CHF Nursing Diagnosis Care Plan: A Comprehensive Guide for Nurses

Heart failure (HF), often denoted as Congestive Heart Failure (CHF), is a chronic, progressive condition where the heart is unable to pump blood sufficiently to meet the body’s needs. This inadequacy affects all major organ systems and requires meticulous nursing care to manage symptoms, improve quality of life, and prevent complications. As a pivotal member of the healthcare team, nurses play a crucial role in assessing, planning, implementing, and evaluating care for patients with CHF. Understanding the pathophysiology of CHF and the nuances of its nursing management is paramount for providing optimal patient outcomes.

This comprehensive guide delves into the nursing process for CHF, focusing on nursing assessments, interventions, and detailed care plans. It aims to equip nurses with the knowledge and skills necessary to deliver evidence-based care, enhance patient education, and effectively address the multifaceted needs of individuals living with CHF. By focusing on the key aspects of CHF nursing care, this article serves as an essential resource for nurses seeking to excel in this challenging yet rewarding field.

Nursing Process for CHF

The nursing process serves as the foundation for providing structured and patient-centered care. For CHF, this process is critical due to the complexity and variability of the condition. It involves a systematic approach encompassing assessment, diagnosis, planning, implementation, and evaluation. Nurses must be adept at each stage to ensure holistic and effective patient management.

Nursing Assessment for CHF

The initial step in the nursing process is a thorough assessment, which forms the basis for all subsequent care decisions. For CHF, the assessment is multifaceted, encompassing the patient’s health history, physical examination, and diagnostic findings.

Review of Health History

A detailed health history provides crucial insights into the patient’s condition, risk factors, and contributing factors to CHF.

1. Comprehensive Symptom Assessment: Document all patient-reported symptoms, which can be diverse and vary in severity. Key symptoms include:

• Dyspnea on Exertion: Shortness of breath triggered by physical activity is a hallmark symptom of CHF. Explore the onset, duration, and factors that exacerbate or relieve dyspnea.
• Orthopnea: Difficulty breathing while lying flat, often quantified by the number of pillows needed for comfortable breathing.
• Fatigue and Weakness: Persistent tiredness and lack of energy are common due to reduced cardiac output and tissue perfusion.
• Edema in Lower Extremities: Swelling in the ankles and legs, often pitting edema, indicates fluid retention associated with CHF.
• Tachycardia and Irregular Heartbeat: Increased heart rate and arrhythmias are compensatory mechanisms for reduced cardiac output.
• Exercise Intolerance: Decreased ability to perform physical activities due to breathlessness and fatigue.
• Persistent Cough and Wheezing: Cough, especially nocturnal or productive of pink-tinged sputum, and wheezing can be signs of pulmonary congestion.
• Abdominal Swelling (Ascites): Fluid accumulation in the abdominal cavity, indicating systemic congestion.
• Rapid Weight Gain: Sudden weight increase due to fluid retention, a critical indicator of worsening CHF.
• Nausea and Lack of Appetite: Gastrointestinal symptoms resulting from hepatic congestion and reduced blood flow to the digestive system.
• Decreased Alertness and Confusion: Central nervous system effects due to reduced cerebral perfusion, especially in severe CHF.
• Chest Pain (Angina): Although less common in typical CHF, chest pain should be assessed to rule out ischemic heart disease as an underlying cause or exacerbating factor.

2. Investigating Underlying Etiologies: CHF is frequently secondary to other cardiac or systemic conditions. Identifying the root cause is crucial for targeted management. Common underlying causes include:

• Coronary Artery Disease (CAD): Blockage or narrowing of coronary arteries reduces blood supply to the heart muscle, leading to ischemia and potential CHF.
• Myocardial Infarction (MI): Heart attack causes damage to the heart muscle, impairing its pumping ability and potentially leading to CHF.
• Hypertension: Chronic high blood pressure increases the heart’s workload, leading to left ventricular hypertrophy and eventual CHF.
• Heart Valve Disease: Valvular stenosis or regurgitation strains the heart, causing it to work harder and potentially fail.
• Myocarditis: Inflammation of the heart muscle, often due to viral infections, can weaken the heart and cause CHF.
• Congenital Heart Defects: Structural abnormalities present at birth can lead to abnormal hemodynamics and CHF over time.
• Cardiac Arrhythmias: Persistent irregular heart rhythms can impair cardiac output and contribute to CHF.
• Chronic Conditions: Poorly managed diabetes mellitus, HIV, hyperthyroidism, hypothyroidism, and other chronic illnesses can damage the heart and precipitate CHF.

3. Determining Heart Failure Stage (NYHA Classification): The New York Heart Association (NYHA) classification system categorizes CHF severity based on symptom limitations during physical activity.

• Class I: Asymptomatic CHF; no limitations in ordinary physical activity.
• Class II: Mild CHF; slight limitation of physical activity; comfortable at rest, but ordinary physical activity results in fatigue, palpitations, or dyspnea.
• Class III: Moderate CHF; marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or dyspnea.
• Class IV: Severe CHF; unable to carry on any physical activity without discomfort; symptoms may be present even at rest.

4. Risk Factor Assessment: Identifying risk factors helps in understanding disease progression and implementing preventive strategies.

Non-modifiable Risk Factors:

• Age: Advanced age is a significant risk factor due to natural stiffening and weakening of the heart muscle.
• Gender: Men are statistically at higher risk of developing heart failure compared to women, although this gap narrows with increasing age in women.
• Family History: Genetic predisposition plays a role, particularly a family history of ischemic heart disease in close relatives at a young age.
• Race/Ethnicity: Certain ethnic groups, such as African Americans and Latinos, have a higher incidence of heart failure, often linked to socioeconomic factors and prevalence of comorbidities.

Modifiable Risk Factors:

• Hypertension: Uncontrolled hypertension is a leading modifiable risk factor, causing left ventricular hypertrophy and diastolic dysfunction.
• Hyperlipidemia/Hypercholesterolemia/CAD: Elevated LDL cholesterol and low HDL cholesterol contribute to atherosclerosis, increasing CHF risk.
• Diabetes Mellitus and Insulin Resistance: These conditions accelerate vascular damage and increase the risk of both systolic and diastolic heart failure.
• Heart Valve Disease: Early detection and management of valvular disorders can prevent progression to CHF.
• Tobacco Use: Smoking significantly increases the risk of atherosclerosis and myocardial damage, doubling the risk of heart failure.
• Obesity: Excess body weight increases cardiac workload and is associated with other CHF risk factors like hypertension and diabetes.
• Physical Inactivity: Sedentary lifestyle almost doubles the risk of heart disease and subsequent heart failure.
• Diet: High intake of saturated fats, processed foods, sodium, and sugars promotes obesity and related chronic diseases leading to CHF.
• Stress: Chronic stress contributes to hypertension and inflammation, increasing cardiovascular risk.
• Alcohol Use: Excessive alcohol consumption can directly damage the heart muscle (alcoholic cardiomyopathy).
• Sleep Deprivation: Insufficient sleep elevates stress hormones and blood pressure, increasing CHF risk.
• Infections: Bacterial and viral infections, including influenza, pneumonia, UTIs, bacteremia, COVID-19, HIV, and endocarditis, can trigger or exacerbate heart failure.

5. Medication and Treatment History: Review current and past medications and treatments, as some can contribute to or worsen CHF.

• NSAIDs: Nonsteroidal anti-inflammatory drugs can cause fluid retention and exacerbate CHF.
• Diabetes Medications: Thiazolidinediones like rosiglitazone and pioglitazone can increase fluid retention and heart failure risk.
• Antihypertensive Medications: Paradoxically, some antihypertensives may worsen CHF in certain patients, necessitating careful review and adjustment.
• Medications for Other Conditions: Chemotherapy drugs (anthracyclines), medications for blood disorders, arrhythmias, nervous system disorders, mental health, lung diseases, urinary issues, inflammatory conditions, and infections can have cardiac side effects or interactions.

Physical Assessment

A comprehensive physical examination is essential to identify objective signs of CHF and assess its severity.

1. Vital Signs Monitoring:

• Heart Rate and Blood Pressure: Expect changes reflecting reduced cardiac output; tachycardia and variable blood pressure (hypotension or hypertension) are common.
• Oxygen Saturation (SpO2): Monitor for hypoxemia, indicating impaired gas exchange due to pulmonary congestion.

2. Systemic Physical Assessment:

• Neck: Assess for jugular venous distention (JVD), a prominent sign of increased central venous pressure due to fluid overload.
• Central Nervous System (CNS): Evaluate mental status for decreased alertness, confusion, or restlessness, indicative of reduced cerebral perfusion.
• Cardiovascular System:
  • Auscultation: Listen for tachycardia, abnormal heart sounds (pathological S3 and S4 gallops), and murmurs. S3 indicates ventricular overload, and S4 suggests decreased ventricular compliance.
  • Palpation: Assess for chest pain and peripheral pulses (decreased or weak pulses indicate reduced cardiac output).
  • Pulse Pressure: Narrowed pulse pressure (<25 mmHg) may indicate reduced cardiac output.
• Respiratory System:
  • Observation: Note dyspnea at rest or on exertion, tachypnea, orthopnea, persistent cough (especially nocturnal or productive), and wheezing.
  • Auscultation: Listen for crackles (rales) or rhonchi in lung bases, indicating pulmonary edema and congestion.
• Gastrointestinal System:
  • Observation: Assess for nausea, vomiting, anorexia, and abdominal distension due to hepatic congestion and ascites.
• Lymphatic System: Evaluate for peripheral edema in lower extremities, noting location, extent, and pitting characteristics.
• Musculoskeletal System: Assess for fatigue, muscle weakness, activity intolerance, and rapid weight gain (fluid retention). Note any pain in the neck, arm, back, jaw, or upper body, which may indicate angina or referred pain.
• Integumentary System: Observe skin color for pallor, cyanosis (especially peripheral or central), and diaphoresis (excessive sweating), signs of poor perfusion and compensatory mechanisms.

Diagnostic Procedures

Diagnostic tests are crucial for confirming CHF, determining its severity, and identifying underlying causes.

1. Electrocardiogram (ECG): ECG findings in CHF are often non-specific but can show signs of left atrial hypertrophy (P wave changes), arrhythmias, or evidence of previous myocardial infarction (Q waves, ST-T wave abnormalities).

2. B-type Natriuretic Peptide (BNP) and NT-proBNP: Elevated BNP or NT-proBNP levels are significant markers for heart failure, reflecting ventricular stretch and stress. These tests are highly sensitive for CHF diagnosis and prognosis.

3. Blood Tests:

• Complete Blood Count (CBC) with Differential: Assesses for infection (elevated WBC), anemia (low RBC), and coagulation status (platelet count).
• Lipid Panel: Cholesterol levels to assess risk for CAD, a major CHF risk factor.
• Thyroid Function Tests (TFTs): Thyroid disorders can cause arrhythmias and contribute to heart failure.
• Electrolytes, Renal Function (BUN, Creatinine), Liver Function Tests (LFTs): To assess for systemic effects of CHF and guide medication management.

4. Chest X-ray: Chest radiography can reveal cardiomegaly (enlarged heart), pulmonary congestion, pleural effusions, and other lung pathologies associated with CHF.

5. Echocardiogram: Echocardiography is the cornerstone of CHF diagnosis. It assesses cardiac structure and function, including:

• Ejection Fraction (EF): Measures the percentage of blood pumped out of the left ventricle with each beat. EF is critical for classifying heart failure type (reduced EF or preserved EF – HFpEF).
  • Normal EF: 55-70%
  • Borderline EF: 40-54%
  • Mild Heart Failure EF: 35-39%
  • Moderate to Severe Heart Failure EF: <35%
• Ventricular Size and Function: Evaluates for ventricular dilation, hypertrophy, and systolic and diastolic function.
• Valve Function: Assesses for valvular stenosis or regurgitation.
• Wall Motion Abnormalities: May indicate areas of ischemia or prior MI.

6. Advanced Diagnostic Tests:

• Exercise Treadmill Test: Evaluates functional capacity and cardiac response to exercise in stable patients with normal resting ECGs.
• Nuclear Stress Test (Myocardial Perfusion Imaging): Assesses blood flow to the heart muscle during stress (exercise or pharmacologically induced). Useful for detecting ischemia.
• Stress Echocardiography: Combines echocardiography with stress testing to assess wall motion abnormalities and valve function under stress.
• Cardiac CT Scan: Detects calcium deposits in coronary arteries and identifies blockages, useful for assessing CAD.
• Cardiac Catheterization and Coronary Angiography: Invasive procedure to visualize coronary arteries, measure intracardiac pressures, and assess ventricular function. Gold standard for diagnosing CAD and assessing severity.
• CT Coronary Angiogram: Less invasive alternative to traditional angiography, using CT scanning with contrast dye to visualize coronary arteries.
• Myocardial Biopsy: Rarely performed, reserved for specific cases to investigate myocarditis, infiltrative cardiomyopathies, or unexplained heart failure.

ECG demonstrating P wave changes indicative of left atrial hypertrophy in a patient with heart failure.

Nursing Interventions for CHF

Nursing interventions are crucial for managing CHF symptoms, improving cardiac function, preventing complications, and enhancing patient quality of life. These interventions are multifaceted, encompassing pharmacological, non-pharmacological, and educational strategies.

Promoting Perfusion

Enhancing cardiac output and tissue perfusion is a primary goal in CHF management.

1. Vasodilators (ACE Inhibitors and ARBs):

• Mechanism: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) reduce afterload by dilating blood vessels, lowering blood pressure, and decreasing cardiac workload. They also prevent ventricular remodeling.
• Nursing Implications: Monitor blood pressure, renal function, and potassium levels. Watch for side effects like cough (ACE inhibitors) and angioedema (rare but serious).

2. Beta-Blockers:

• Mechanism: Beta-adrenergic blockers reduce heart rate and blood pressure, decrease myocardial oxygen demand, and improve diastolic filling time. They also protect against arrhythmias and sudden cardiac death.
• Nursing Implications: Initiate at low doses and titrate gradually. Monitor heart rate, blood pressure, and for signs of bradycardia, hypotension, and bronchospasm.

3. Diuretics:

• Mechanism: Loop diuretics (furosemide, bumetanide), thiazide diuretics (hydrochlorothiazide), and potassium-sparing diuretics (spironolactone) promote fluid excretion, reducing preload and pulmonary congestion.
• Nursing Implications: Monitor fluid balance, daily weights, electrolyte levels (especially potassium), and renal function. Educate patients about timing of diuretic administration and signs of dehydration or electrolyte imbalance.

4. Potassium-Sparing Diuretics (Aldosterone Antagonists):

• Mechanism: Aldosterone antagonists like spironolactone and eplerenone are particularly beneficial in systolic heart failure. They block aldosterone, promoting sodium and water excretion while retaining potassium. They also have antifibrotic effects.
• Nursing Implications: Monitor potassium levels closely to prevent hyperkalemia, especially in patients with renal impairment or those taking ACE inhibitors/ARBs.

5. Inotropes:

• Mechanism: Inotropes increase myocardial contractility, enhancing cardiac output. Digoxin is a mild inotrope, while more potent inotropes like dobutamine and milrinone are typically used in acute decompensated heart failure (ADHF) settings intravenously.
• Nursing Implications: For digoxin, monitor for digoxin toxicity (nausea, vomiting, visual disturbances, arrhythmias), check serum digoxin levels, and monitor potassium levels (hypokalemia increases digoxin toxicity risk). IV inotropes require continuous cardiac monitoring and hemodynamic assessment.

6. Management of Underlying Conditions:

• Coronary Artery Bypass Graft (CABG): Surgical revascularization to bypass blocked coronary arteries, improving myocardial blood flow and potentially preventing further heart failure progression in patients with CAD.
• Heart Valve Repair or Replacement: Surgical or percutaneous procedures to correct valvular stenosis or regurgitation, reducing hemodynamic stress on the heart.
• Cardiac Resynchronization Therapy (CRT): Implantation of a biventricular pacemaker to coordinate contractions of the left and right ventricles, improving cardiac function in patients with conduction delays and reduced EF.
• Ventricular Assist Devices (VADs): Mechanical pumps implanted to support ventricular function in severe heart failure, serving as a bridge to transplant or destination therapy.
• Heart Transplantation: Considered for end-stage heart failure patients when other treatments are no longer effective.

Cardiac Rehabilitation

Cardiac rehabilitation is a comprehensive, multidisciplinary program designed to improve cardiovascular health, functional capacity, and quality of life in patients with heart disease, including CHF.

1. Multidisciplinary Team Collaboration: Cardiac rehab involves cardiologists, cardiac rehab nurses, dietitians, social workers, physical and occupational therapists. This team approach ensures holistic care addressing physical, psychosocial, and educational needs.

2. Enhancing Activity Tolerance: Gradual, supervised exercise programs are designed to improve cardiovascular fitness, muscle strength, and endurance. Exercise is carefully monitored to avoid overexertion and adverse events.

3. Comprehensive Health Improvement: Cardiac rehab focuses on:

• Exercise Training: Tailored exercise regimens to improve cardiovascular function and exercise capacity.
• Nutritional Counseling: Education on heart-healthy diets (low sodium, low fat, DASH diet) to manage weight, blood pressure, and cholesterol.
• Risk Factor Modification: Strategies to address modifiable risk factors like smoking cessation, weight management, stress reduction, and medication adherence.
• Psychosocial Support: Counseling and support groups to address anxiety, depression, and improve coping mechanisms.
• Education: Patient and family education on CHF management, medications, symptoms to watch for, and lifestyle modifications.

Reducing the Risk of Complications

Preventing complications is crucial in CHF management to improve prognosis and reduce hospitalizations.

1. Implantable Cardioverter-Defibrillators (ICDs): For patients at high risk of sudden cardiac death due to ventricular arrhythmias, ICDs are implanted to monitor heart rhythm and deliver electrical shocks to restore normal rhythm.

2. Emphasizing Lifestyle Modifications: Reinforce the importance of lifestyle changes to manage CHF symptoms and slow disease progression:

• Regular Exercise: Encourages regular aerobic exercise within tolerance levels to improve cardiac function.
• Heart-Healthy Diet: Emphasizes a diet low in sodium, saturated and trans fats, cholesterol, and rich in fruits, vegetables, and whole grains.
• Smoking Cessation: Provides resources and support for smoking cessation.
• Avoiding Secondhand Smoke: Educates patients about the risks of secondhand smoke exposure.
• Stress Management: Techniques to reduce stress, such as relaxation exercises, meditation, yoga, and counseling.
• Vaccinations: Annual influenza and pneumococcal vaccinations to prevent respiratory infections, which can exacerbate CHF.
• Limiting Alcohol Consumption: Advises moderation or abstinence from alcohol, depending on individual circumstances.
• Restful Sleep: Promotes good sleep hygiene and addresses sleep disorders.

3. Activity Management: Advise on appropriate activity levels. Start with short durations of moderate-paced aerobic exercise (5-10 minutes) and gradually increase duration as tolerated.

4. Weight Management: Counsel on maintaining a healthy weight through diet and exercise. Weight loss, even modest, can significantly improve blood pressure, cholesterol, and metabolic function.

5. Promoting Treatment Adherence: Emphasize the importance of medication adherence, follow-up appointments, and lifestyle recommendations. Provide tools and strategies to improve adherence.

6. Stress Reduction Techniques: Teach and encourage stress reduction techniques like guided imagery, yoga, deep breathing exercises, muscle relaxation, and meditation.

7. Preventing Fluid Accumulation:

• Edema Monitoring: Instruct patients to monitor for peripheral edema and report any new or worsening swelling.
• Daily Weight Monitoring: Advise daily weight measurement at the same time each day and to report weight gains of more than 2-2.5 lbs in 24 hours or 5 lbs in a week.
• Sodium Restriction: Educate on limiting sodium intake to 2-3 grams per day to prevent fluid retention.

8. Recognizing When to Seek Medical Attention: Educate patients about warning signs and symptoms that require immediate medical attention:

• Chest pain
• Sudden unexplained weight gain
• Syncope (fainting) or near-syncope
• Worsening dyspnea
• Sudden onset of productive cough with white or pink, foamy sputum

9. Regular Cardiology Follow-up: Emphasize the importance of regular visits to a cardiologist and routine monitoring (blood tests, echocardiograms) to track disease progression and adjust treatment. Recommended follow-up frequency is typically every 3-6 months, or as directed by the cardiologist.

10. Medical Identification: Advise patients to wear medical identification (bracelet, necklace, or ID tag) indicating their CHF diagnosis, especially for those living alone. This is crucial for emergency responders in case of an event.

Cardiac rehabilitation program improving strength and quality of life for a patient with heart failure.

CHF Nursing Care Plans

Nursing care plans are essential tools for organizing and prioritizing nursing care. For CHF, care plans address common nursing diagnoses and guide interventions to achieve specific patient outcomes. Here are examples of nursing care plans for common CHF-related diagnoses:

Activity Intolerance Care Plan

Nursing Diagnosis: Activity Intolerance related to imbalance between oxygen supply and demand, weakness/deconditioning, and sedentary lifestyle, as evidenced by fatigue, dyspnea, immobility, vital sign changes with activity, chest pain on exertion, and diaphoresis.

Expected Outcomes:

• Patient will perform activities within their limitations without excessive cardiac workload.
• Patient will use energy conservation techniques to complete ADLs.
• Patient will maintain stable vital signs and heart rhythm during activity.

Assessments:

1. Cardiopulmonary Response to Activity: Monitor heart rate, blood pressure, oxygen saturation, and cardiac rhythm before, during, and after activity. Note any significant changes (rise or drop in BP, tachycardia, arrhythmias) indicating overexertion.
2. Patient’s Perception of Limitations: Assess the patient’s understanding of their activity limitations and their perceived exertion levels. Ensure they are not overexerting but also encouraged to progress within safe limits.
3. Degree of Debility: Evaluate the patient’s level of fatigue, weakness, and dyspnea in relation to activity. Determine the extent of assistance needed with ADLs and adjust activity plans accordingly for safety.

Interventions:

1. Provide a Calm Environment: Minimize environmental stressors (noise, clutter). Ensure a cool, well-ventilated room. Encourage slow, controlled breathing during activities. Provide emotional support to reduce anxiety related to dyspnea.
2. Encourage Participation in Self-Care: Promote patient participation in ADLs within their tolerance. Provide bedside supplies to facilitate self-care (e.g., toiletries, grooming aids). Encourage even minimal participation to maintain independence and prevent complications of immobility.
3. Teach Energy Conservation Methods: Instruct on techniques like grouping activities, sitting down for tasks, planning rest periods, avoiding rushing, and avoiding activities in extreme temperatures. Promote restful sleep.
4. Recommend Cardiac Rehabilitation: Refer to a cardiac rehabilitation program for supervised exercise training, education, and support to improve activity tolerance and overall cardiac health.

Decreased Cardiac Output Care Plan

Nursing Diagnosis: Decreased Cardiac Output related to altered heart rate/rhythm, altered contractility, and structural changes, as evidenced by increased heart rate, dysrhythmias, fatigue, shortness of breath, anxiety, orthopnea, jugular vein distention, edema, central venous pressure changes, murmurs, decreased peripheral pulses, decreased urine output, skin pallor, mottling, or cyanosis.

Expected Outcomes:

• Patient will demonstrate hemodynamic stability with vital signs, cardiac output, and renal perfusion within acceptable limits.
• Patient will engage in activities that reduce cardiac workload.
• Patient will report absence of chest pain and decreased shortness of breath.

Assessments:

1. Vital Signs, Cardiac Rhythm, and Hemodynamics: Continuously monitor ECG for dysrhythmias. Regularly assess blood pressure, heart rate, oxygen saturation. Hemodynamic monitoring may be necessary in unstable patients to assess cardiac output and guide interventions.
2. Peripheral Perfusion: Assess skin color and temperature, peripheral pulses, and capillary refill. Monitor for pallor, cyanosis, mottling, coolness, and weak or irregular pulses, indicating poor tissue perfusion.
3. Mental Status: Monitor for changes in mental status, including confusion, restlessness, or decreased alertness, which can indicate reduced cerebral perfusion due to decreased cardiac output.

Interventions:

1. Administer Oxygen: Provide supplemental oxygen as needed to maintain SpO2 at the ordered level, especially in patients with hypoxemia. Chronic CHF patients may require home oxygen therapy.
2. Medication Administration: Administer prescribed medications, such as vasodilators, diuretics, beta-blockers, and inotropes, as ordered. Monitor for therapeutic effects and side effects. Provide medications to reduce anxiety and pain as prescribed to decrease cardiac workload.
3. Reduce Cardiac Workload: Advise and assist with activity modifications, rest periods, and energy conservation techniques. Ensure assistance with ADLs as needed to minimize cardiac strain.
4. Patient Education on Risk Factors and Lifestyle Modifications: Educate patients and families about CHF risk factors, prevention strategies, and lifestyle modifications (diet, exercise, smoking cessation, stress management).

Decreased Cardiac Tissue Perfusion Care Plan

Nursing Diagnosis: Decreased Cardiac Tissue Perfusion related to structural impairment of the heart, malfunctions of heart structures, difficulty of the heart muscle to pump, increased exertion in workload, inadequate blood supply to the heart, inability to contract and relax effectively, and erratic signals causing irregular heart contraction, as evidenced by decreased cardiac output, hypotension, decreased peripheral pulses, increased CVP and PAP, tachycardia, dysrhythmias, EF <40%, decreased oxygen saturation, S3 and S4 heart sounds, and chest pain.

Expected Outcomes:

• Patient will maintain pulse rate and rhythm within normal limits.
• Patient will demonstrate ejection fraction >40%.
• Patient will maintain palpable peripheral pulses.

Assessments:

1. Auscultate Heart Sounds: Auscultate at the apex for abnormal heart sounds (S3, S4). S3 in adults often signifies ventricular overload; S4 suggests decreased ventricular compliance.
2. Assist with Myocardial Perfusion Testing: Prepare patient for and assist with myocardial perfusion imaging (nuclear stress test) to evaluate blood flow to the heart muscle and cardiac pumping efficiency.
3. BNP/NT-proBNP Levels: Monitor BNP or NT-proBNP levels to assess heart failure severity and response to treatment.
4. ECG Monitoring: Obtain and monitor ECG for arrhythmias, ischemia, or other changes indicating decreased cardiac tissue perfusion.
5. Assist with TEE: Prepare patient for and assist with transesophageal echocardiography (TEE) to assess ejection fraction, left atrial pressure, and cardiac output.
6. Prepare for Cardiac Catheterization/Angiography: Prepare patient for possible left heart catheterization or coronary angiography to identify coronary artery blockages or abnormalities.

Interventions:

1. Collaborative Goal Setting: Work with the patient to establish therapy goals focused on improving survival, symptom management, reducing hospitalizations, preventing organ damage, and suppressing symptoms.
2. Medication Administration: Administer prescribed medications, including diuretics, ACE inhibitors/ARBs/ARNIs, beta-blockers, and nitrates/hydralazine as ordered. Monitor for effectiveness and side effects.
3. Lifestyle Modification Education: Educate on dietary and nutritional recommendations (sodium restriction, fluid restriction), weight monitoring, aerobic exercise training, management of risk factors (DM, lipid disorders), and smoking/alcohol/illicit drug cessation.
4. Consider Device Therapy: Discuss device therapies like CRT and ICDs as appropriate, ensuring patients have received optimal medical therapy (ACE inhibitors/ARB plus beta-blockers) for at least three months prior to considering device therapy.
5. Anticipate Surgical Interventions: Prepare for potential surgical interventions (heart transplant, valve replacement, catheter ablation) if medical management is insufficient.

Excess Fluid Volume Care Plan

Nursing Diagnosis: Excess Fluid Volume related to fluid or sodium intake, reduced glomerular filtration rate, and increased ADH secretion, as evidenced by shortness of breath, weight gain, edema, jugular vein distention, adventitious breath sounds (crackles), hypertension, oliguria, tachycardia, pulmonary congestion, cough, and S3 heart sound.

Expected Outcomes:

• Patient will demonstrate stable fluid volume as evidenced by balanced intake and output, stable baseline weight, and absence of peripheral edema.
• Patient will verbalize signs and symptoms of fluid overload and when to seek help.
• Patient will adhere to dietary sodium restrictions and fluid limitations.

Assessments:

1. Fluid Retention Signs: Assess for peripheral edema (location, pitting), anasarca, and jugular venous distention (JVD). JVD is a reliable indicator of fluid overload.
2. Respiratory and Cardiac Auscultation: Monitor breath sounds for crackles (rales) indicating pulmonary edema. Auscultate heart sounds for S3 gallop. Assess for cough, especially productive cough with pink-tinged sputum.
3. Fluid Balance Monitoring: Monitor urine output and maintain strict intake and output (I&O) records. Assess urine specific gravity and color. Monitor daily weights at the same time each day.

Interventions:

1. Positioning: Maintain semi-Fowler’s or Fowler’s position to facilitate breathing and reduce preload. Use extra pillows or advise sleeping in a recliner if needed at home.
2. Diuretic Administration: Administer diuretics as prescribed. Monitor for effectiveness (increased urine output, decreased edema) and side effects (dehydration, electrolyte imbalances, hypotension). Monitor electrolyte levels, particularly potassium.
3. Sodium and Fluid Restriction Education: Provide education on sodium restriction (2-3 g/day) and fluid restriction (if ordered, typically 2L/day). Educate on hidden sodium in processed foods and fluid content of various foods and beverages.
4. Fluid Overload Monitoring Education: Teach patients to monitor for signs of fluid overload: daily weight monitoring, edema assessment, and recognizing worsening dyspnea. Instruct on when to contact healthcare provider (weight gain >2 lbs in 24 hours or 5 lbs in a week, increased edema, worsening dyspnea).

Impaired Gas Exchange Care Plan

Nursing Diagnosis: Impaired Gas Exchange related to ventilation-perfusion imbalance due to altered blood flow, changes in alveolar-capillary membrane, and pulmonary congestion, as evidenced by dyspnea, changes in mental status, restlessness, anxiety, abnormal ABGs, changes in respiratory rate, depth, or rhythm, and tachycardia.

Expected Outcomes:

• Patient will maintain adequate ventilation and perfusion as evidenced by ABGs within normal limits.
• Patient will demonstrate improved oxygenation with SpO2 >95%.
• Patient will participate in ambulation and ADLs as tolerated by respiratory status.

Assessments:

1. Auscultate Breath Sounds: Assess breath sounds for adventitious sounds (crackles, wheezes, diminished breath sounds) indicating pulmonary congestion or airway obstruction. Monitor for changes in respiratory status.
2. Pulse Oximetry: Continuously monitor SpO2 levels. Note any desaturations, especially with activity.
3. Arterial Blood Gases (ABGs): Monitor ABGs if indicated to assess oxygenation (PaO2), carbon dioxide removal (PaCO2), and acid-base balance.

Interventions:

1. Coughing and Deep Breathing Exercises: Instruct and assist with coughing and deep breathing exercises to clear airways and improve lung expansion.
2. Position Changes and Ambulation: Encourage frequent position changes to promote secretion drainage and prevent atelectasis. Encourage ambulation as tolerated to improve ventilation and perfusion.
3. Semi-Fowler’s Position: Maintain semi-Fowler’s position to improve lung expansion and reduce pressure on the diaphragm.
4. Supplemental Oxygen: Administer supplemental oxygen as prescribed to maintain SpO2 at ordered levels. Titrate oxygen based on patient needs and ABGs.
5. Medication Administration: Administer medications to address underlying causes of impaired gas exchange, such as diuretics for fluid overload and bronchodilators for wheezing.

Ineffective Health Maintenance Care Plan

Nursing Diagnosis: Ineffective Health Maintenance related to lack of knowledge about heart failure and prognosis, difficulty following treatment plan, poor motivation, insufficient resources, and lack of family support, as evidenced by demonstrated lack of knowledge, continued inappropriate diet or behaviors, and inconsistent adherence to appointments and medications.

Expected Outcomes:

• Patient will actively seek information to prevent worsening heart failure.
• Patient will identify at least three lifestyle modifications to improve heart failure management.
• Patient will demonstrate responsibility for their health by identifying areas for improvement and adhering to the treatment plan.

Assessments:

1. Assess Knowledge Level: Evaluate the patient’s understanding of CHF, risk factors, symptoms, treatments, and prognosis. Identify knowledge gaps to tailor education.
2. Assess Support System: Evaluate the patient’s social support network, including family and caregivers, and their ability to provide encouragement and assistance with CHF management.

Interventions:

1. Educate on Heart Function and CHF: Explain normal heart function compared to the patient’s current heart function in simple terms. Review test results (EF, BNP) and NYHA classification to enhance understanding and engagement.
2. Reinforce Treatment Rationale: Explain the rationale behind treatments (medications, diet, fluid restrictions, weight monitoring) and their importance in managing CHF and preventing complications. Provide written educational materials.
3. Exercise Benefits Education: Educate on the importance and benefits of regular, safe exercise for cardiovascular health and overall well-being. Ensure exercise plans are individualized and approved by the healthcare provider.
4. Medication Review: Conduct thorough medication reconciliation and review at each visit and before discharge. Provide clear instructions on medication names, dosages, frequency, side effects, and special considerations.

Risk for Unstable Blood Pressure Care Plan

Nursing Diagnosis: Risk for Unstable Blood Pressure related to conditions compromising blood supply, structural heart impairment, malfunctions of heart structures, difficulty of heart muscle to pump, increased workload, inadequate blood supply, ineffective contractility/relaxation, and erratic heart signals.

Expected Outcomes:

• Patient will maintain blood pressure within normal limits.
• Patient will not experience hypotension with activity.
• Patient will demonstrate consistent adherence to prescribed antihypertensive medications.

Assessments:

1. Blood Pressure Monitoring: Closely monitor blood pressure in various positions (supine, sitting, standing) to assess for orthostatic hypotension. Target BP for CHF patients is typically around 130/80 mmHg, but individualize based on patient tolerance and comorbidities.
2. Laboratory Tests Review: Review blood urea nitrogen (BUN), serum creatinine, electrolyte levels, thyroid function tests, lipid panel, blood glucose, and liver function tests to assess for contributing factors and guide medication management.
3. Medication and Herbal Remedy Review: Review all medications and herbal supplements the patient is taking, as some can interact with CHF medications or exacerbate blood pressure instability.
4. Identify Underlying Conditions: Assess for underlying conditions that can contribute to unstable blood pressure in CHF, such as CAD, hypertension, diabetes, renal disease, and thyroid disorders.

Interventions:

1. Treat Underlying Conditions: Focus on managing underlying conditions contributing to CHF and unstable blood pressure, such as hypertension, CAD, and diabetes.
2. Educate on Emergency Symptoms: Instruct patients on symptoms of hypotension and hypertension that require immediate medical attention (rapid heartbeat, dizziness, fainting, sweating, headache, blurred vision, chest pain).
3. Accurate Blood Pressure Measurement Education: Teach patients how to accurately measure blood pressure at home, including proper cuff size and placement, positioning, and timing.
4. Blood Pressure Log Maintenance: Advise patients to keep a log of blood pressure readings, recording date, time, and position, to help monitor treatment effectiveness and identify trends.

References

References (from original article)