstruction. Monitor for acute changes in respiratory status.

2. Pulse Oximetry Monitoring:

Continuously monitor oxygen saturation (SpO2). Hypoxemia indicates impaired gas exchange and the need for oxygen therapy.

3. Arterial Blood Gas (ABG) Monitoring:

Monitor ABGs to assess oxygenation (PaO2) and carbon dioxide removal (PaCO2). Abnormal ABGs indicate impaired gas exchange and ventilation.

Interventions:

1. Coughing and Deep Breathing Exercises:

Educate and encourage coughing and deep breathing exercises to clear airways and improve lung expansion.

2. Frequent Position Changes:

Reposition patient frequently to promote drainage of secretions and prevent complications like atelectasis and pneumonia. Encourage ambulation as tolerated.

3. Semi-Fowler’s Positioning:

Maintain patient in semi-Fowler’s position to optimize lung expansion and airway patency. Adjust position for patient comfort.

4. Supplemental Oxygen Administration:

Administer supplemental oxygen as prescribed to maintain adequate oxygen saturation. Titrate oxygen as needed based on SpO2 and ABGs.

5. Medication Administration:

Administer medications as ordered to address underlying causes of impaired gas exchange, such as diuretics for fluid overload.

Ineffective Health Maintenance related to Heart Failure

Ineffective health maintenance is a crucial nursing diagnosis addressing patient understanding and self-management of CHF.

Nursing Diagnosis: Ineffective Health Maintenance

Alt text: Nurse conducting medication reconciliation with a patient, addressing ineffective health maintenance in heart failure management.

Related to:

• Lack of understanding of heart failure and prognosis
• Difficulty adhering to the recommended treatment plan
• Poor motivation to make necessary lifestyle changes
• Insufficient resources (financial constraints, access to specialist care)
• Lack of social support to encourage or monitor condition

As evidenced by:

• Demonstrates a lack of knowledge about heart failure management
• Continues inappropriate dietary or lifestyle behaviors despite education
• Inconsistent with appointments, medication adherence, or other aspects of the treatment plan

Expected outcomes:

• Patient will actively seek information to enhance understanding and prevent worsening of heart failure.
• Patient will identify at least three lifestyle modifications necessary to improve heart failure management.
• Patient will take responsibility for their health outcomes by identifying areas for improvement in self-management.

Assessment:

1. Understanding of Disease Process:

Assess patient’s current knowledge of heart failure, risk factors, symptoms, treatments, and prognosis to tailor education to their specific needs.

2. Support System Assessment:

Evaluate the patient’s social support system, as strong support enhances treatment adherence and self-management.

Interventions:

1. Heart Function Education:

Educate patient on normal heart function versus their current heart function, explaining test results (ejection fraction), and using the HF classification system to promote understanding and engagement in care.

2. Rationale for Treatments:

Explain the rationale behind treatments, including fluid restrictions, daily weight monitoring, and medication importance, providing clear, simple explanations and written materials.

3. Exercise Benefits Education:

Educate on the importance and benefits of regular, safe exercise for maintaining strength and organ function, ensuring exercise plans are appropriate and provider-approved.

4. Medication Review and Education:

Conduct thorough medication reconciliation and review at discharge and after provider visits. Educate on medication names, dosages, frequency, side effects, and important considerations for each medication.

Risk for Unstable Blood Pressure related to Heart Failure

Risk for unstable blood pressure is a potential complication in heart failure, requiring proactive nursing interventions.

Nursing Diagnosis: Risk for Unstable Blood Pressure

Alt text: Patient accurately monitoring blood pressure at home, a crucial aspect of managing risk for unstable blood pressure in heart failure.

Related to:

• Conditions that compromise blood supply to the heart
• Structural impairment of the heart muscle
• Malfunctions of heart structures
• Difficulty of the heart muscle to pump effectively
• Increased cardiac workload
• Inadequate blood supply to the heart
• Inability to contract and relax effectively
• Erratic electrical signals causing irregular heart contractions

As evidenced by:

A risk diagnosis is not evidenced by existing signs and symptoms; interventions are focused on prevention.

Expected outcomes:

• Patient will maintain blood pressure within normal limits for their age and condition.
• Patient will not experience hypotension associated with activity or position changes.
• Patient will adhere strictly to prescribed antihypertensive medications.

Assessment:

1. Blood Pressure Monitoring:

Closely monitor blood pressure for trends and fluctuations. Target blood pressure for heart failure patients with reduced ejection fraction is typically around 130/80 mmHg.

2. Laboratory Blood Tests:

Obtain blood samples for lab tests to assess contributing factors:

• Blood urea nitrogen (BUN) and serum creatinine (renal function)
• Electrolyte levels (sodium, potassium)
• Thyroid function tests
• Cholesterol (lipid) levels
• Blood glucose levels
• Liver function tests

3. Treatment Review:

Review patient’s current medications and herbal remedies, identifying potential interactions or agents that could exacerbate heart failure or affect blood pressure.

4. Underlying Conditions Identification:

Identify underlying conditions that may contribute to heart failure and unstable blood pressure, such as coronary artery disease, hypertension, diabetes, and previous myocardial infarction.

Interventions:

1. Treat Underlying Conditions:

Manage underlying conditions like hypertension, diabetes, and coronary artery disease to prevent and manage unstable blood pressure. Encourage lifestyle modifications for risk factor reduction.

2. Educate on Emergency Warning Signs:

Educate patient on symptoms of hypertension and hypotension and when to seek emergency medical care:

• Rapid heartbeat
• Dizziness or fainting
• Profuse sweating
• Headache
• Blurred vision
• Chest pain

3. Blood Pressure Measurement Education:

Instruct patient on accurate home blood pressure monitoring technique, emphasizing:

• Consistent timing of measurements
• Resting for 5-10 minutes before measurement
• Proper body positioning (not crossing legs)
• Avoiding talking during measurement
• Correct cuff size and placement

4. Blood Pressure Log Maintenance:

Advise patient to maintain a blood pressure log to track readings and allow the healthcare team to monitor treatment effectiveness and identify trends.

References

(References from the original article are assumed to be listed here in the final output)