NANDA Nursing Diagnoses for CHF: A Comprehensive Guide

Heart failure (HF), often known as congestive heart failure (CHF), is a chronic progressive condition where the heart is unable to pump sufficient blood to meet the body’s needs. This condition can significantly impact a patient’s quality of life, necessitating comprehensive nursing care. As a pivotal member of the healthcare team, nurses play a vital role in managing CHF, from initial assessment to implementing effective interventions and educating patients for long-term management. Understanding and applying appropriate NANDA nursing diagnoses is fundamental to providing optimal care for CHF patients.

Nursing Process in CHF Management

The nursing process is crucial in addressing the multifaceted needs of patients with CHF. It provides a systematic approach to patient care, encompassing assessment, diagnosis, planning, implementation, and evaluation. For CHF patients, this process is iterative and dynamic, requiring continuous monitoring and adjustments to the care plan as the patient’s condition evolves.

Nursing Assessment for CHF

The initial step in the nursing process is a thorough assessment. This involves gathering both subjective and objective data to understand the patient’s overall health status and the specific impact of CHF.

1. Review of Health History:

• General Symptoms: Elicit patient reports of common CHF symptoms:

  • Dyspnea on exertion: Shortness of breath during activity, a hallmark symptom of CHF.
  • Orthopnea: Difficulty breathing when lying flat, often relieved by sitting upright or using pillows.
  • Fatigue and Weakness: Reduced energy levels and muscle weakness due to decreased cardiac output.
  • Edema in Lower Extremities: Swelling in ankles, legs, and feet due to fluid retention.
  • Tachycardia and Irregular Heartbeat: Compensatory mechanisms to maintain cardiac output.
  • Exercise Intolerance: Decreased ability to perform physical activities due to symptoms.
  • Persistent Cough and Wheezing: May indicate pulmonary congestion.
  • Abdominal Swelling: Ascites, fluid accumulation in the abdomen, reflecting systemic congestion.
  • Rapid Weight Gain: Fluid retention is a key indicator of worsening CHF.
  • Nausea and Lack of Appetite: Gastrointestinal symptoms related to systemic congestion.
  • Decreased Alertness: Reduced cerebral perfusion can affect mental status.
  • Chest Pain: Angina, although less common in typical CHF, can be present, especially if CAD is the underlying cause.

• Underlying Causes: Investigate potential conditions that may have contributed to CHF:

  • Coronary Artery Disease (CAD): The most common cause of CHF, resulting from reduced blood flow to the heart muscle.
  • Myocardial Infarction (MI): Heart attack, causing damage to the heart muscle and impaired function.
  • Hypertension: Chronic high blood pressure increases the workload on the heart, leading to CHF.
  • Heart Valve Disease: Valvular dysfunction can strain the heart and lead to failure.
  • Myocarditis: Inflammation of the heart muscle, often due to viral infections.
  • Congenital Heart Defects: Structural abnormalities present at birth affecting heart function.
  • Cardiac Arrhythmias: Irregular heart rhythms that can impair pumping efficiency.
  • Chronic Conditions: Poorly managed diabetes mellitus, HIV, hyperthyroidism, or hypothyroidism can contribute to CHF.

• Stage of Heart Failure: Determine the severity of CHF symptoms using the New York Heart Association (NYHA) Functional Classification:

  1. Class I: Asymptomatic CHF; no limitations in physical activity.
  2. Class II: Mild CHF; comfortable at rest, but ordinary physical activity causes fatigue, dyspnea, or palpitations.
  3. Class III: Moderate CHF; comfortable at rest, but less than ordinary activity causes symptoms.
  4. Class IV: Severe CHF; symptoms occur even at rest; unable to carry out any physical activity without discomfort.

• Risk Factors: Identify both non-modifiable and modifiable risk factors for CHF:

  • Non-modifiable:
    • Age: Risk increases with age, especially over 65.
    • Gender: Men are more likely to develop heart failure.
    • Family History: Genetic predisposition to ischemic heart disease.
    • Race/Ethnicity: Higher prevalence in African-Americans and Latinos.
  • Modifiable:
    • Hypertension: Uncontrolled high blood pressure.
    • Hyperlipidemia: High cholesterol, contributing to atherosclerosis.
    • Diabetes Mellitus: Increases risk of vascular damage and heart disease.
    • Heart Valve Disease: Can be treated or managed to reduce CHF risk.
    • Tobacco Use: Smoking significantly increases cardiovascular risk.
    • Obesity: Increases risk of hypertension, hyperlipidemia, and diabetes.
    • Physical Inactivity: Sedentary lifestyle increases heart disease risk.
    • Unhealthy Diet: High in fats, sodium, and processed foods.
    • Stress: Chronic stress can negatively impact cardiovascular health.
    • Excessive Alcohol Use: Can weaken the heart muscle (cardiomyopathy).
    • Lack of Sleep: Insufficient sleep increases stress and blood pressure.
    • Infections: Influenza, pneumonia, UTIs, COVID-19, HIV, endocarditis, etc.

• Treatment Record: Review current and past medications and surgeries:

  • NSAIDs: Can exacerbate fluid retention.
  • Diabetes Medications: Thiazolidinediones (e.g., rosiglitazone, pioglitazone) can worsen CHF.
  • Antihypertensive Medications: Type and effectiveness need to be assessed.
  • Medications for other conditions: Cancer, blood disorders, arrhythmias, nervous system disorders, mental health issues, lung and urinary issues, inflammatory diseases, and infections.

A nurse carefully assesses a patient for edema in their lower extremities, a key indicator of fluid retention associated with congestive heart failure.

2. Physical Assessment:

• Vital Signs: Monitor for changes indicative of CHF:
  • Elevated or decreased blood pressure.
  • Tachycardia.
  • Decreased oxygen saturation (SpO2).
• Systemic Assessment:
  • Neck: Jugular Vein Distention (JVD) – a prominent sign of increased central venous pressure and fluid overload in CHF.
  • CNS: Decreased Alertness – may indicate reduced cerebral perfusion.
  • Cardiovascular:
    • Tachycardia, arrhythmias.
    • Chest Pain – assess characteristics and triggers.
    • Abnormal Heart Sounds – Pathological S3 (ventricular gallop) is a classic sign of CHF, indicating increased ventricular filling pressure; S4 (atrial gallop) may also be present.
  • Circulatory:
    • Decreased Peripheral Pulses – reduced cardiac output.
    • Narrow Pulse Pressure (<25 mmHg) – indicative of reduced stroke volume.
  • Respiratory:
    • Dyspnea (exertional or at rest).
    • Tachypnea (rapid breathing).
    • Orthopnea.
    • Persistent or Nocturnal Cough.
    • Crackles or Rhonchi in Lung Bases – indicative of pulmonary edema.
  • Gastrointestinal:
    • Nausea and Vomiting.
    • Lack of Appetite.
    • Abdominal Swelling (Ascites) – due to hepatic congestion.
  • Lymphatic: Edema in Lower Extremities (pitting or non-pitting).
  • Musculoskeletal: Fatigue, Muscle Weakness, Activity Intolerance, Rapid Weight Gain (fluid).
  • Integumentary: Cyanotic or Pale Skin, Excessive Sweating, Cool and clammy skin.

3. Diagnostic Procedures:

• Electrocardiogram (ECG): Detects arrhythmias, ischemia, and left atrial hypertrophy (P wave changes).
• Brain Natriuretic Peptide (BNP) or NT-proBNP Lab Results: Elevated levels are a key diagnostic marker for CHF.
• Other Blood Tests:
  • Complete Blood Count (CBC) with differential: Rule out infection (WBC), assess for anemia (RBC), and coagulation status (platelets).
  • Cholesterol Levels: Assess risk for CAD.
  • Thyroid Levels: Rule out thyroid disorders that can mimic or exacerbate CHF.
• Chest X-ray: Evaluate heart size (cardiomegaly) and pulmonary congestion (pleural effusions, pulmonary edema).
• Echocardiogram: Gold standard for assessing heart structure and function, including:
  • Ejection Fraction (EF): Measures the percentage of blood pumped out of the left ventricle with each beat.
    • Normal EF: 55-70%.
    • Borderline EF: 40-54%.
    • Mild Heart Failure: 35-39%.
    • Moderate to Severe Heart Failure: <35%.
• Further Investigations (as indicated):
  • Exercise Treadmill Test: Assesses functional capacity and ischemia.
  • Nuclear Stress Test: Evaluates myocardial perfusion.
  • Stress Imaging: For patients unable to exercise or with ECG interpretation challenges.
  • Cardiac CT Scan: Detects calcium deposits and coronary artery blockages.
  • Cardiac Catheterization: Definitive diagnosis of CAD and hemodynamic assessment.
  • CT Coronary Angiogram: Detailed imaging of coronary arteries.
  • Myocardial Biopsy: Investigates specific cardiomyopathies or infiltrative diseases.

Common NANDA Nursing Diagnoses for CHF

Based on the comprehensive assessment, several NANDA nursing diagnoses are commonly identified in patients with CHF. These diagnoses guide the planning and implementation of individualized nursing care. Key NANDA diagnoses relevant to CHF include:

• Activity Intolerance: Related to imbalance between oxygen supply and demand, weakness, and sedentary lifestyle, as evidenced by fatigue, dyspnea, and abnormal vital sign response to activity.
• Decreased Cardiac Output: Related to altered heart rate/rhythm, altered contractility, and structural changes, as evidenced by tachycardia, dysrhythmias, fatigue, edema, and decreased peripheral pulses.
• Decreased Cardiac Tissue Perfusion: Related to structural impairment of the heart, malfunctions of heart structures, and increased workload, as evidenced by decreased cardiac output, hypotension, dysrhythmias, and chest pain.
• Excess Fluid Volume: Related to excess fluid and sodium intake, reduced glomerular filtration rate, and increased ADH secretion, as evidenced by edema, weight gain, JVD, and adventitious breath sounds.
• Impaired Gas Exchange: Related to ventilation-perfusion imbalance and pulmonary congestion, as evidenced by dyspnea, changes in mental status, restlessness, and abnormal ABGs.
• Ineffective Health Maintenance: Related to lack of knowledge about CHF and treatment regimen, difficulty following recommendations, and insufficient resources, as evidenced by lack of knowledge and inconsistent adherence to treatment.
• Risk for Unstable Blood Pressure: Related to impaired cardiac function and regulatory mechanisms.

Nursing Interventions for CHF

Nursing interventions are aimed at addressing the identified NANDA diagnoses, managing symptoms, improving cardiac function, preventing complications, and enhancing the patient’s quality of life.

Promoting Perfusion and Cardiac Function

1. Optimize Vasodilation:

• Administer ACE inhibitors and ARBs: These medications relax blood vessels, reduce blood pressure, and decrease cardiac workload.
  2. Manage Heart Rate and Blood Pressure:
• Administer Beta-blockers: Reduce heart rate and blood pressure, improving cardiac efficiency.
  3. Reduce Fluid Overload:
• Administer Diuretics: Promote diuresis to remove excess fluid and alleviate congestion.
  4. Potassium-Sparing Diuretics:
• Aldosterone Antagonists (e.g., spironolactone, eplerenone): Help manage systolic heart failure while conserving potassium.
  5. Enhance Cardiac Contractility:
• Inotropes (e.g., dobutamine, milrinone): IV medications used in acute settings to strengthen heart contractions.
• Digoxin: Oral inotrope that increases heart contraction strength; requires careful monitoring for toxicity.
  6. Treat Underlying Conditions:
• Coronary Artery Bypass Graft (CABG): Improves blood flow to the heart muscle.
• Heart Valve Repair or Replacement: Corrects valvular dysfunction.
• Cardiac Resynchronization Therapy (CRT): Pacemaker therapy to improve coordinated ventricular contraction in certain types of CHF.
• Ventricular Assist Devices (VADs): Mechanical pumps to support heart function in severe CHF.
• Heart Transplant: For end-stage CHF when other treatments are ineffective.

Cardiac Rehabilitation

1. Multidisciplinary Approach: Collaborate with cardiologists, cardiac rehab specialists, dietitians, social workers, and therapists for holistic care.
2. Improve Activity Tolerance: Gradually increase exercise to strengthen the heart and improve functional capacity.
3. Enhance Overall Health: Cardiac rehab programs focus on exercise, education, and lifestyle modification to improve health and prevent recurrence.

Reducing Risk of Complications

1. Regulate Heart Rhythm:

• Implantable Cardioverter-Defibrillators (ICDs): Prevent sudden cardiac death in high-risk patients by detecting and treating life-threatening arrhythmias.
  2. Lifestyle Modifications Education: Reinforce the importance of:
• Regular Exercise.
• Heart-Healthy Diet (low sodium, low fat).
• Smoking Cessation.
• Avoiding Secondhand Smoke.
• Stress Management Techniques.
• Vaccinations (Influenza, Pneumonia).
• Limiting Alcohol Consumption.
• Restful Sleep.
  3. Activity Guidance: Advise on safe exercise levels, starting slowly and gradually increasing duration and intensity.
  4. Weight Management: Promote maintaining a healthy weight to reduce cardiac workload.
  5. Treatment Adherence: Educate and support patient adherence to medications, diet, and lifestyle changes.
  6. Stress Reduction Techniques: Teach relaxation techniques like guided imagery, yoga, deep breathing, and meditation.
  7. Fluid Management: Monitor for edema, teach patients to monitor weight and fluid intake, and limit sodium intake.
  8. Recognize When to Seek Medical Attention: Educate patients on warning signs:
• Chest Pain.
• Sudden Weight Gain.
• Fainting.
• Worsening Dyspnea.
• Cough with Pink or White Sputum.
  9. Cardiologist Follow-up: Emphasize the importance of regular follow-up appointments.
  10. Medical Identification: Recommend medical ID bracelet or necklace to alert emergency responders about CHF history.

Nursing Care Plans Examples for CHF

Nursing care plans provide a structured framework for delivering individualized care based on the identified NANDA diagnoses. Examples of care plans for common CHF diagnoses are detailed below:

Activity Intolerance Care Plan

Nursing Diagnosis: Activity Intolerance

Related to: Imbalance between oxygen supply and demand, weakness/deconditioning, sedentary lifestyle.

As evidenced by: Fatigue, dyspnea, vital sign changes with activity, chest pain on exertion.

Expected Outcomes:

• Patient will perform activities within limitations without excessive cardiac workload.
• Patient will alternate rest and activity to complete ADLs.
• Patient will maintain stable vital signs and heart rhythm during activity.

Assessments:

1. Monitor cardiopulmonary response to activity (HR, SpO2, rhythm, BP).
2. Assess patient’s perception of limitations and understanding of condition.
3. Assess degree of debility and need for assistance with ADLs.

Interventions:

1. Provide a calm and restful environment to reduce anxiety and promote relaxation.
2. Encourage patient participation in self-care within their limits to prevent deconditioning.
3. Teach energy conservation techniques: pacing activities, rest periods, sitting during tasks, avoiding temperature extremes.
4. Recommend cardiac rehabilitation to improve activity tolerance and overall function.

Decreased Cardiac Output Care Plan

Nursing Diagnosis: Decreased Cardiac Output

Related to: Altered heart rate/rhythm, altered contractility, structural changes.

As evidenced by: Tachycardia, dysrhythmias, fatigue, shortness of breath, edema, decreased peripheral pulses.

Expected Outcomes:

• Patient will demonstrate hemodynamic stability (vital signs, cardiac output, renal perfusion within acceptable limits).
• Patient will participate in activities that reduce cardiac workload.
• Patient will report absence of chest pain or shortness of breath.

Assessments:

1. Monitor vital signs, cardiac rhythm continuously (telemetry), hemodynamic parameters if indicated.
2. Assess skin color, temperature, and peripheral pulses for signs of poor perfusion.
3. Monitor mental status for changes indicating decreased cerebral perfusion.

Interventions:

1. Administer supplemental oxygen as needed to maintain adequate oxygen saturation.
2. Administer medications as prescribed: vasodilators, diuretics, inotropes, antiarrhythmics.
3. Instruct on ways to reduce cardiac workload: rest, avoid overexertion, manage stress.
4. Educate on risk factors for CHF and lifestyle modifications for prevention and management.

Decreased Cardiac Tissue Perfusion Care Plan

Nursing Diagnosis: Decreased Cardiac Tissue Perfusion

Related to: Structural impairment, heart muscle dysfunction, increased workload, inadequate blood supply.

As evidenced by: Decreased cardiac output, hypotension, dysrhythmias, chest pain, decreased EF.

Expected Outcomes:

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

Assessments:

1. Auscultate heart sounds, particularly for S3 and S4 gallops.
2. Assist with myocardial perfusion tests (nuclear stress test).
3. Monitor BNP or NT-proBNP levels.
4. Obtain and monitor ECG findings.
5. Assist with echocardiography (TEE).
6. Prepare patient for cardiac catheterization or coronary angiography if indicated.

Interventions:

1. Collaborate with the patient to set realistic treatment goals focused on symptom management and improved quality of life.
2. Administer medications as ordered: diuretics, ACE inhibitors/ARBs/ARNIs, beta-blockers, nitrates.
3. Instruct on lifestyle modifications: low-sodium diet, fluid restriction, weight monitoring, regular exercise, smoking cessation, manage risk factors (DM, hyperlipidemia).
4. Consider device therapy: CRT, ICD as appropriate.
5. Anticipate potential surgical interventions: heart transplant, valve replacement, if medical management is insufficient.

Excess Fluid Volume Care Plan

Nursing Diagnosis: Excess Fluid Volume

Related to: Fluid and sodium intake, reduced glomerular filtration, increased ADH.

As evidenced by: Shortness of breath, weight gain, edema, JVD, crackles, S3 heart sound.

Expected Outcomes:

• Patient will demonstrate stable fluid volume (balanced I&O, stable weight, no edema).
• Patient will verbalize signs and symptoms of fluid overload and when to seek help.
• Patient will verbalize dietary and fluid restrictions.

Assessments:

1. Assess for peripheral edema, anasarca, and JVD.
2. Monitor breath sounds for crackles and heart sounds for S3.
3. Monitor urine output and maintain strict I&Os, especially with diuretic therapy.

Interventions:

1. Maintain upright position (semi-Fowler’s or Fowler’s) to ease breathing.
2. Administer diuretics as prescribed and monitor electrolytes (potassium).
3. Instruct on sodium and fluid restrictions, providing detailed dietary guidance.
4. Teach patient how to monitor for fluid overload: daily weights, edema assessment, dyspnea monitoring, and when to contact healthcare provider.

Impaired Gas Exchange Care Plan

Nursing Diagnosis: Impaired Gas Exchange

Related to: Ventilation-perfusion imbalance, pulmonary congestion.

As evidenced by: Dyspnea, changes in mental status, restlessness, abnormal ABGs, changes in respiratory rate/rhythm, tachycardia.

Expected Outcomes:

• Patient will maintain adequate ventilation and perfusion (ABGs within normal limits).
• Patient will demonstrate improved oxygenation (SpO2 >95%).
• Patient will participate in activities as tolerated by respiratory status.

Assessments:

1. Auscultate breath sounds for crackles, wheezes, or diminished sounds.
2. Monitor pulse oximetry continuously.
3. Monitor arterial blood gases (ABGs) as indicated.

Interventions:

1. Educate on coughing and deep breathing exercises to clear airways.
2. Encourage frequent position changes and ambulation to mobilize secretions.
3. Maintain semi-Fowler’s position to optimize lung expansion.
4. Administer supplemental oxygen as needed to maintain SpO2.
5. Administer medications as ordered, such as diuretics to reduce pulmonary congestion.

Ineffective Health Maintenance Care Plan

Nursing Diagnosis: Ineffective Health Maintenance

Related to: Lack of knowledge, difficulty following treatment plan, poor motivation, insufficient resources.

As evidenced by: Lack of knowledge about CHF, continued inappropriate behaviors, inconsistent adherence to appointments/medications.

Expected Outcomes:

• Patient will actively seek information to prevent worsening CHF.
• Patient will identify lifestyle modifications to improve CHF management.
• Patient will take responsibility for health outcomes by identifying areas for improvement.

Assessments:

1. Assess patient’s understanding of CHF disease process, risk factors, symptoms, and treatment goals.
2. Assess patient’s support system and available resources.

Interventions:

1. Educate on normal heart function vs. CHF dysfunction, using clear and simple language.
2. Reinforce the rationale for treatments (medications, diet, fluid restrictions, exercise).
3. Educate on the benefits of regular exercise and provide safe exercise guidelines.
4. Review all medications, including dosage, frequency, side effects, and importance of adherence.

Risk for Unstable Blood Pressure Care Plan

Nursing Diagnosis: Risk for Unstable Blood Pressure

Related to: Conditions compromising blood supply, structural heart impairment, heart muscle dysfunction, increased workload.

As evidenced by: (Risk diagnosis – no evidence by symptoms, interventions aimed at prevention).

Expected Outcomes:

• Patient will maintain blood pressure within normal limits.
• Patient will not experience hypotension with activity.
• Patient will adhere to antihypertensive medication regimen.

Assessments:

1. Closely monitor blood pressure in various positions and with activity.
2. Obtain blood samples for lab tests: BUN, creatinine, electrolytes, thyroid function, lipid profile, glucose, liver function.
3. Review patient’s current medications and herbal remedies for potential interactions.
4. Identify underlying conditions contributing to unstable blood pressure.

Interventions:

1. Treat underlying conditions contributing to CHF and unstable BP (CAD, hypertension, etc.).
2. Educate patient on symptoms of hypertension and hypotension and when to seek emergency care.
3. Instruct patient on proper technique for home blood pressure monitoring, including cuff size and positioning.
4. Advise patient to maintain blood pressure logs and share with healthcare team for monitoring treatment effectiveness.

References

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