Nursing Diagnosis for Cardiac Patients: Comprehensive Guide for Heart Failure

What is Heart Failure?

Heart failure (HF), also known as Congestive Heart Failure (CHF), is a clinical syndrome where the heart is unable to pump an adequate supply of blood to meet the body’s metabolic demands. This condition arises from structural or functional impairments that affect ventricular filling or blood ejection. It’s crucial to understand that heart failure isn’t a disease in itself, but rather a consequence of underlying cardiac issues.

Heart failure often stems from systolic or diastolic dysfunction of the left ventricle. The heart’s ability to manage normal blood volume is compromised, either due to intrinsic disease or structural abnormalities. Even without pre-existing conditions, the heart may struggle to cope with sudden increases in blood volume. Conditions like chronic hypertension, coronary artery disease, and valvular disease are common culprits leading to heart failure. This progressive, chronic condition necessitates significant lifestyle adjustments and ongoing medical management to improve the patient’s quality of life.

Clinically, heart failure presents as a syndrome marked by volume overload, inadequate tissue perfusion, and reduced exercise tolerance. Regardless of the underlying cause, pump failure leads to hypoperfusion of tissues, subsequently causing pulmonary and systemic venous congestion.

Clinical Manifestations

Heart failure can affect the left, right, or both sides of the heart, although it typically begins on the left side. The symptoms vary depending on which ventricle is primarily affected.

Left-Sided Heart Failure

• Dyspnea on exertion (shortness of breath during activity)
• Pulmonary congestion, indicated by pulmonary crackles (abnormal lung sounds)
• Persistent cough, initially dry and nonproductive
• Frothy sputum, sometimes blood-tinged
• Inadequate tissue perfusion
• Weak, thready pulse
• Tachycardia (rapid heart rate)
• Oliguria (decreased urine output), nocturia (frequent urination at night)
• Fatigue

Right-Sided Heart Failure

• Congestion of visceral and peripheral tissues
• Edema (swelling) in the lower extremities
• Hepatomegaly (enlarged liver)
• Ascites (fluid accumulation in the abdomen)
• Anorexia (loss of appetite), nausea
• General weakness
• Weight gain due to fluid retention

While “congestive heart failure” highlights the vascular congestion associated with the condition, cardiac specialists often prefer terms like chronic heart failure, cardiac decompensation, cardiac insufficiency, or ventricular failure to describe this syndrome.

Nursing Care Plans & Management

Nurses play a vital role in improving the outcomes for patients with heart failure. Through comprehensive education and diligent monitoring, nurses can significantly impact patient adherence to treatment plans and facilitate early detection of complications. This proactive approach is essential in managing heart failure, a condition with high morbidity and mortality rates. Empowering patients with knowledge enhances their self-management capabilities, while vigilant monitoring ensures timely interventions, ultimately reducing risks and improving patient outcomes.

Nursing Problem Priorities

The primary nursing priorities for patients with congestive heart failure are focused on managing the complex symptoms and improving overall cardiac function.

Nursing Assessment

A thorough nursing assessment is paramount in managing heart failure. It focuses on evaluating the effectiveness of current treatments and the patient’s adherence to self-management strategies. Crucially, nurses monitor for and report any worsening signs and symptoms of heart failure, which informs necessary adjustments to the patient’s therapy. Beyond the physical aspects, nursing assessment also addresses the patient’s emotional well-being. Heart failure, being a chronic condition, is often linked to depression and various psychosocial challenges.

Health History

• Document any signs and symptoms reported by the patient, such as dyspnea, shortness of breath, fatigue, and edema.
• Inquire about sleep disturbances, particularly instances where sleep is suddenly interrupted by shortness of breath, which could indicate paroxysmal nocturnal dyspnea.
• Assess the patient’s understanding of heart failure, their knowledge of self-management strategies, and their willingness and ability to adhere to these strategies.

Physical Examination

• Auscultate the lungs to detect the presence of crackles or wheezes, indicative of pulmonary congestion.
• Listen to heart sounds to identify an S3 heart sound, a potential sign of increased ventricular volume and heart failure.
• Assess for Jugular Vein Distention (JVD), which can indicate elevated central venous pressure.
• Evaluate the patient’s sensorium and level of consciousness to detect any changes related to decreased cerebral perfusion.
• Examine dependent body parts for edema and assess tissue perfusion.
• Assess the liver for hepatojugular reflux, a sign of right-sided heart failure.
• Measure and carefully document urinary output to establish a baseline for evaluating the effectiveness of diuretic therapy.
• Monitor the patient’s weight daily, both in the hospital and at home, to track fluid balance.

Assess for the following subjective and objective data:

• Increased heart rate (tachycardia)
• ECG changes (arrhythmias, ischemia)
• Blood pressure variations (hypotension or hypertension)
• Extra heart sounds (S3, S4)
• Decreased urine output (oliguria)
• Diminished peripheral pulses
• Orthopnea (shortness of breath when lying down)
• Crackles in the lungs
• Jugular vein distention
• Edema
• Chest pain
• Weakness
• Fatigue
• Changes in vital signs
• Presence of dysrhythmias
• Dyspnea
• Pallor (pale skin)
• Diaphoresis (excessive sweating)
• Weight gain
• Respiratory distress
• Abnormal breath sounds

Assess for factors related to the cause of congestive heart failure:

• Altered circulation
• Altered myocardial contractility/inotropic changes
• Alterations in heart rate, rhythm, or electrical conduction
• Decreased cardiac output
• Structural heart changes (e.g., valvular defects, ventricular aneurysm)
• Poor cardiac reserve
• Medication side effects
• Imbalance between oxygen supply and demand
• Prolonged bed rest and immobility
• Reduced glomerular filtration rate (due to decreased cardiac output) and increased antidiuretic hormone (ADH) production, leading to sodium and water retention.
• Changes in glomerular filtration rate
• Use of diuretics
• Lack of understanding about heart failure
• Misconceptions about the interconnectedness of cardiac function, disease, and failure
• Invasive procedures
• Prolonged hospitalization
• Alveolar edema secondary to increased ventricular pressure
• Retained secretions
• Increased metabolic rate secondary to conditions like pneumonia

heart failure

Common Nursing Diagnoses for Cardiac Patients with Heart Failure

Following a comprehensive assessment, nurses formulate nursing diagnoses to specifically address the challenges associated with heart failure. These diagnoses are based on clinical judgment and a deep understanding of the patient’s unique health condition. While nursing diagnoses provide a structured framework for organizing care, their direct application can vary in different clinical settings. In practice, a nurse’s clinical expertise and judgment are paramount in shaping a patient-centered care plan that prioritizes individual health concerns and needs.

However, for educational purposes and standardized care planning, common nursing diagnoses for cardiac patients with heart failure include:

• Decreased Cardiac Output related to impaired myocardial function as evidenced by fatigue, dyspnea, and abnormal heart rate or blood pressure.
• Risk for Ineffective Health Maintenance related to a lack of knowledge regarding diagnostic and laboratory procedures necessary for monitoring heart failure status.
• Impaired Gas Exchange related to fluid overload and pulmonary congestion as evidenced by orthopnea, paroxysmal nocturnal dyspnea, and hypoxemia.
• Excess Fluid Volume related to compromised heart function and renal perfusion as evidenced by peripheral edema, ascites, and weight gain.
• Acute Pain related to decreased myocardial oxygenation as evidenced by reports of chest pain or discomfort exacerbated by physical exertion or stress.
• Ineffective Tissue Perfusion (Cardiopulmonary) related to decreased cardiac output as evidenced by altered mental status, cool and clammy skin, and decreased urine output.
• Imbalanced Nutrition: Less Than Body Requirements related to dietary restrictions and fluid management in heart failure as evidenced by confusion about low-sodium diet recommendations and fluid intake limits.
• Activity Intolerance related to an imbalance between oxygen supply and demand as evidenced by reports of fatigue, dyspnea on exertion, and decreased endurance.
• Anxiety related to changes in health status and uncertainty about the future due to a heart failure diagnosis as evidenced by verbalization of worries, restlessness, frequent questions about prognosis, and concerns regarding the impact of illness on family roles and responsibilities.

Nursing Goals

The major goals in nursing care for patients with heart failure encompass promoting physical activity within limitations, reducing fatigue, alleviating symptoms of fluid overload, managing anxiety, empowering patients in decision-making, and providing comprehensive health education to both the patient and their family.

Specific goals and expected outcomes may include:

• The patient will demonstrate optimal cardiac output, indicated by vital signs within acceptable ranges, absence or control of dysrhythmias, and absence of heart failure symptoms.
• The patient will engage in activities that minimize cardiac workload.
• The patient will actively participate in desired activities and meet their self-care needs.
• The patient will maintain stable fluid volume, evidenced by balanced intake and output, clear breath sounds, stable vital signs, stable weight, and absence of edema.
• The patient will verbalize understanding of individual dietary and fluid restrictions.
• The patient will prioritize maintaining skin integrity.
• The patient will effectively manage pain.
• The patient will identify strategies to reduce anxiety.
• The patient will demonstrate improved concentration.
• The patient will actively participate in their treatment regimen based on their abilities and situation.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with congestive heart failure are multifaceted and aim to address the various challenges posed by this condition.

1. Initiating Interventions for Decreased Cardiac Output

Decreased cardiac output is a central problem in heart failure, stemming from the heart muscle’s weakened ability to contract and relax effectively. Addressing this issue is paramount in preventing disease progression and minimizing complications.

Nursing Diagnosis: Decreased Cardiac Output related to impaired myocardial function.

Nursing Interventions:

1. Auscultate apical pulse and assess heart rate. Tachycardia is an early compensatory mechanism for reduced cardiac output. Persistent tachycardia, however, is detrimental and can worsen heart failure. Heart rate control is crucial for better clinical outcomes.
2. Obtain a comprehensive health history, focusing on heart failure symptoms and self-management strategies to understand the patient’s baseline and adherence.
3. Note heart sounds. An S3 heart sound may indicate increased ventricular volume and worsening heart failure. Weak S1 and S2 sounds can reflect decreased pumping action.
4. Assess rhythm and document dysrhythmias if telemetry is available. Dysrhythmias are common in heart failure due to myocardial changes. Atrial fibrillation is particularly prevalent and increases with heart failure severity.
5. Assess for palpitations or irregular heartbeat. These can be indicative of dysrhythmias, often atrial fibrillation, which is common in heart failure.
6. Palpate peripheral pulses. Diminished pulses can indicate decreased cardiac output and poor peripheral perfusion.
7. Monitor blood pressure (BP). Elevated BP may be present in acute heart failure due to increased systemic vascular resistance. BP monitoring guides interventions and medication adjustments.
8. Inspect the skin for mottling. Mottling, a bluish or grayish skin discoloration, can indicate poor peripheral perfusion due to low cardiac output.
9. Inspect the skin for pallor or cyanosis. Cool, clammy skin, pallor, or cyanosis are signs of diminished perfusion and hypoperfusion.
10. Monitor urine output, noting decreases and concentration. Reduced urine output can be due to decreased renal perfusion and fluid retention.
11. Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression. Cerebral hypoperfusion due to decreased cardiac output can lead to neurological changes. Depression is also common in heart failure and can negatively impact treatment adherence.
12. Evaluate the patient’s level of consciousness for changes indicating decreased cerebral perfusion.
13. Examine lower extremities for edema and rate its severity. Edema is a hallmark of heart failure and reflects fluid status.
14. Assess the abdomen for tenderness, hepatomegaly, and signs of ascites. These findings can indicate complications like hepatic congestion and ascites.
15. Assess jugular vein distention (JVD) to estimate central venous pressure and identify right ventricular failure.
16. Monitor results of laboratory and diagnostic tests to determine the underlying cause of heart failure and the patient’s response to treatment.
17. Monitor oxygen saturation and ABGs. Baseline oxygen saturation helps establish the diagnosis and severity of heart failure.
18. Administer oxygen as indicated by symptoms, oxygen saturation, and ABGs to increase oxygen availability to the myocardium and relieve hypoxemia.
19. Provide a restful environment and encourage periods of rest and sleep to reduce cardiac workload and oxygen demand.
20. Encourage rest, in a semirecumbent position to improve cardiac contraction efficiency and decrease myocardial oxygen demand.
21. Provide a quiet environment to reduce emotional stress, which can elevate BP and heart rate.
22. Assist the patient in assuming a high Fowler’s position to improve chest expansion and reduce venous return.
23. Check for calf tenderness, diminished pedal pulses, swelling, local redness, or pallor of extremity. To monitor for thrombophlebitis risk due to bed rest and reduced cardiac output.
24. Elevate legs, avoiding pressure under the knee to decrease venous return and preload.
25. Reposition patient every two (2) hours to prevent pressure ulcers, especially in edematous areas.
26. Provide bedside commode and stool softeners. To prevent vasovagal responses from straining during defecation.
27. Encourage active and passive exercises and increase activity as tolerated to maintain physical function.
28. Administer medications as indicated, including diuretics, vasodilators, ACE inhibitors, beta-blockers, and digoxin.
29. Withhold digitalis preparation as indicated, and notify the physician of changes in cardiac rate or rhythm or signs of digitalis toxicity due to its narrow therapeutic range.
30. Administer IV solutions, restricting total amount as indicated. Avoid saline solutions to prevent fluid overload.
31. Monitor for signs and symptoms of fluid and electrolyte imbalances due to fluid shifts and diuretic use.
32. Monitor serial electrocardiogram (ECG) and chest x-ray changes to assess for underlying causes of heart failure and pulmonary congestion.
33. Measure cardiac output and other functional parameters as indicated to determine the effectiveness of therapeutic interventions.
34. Prepare for insertion and maintenance of pacemaker, if indicated to correct bradydysrhythmias.
35. Assist with mechanical circulatory support systems, such as VAD as a bridge to transplant or destination therapy.
36. Recognize that some patients may need an intra-aortic balloon pump (IABP) for temporary support in critical cases.
37. Withhold digitalis preparation as indicated, and notify the physician of changes in cardiac rate or rhythm or signs of digitalis toxicity.
38. Administer IV solutions, restricting total amount as indicated. Avoid saline solutions to prevent fluid overload.
39. Monitor for signs and symptoms of fluid and electrolyte imbalances.
40. Measure cardiac output and other functional parameters as indicated.

2. Monitoring Diagnostic Procedures and Laboratory Studies

Regular monitoring of diagnostic procedures and laboratory values is crucial for assessing the severity and progression of heart failure, guiding treatment decisions, and tracking the patient’s response to therapy.

1. Blood urea nitrogen (BUN) and creatinine. Elevated levels indicate decreased renal perfusion, which can be caused by heart failure or medications.
2. Liver function studies (AST, LDH). Abnormalities may indicate liver congestion due to heart failure.
3. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) coagulation studies. To assess clotting risk and monitor anticoagulant therapy.
4. Atrial natriuretic peptide (ANP). Elevated in congestive heart failure due to increased atrial pressure.
5. Beta-type natriuretic peptide (BNP). Elevated BNP levels correlate with ventricular volume and fluid overload, increasing with worsening heart failure.
6. Electrocardiogram (ECG). Can reveal underlying causes of heart failure, such as ischemia or arrhythmias.
7. Echocardiogram. Provides detailed images of heart structure and function, including ejection fraction, chamber size, and valve function.
8. Cardiac stress test. Evaluates the heart’s response to exertion, identifying exercise capacity and potential coronary artery blockages.
9. Complete blood count (CBC). Detects anemia, infection, or other blood abnormalities that can affect heart failure management.
10. Kidney function tests. Serum creatinine and BUN assess kidney function, which is often impaired in heart failure.
11. Electrolyte levels. Sodium, potassium, and magnesium imbalances can affect heart rhythm and cardiac function.
12. Chest X-ray. May show cardiomegaly (enlarged heart) and pulmonary congestion.

3. Administering Medication and Providing Pharmacological Interventions

Pharmacological interventions are essential for managing heart failure symptoms, improving cardiac function, and preventing disease progression.

1. Diuretics. First-line drugs for managing fluid overload in heart failure. They reduce blood volume, venous pressure, and edema.

   • Thiazide Diuretics (Hydrochlorothiazide): For long-term therapy in moderate edema.
   • Loop Diuretics (Furosemide): Preferred for severe heart failure and effective even with low GFR.
   • Potassium-Sparing Diuretics (Spironolactone): Counteract potassium loss from other diuretics.

   Nursing interventions for patients taking diuretics include:

   • Monitor weight daily.
   • Monitor intake and output.
   • Assess for edema.
   • Auscultate lungs for crackles.
   • Monitor electrolyte levels, especially potassium.
   • Administer diuretics in the morning to avoid nocturia.
   • Educate patients about the medication’s purpose, side effects, and the importance of adherence.

2. Vasodilators, arterial dilators, and combination drugs. Reduce ventricular workload by increasing cardiac output, reducing circulating volume, and decreasing systemic vascular resistance.

   • Isosorbide dinitrate (ISDN): Dilates veins, reducing congestive symptoms.
   • Hydralazine: Dilates arterioles, improving cardiac output and renal blood flow. Often used with ISDN (BiDil).
   • Nitroglycerin (IV): Powerful venodilator for acute pulmonary edema.
   • Sodium nitroprusside (Nitropress): Rapidly dilates arterioles and veins. Requires continuous BP monitoring.
   • Nesiritide: Balanced vasodilator, reducing ventricular filling pressures and increasing cardiac output.

3. Angiotensin-converting Enzyme Inhibitors (ACE Inhibitors). Block the renin-angiotensin-aldosterone system (RAAS), decreasing mortality, morbidity, and hospitalizations.

   • Examples: benazepril, captopril, lisinopril, enalapril.

   Nursing interventions for patients taking ACE inhibitors include:

   • Monitor vital signs, especially BP, before and after administration.
   • Monitor serum potassium levels regularly.
   • Educate patients about medication adherence and follow-up appointments.
   • Assess for dry, persistent cough and report to the provider.
   • Monitor for signs of angioedema and report immediately.
   • Collaborate with the provider to adjust dosage based on patient status.

4. Angiotensin II receptor blockers (ARBs). Used for patients intolerant to ACE inhibitors. Similar effects and monitoring as ACE inhibitors.

   • Examples: eprosartan, irbesartan, valsartan.

5. Cardiac glycosides (Digitalis – Digoxin). Increase myocardial contractile force and cardiac output. Second-line agent for heart failure, mainly for symptom control and preventing hospital readmissions.

   • Monitor renal function and serum potassium levels.
   • Assess for digoxin toxicity: anorexia, nausea, visual disturbances, confusion, bradycardia.
   • Educate patients about toxicity signs and medication adherence.

6. Inotropic agents. Short-term IV treatment for acute heart failure unresponsive to other medications. Increase myocardial contractility and cause vasodilation.

   • Examples: dobutamine, milrinone.

   Nursing interventions for patients taking inotropic agents include:

   • Administer IV inotropes to hospitalized patients with acute decompensated heart failure.
   • Monitor blood pressure closely before and during milrinone administration.
   • Monitor BP, ECG, and cardiac rhythm during and after milrinone infusions.
   • Administer dobutamine to patients with significant left ventricular dysfunction.
   • Monitor heart rate and rhythm closely during dobutamine administration.
   • Monitor and document hemodynamic data.
   • Assess the need for continuous IV inotropic therapy at home for end-stage heart failure patients.

7. Beta-Blockers: Beta-adrenergic receptor antagonists. First-line therapy to block adverse effects of the sympathetic nervous system, leading to vasodilation and reduced cardiac workload.

   • Examples: carvedilol, bisoprolol, metoprolol.

   Nursing interventions for patients taking beta-blockers include:

   • Monitor vital signs, especially BP and heart rate, before and after administration.
   • Educate patients about gradual dosage titration and delayed therapeutic effects.
   • Assess and document patient response and side effects.
   • Provide support for side effects during initial treatment phase.
   • Assess respiratory status, especially in patients with bronchospastic diseases.
   • Document and report any significant cardiovascular or respiratory changes.

8. Morphine sulfate. Reduces vascular resistance and venous return, decreasing myocardial workload, particularly with pulmonary congestion. Reserved for patients with myocardial ischemia refractory to other drugs.

9. Antianxiety agents and sedatives. Promote rest, reduce oxygen demand and myocardial workload.

10. Anticoagulants. For patients with atrial fibrillation or thromboembolic events. Prevent thrombus and embolus formation.

    • Examples: heparin, warfarin.
    • Monitor INR and PT for warfarin.

11. Bronchodilators: aminophylline. Increase oxygen delivery by dilating airways and exert mild diuretic effect.

4. Maintaining or Improving Respiratory Function

Respiratory function is often compromised in heart failure due to fluid accumulation in the lungs. Nursing interventions are crucial to optimize breathing and oxygenation.

Nursing Diagnosis: Impaired Gas Exchange related to fluid overload and pulmonary congestion.

Nursing Interventions:

1. Assess respiratory rate, use of accessory muscles, signs of air hunger, lung excursion, cyanosis, and vital signs. These parameters indicate respiratory status and the severity of pulmonary congestion.
2. Auscultate breath sounds, noting crackles and wheezes, which indicate pulmonary congestion and secretions.
3. Monitor oxygen saturation and ABG findings to detect hypoxemia.
4. Observe skin color, mucous membranes, and nail beds for cyanosis.
5. Monitor potassium levels as hypokalemia can occur with diuretics.
6. Instruct patient in effective coughing and deep breathing to clear airways and improve oxygen delivery.
7. Encourage frequent position changes to prevent atelectasis and pneumonia.
8. Position the patient in a High Fowler’s position to promote maximal inspiration and reduce pulmonary congestion.
9. Suction secretions PRN to clear airway obstruction.
10. Graph serial ABGs and pulse oximetry to track oxygenation status.
11. Administer supplemental oxygen as indicated to maintain oxygen saturation above 92%.
12. Administer medications as indicated, including diuretics, vasodilators, and bronchodilators.
13. Assist patient to use relaxation techniques to reduce muscle tension and the work of breathing.

5. Managing Fluid Volume and Electrolyte Imbalance

Fluid management is critical in heart failure. Nursing interventions focus on maintaining fluid balance, preventing overload, and addressing electrolyte imbalances.

Nursing Diagnosis: Excess Fluid Volume related to compromised heart function and renal perfusion.

Nursing Interventions:

1. Monitor urine output, noting amount, color, and timing of diuresis.
2. Monitor and calculate 24-hour intake and output (I&O) balance.
3. Maintain chair or bed rest in semi-Fowler’s position to reduce venous return and pulmonary congestion.
4. Establish a fluid intake schedule if fluids are medically restricted. Provide frequent mouth care.
5. Weigh daily. Frequently monitor BUN, creatinine, and serum electrolytes (potassium, sodium, chloride, magnesium).
6. Assess for distended neck and peripheral vessels. Inspect dependent areas for edema and note generalized edema (anasarca).
7. Auscultate breath sounds, noting adventitious sounds and signs of pulmonary congestion.
8. Investigate reports of sudden extreme dyspnea and air hunger as they may indicate pulmonary edema or embolus.
9. Administer oral diuretics in the morning.
10. Monitor fluid status closely, including lung sounds and daily weights.
11. Promote adherence to a low-sodium diet.
12. Plan fluid intake throughout the day if fluid restriction is needed.
13. Monitor IV fluids and consult with providers to minimize fluid volume.
14. Position the patient for optimal breathing in High Fowler’s position.
15. Assess for and prevent pressure ulcers, especially in edematous areas.
16. Monitor BP and central venous pressure (CVP) to assess fluid volume status.
17. Assess bowel sounds. Note anorexia, nausea, abdominal distension, constipation, indicating visceral congestion.
18. Obtain patient history to ascertain the cause of fluid disturbance.
19. Monitor for distended neck veins and ascites indicating fluid overload.
20. Evaluate urine output in response to diuretic therapy.
21. Assess the need for an indwelling urinary catheter for accurate output monitoring.
22. Auscultate breath sounds q 2hr and pm for crackles and monitor for frothy sputum.
23. Assess for peripheral edema. Do not elevate legs if the client is dyspneic.
24. Measure abdominal girth, as indicated for ascites.
25. Palpate abdomen. Note right upper quadrant pain and tenderness for liver engorgement.
26. Encourage verbalization of feelings regarding limitations.
27. Weigh the patient daily and compare to previous measurement.
28. Follow a low-sodium diet and/or fluid restriction.
29. Encourage or provide oral care q2 for dry mouth due to fluid restriction.
30. Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding. To prevent pressure ulcers.
31. Provide small, frequent, easily digestible meals for reduced gastric motility.
32. Institute/instruct patient regarding fluid restrictions as appropriate.
33. Administer medications as indicated, especially diuretics and electrolytes.
34. Maintain fluid and sodium restrictions as indicated.
35. Consult with a dietitian for dietary planning.
36. Monitor chest x-ray for resolution of pulmonary congestion.
37. Assist with rotating tourniquets and/or phlebotomy, dialysis, or ultrafiltration as indicated for severe fluid overload.

6. Providing Perioperative Nursing Care

Patients with heart failure undergoing surgery require specialized perioperative care to minimize risks and optimize outcomes.

Surgical procedures for heart failure include:

1. Coronary artery bypass graft (CABG) surgery. Nursing interventions: monitor vital signs, pain management, bleeding/infection monitoring, respiratory support, patient education.
2. Heart valve replacement surgery. Nursing interventions: monitor vital signs, cardiac function, medication administration, bleeding/infection monitoring, respiratory support, patient education.
3. Angioplasty. Nursing interventions: informed consent, patient preparation, procedural assistance, vital sign monitoring, documentation, post-procedure care instructions.
4. Cardiomyoplasty. Experimental procedure with limited benefit and not generally recommended.
5. Transmyocardial revascularization. Newer surgical technique using laser technology.
6. Pacemaker insertion and maintenance. For bradydysrhythmias.
7. Ventricular assist device (VAD) placement. Mechanical circulatory support.
8. Intra-aortic balloon pump (IABP). Temporary circulatory support in critical cases.

7. Managing Acute Pain and Discomfort

Heart failure can cause chest pain (angina) and other discomforts. Pain management is essential for patient comfort and reducing cardiac workload.

Nursing Diagnosis: Acute Pain related to decreased myocardial oxygenation.

Nursing Interventions:

1. Assess patient pain for intensity, location, and precipitating factors using a pain scale.
2. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
3. Assess the response to medications every 5 minutes to determine effectiveness.
4. Administer or assist with self-administration of vasodilators (nitroglycerin) as ordered.
5. Provide comfort measures such as positioning and relaxation techniques.
6. Establish a quiet environment to reduce energy demands.
7. Elevate the head of the bed to improve chest expansion.
8. Teach patient relaxation techniques to reduce stress and pain.
9. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.

8. Promoting Adequate Tissue Perfusion and Managing Decreased Cardiac Tissue Perfusion

Adequate tissue perfusion is vital. Nursing interventions aim to optimize blood flow and oxygen delivery to tissues.

Nursing Diagnosis: Ineffective Tissue Perfusion (Cardiopulmonary) related to decreased cardiac output.

Nursing Interventions:

1. Assess patient pain for intensity, location, and precipitating factors.
2. Monitor vital signs, especially blood pressure every 15 minutes or more frequently if unstable, watching for hypotension.
3. Assess extremities for color, temperature, capillary refill, pulse presence, and amplitude.
4. Assess cardiac and circulatory status to establish baseline and detect changes.
5. Assess changes in mental status for signs of reduced cerebral perfusion.
6. Assess the response to medications every 5 minutes to evaluate effectiveness.
7. Assess results of cardiac markers to rule out myocardial infarction.
8. Monitor cardiac rhythms on patient monitor and ECG.
9. Administer or assist with self-administration of vasodilators (nitroglycerin).
10. Give beta-blockers as ordered to decrease myocardial oxygen consumption.
11. Establish a quiet environment to reduce energy demands.
12. Elevate the head of the bed to improve oxygenation.
13. Provide oxygen and monitor oxygen saturation via pulse oximetry as ordered.
14. Teach the patient relaxation techniques to reduce stress.
15. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
16. Reposition the patient every 2 hours to prevent bedsores.
17. Instruct patient on eating small frequent feedings to prevent heartburn.

9. Promoting Optimal Nutritional Balance and Adherence to Low-Sodium Diet

Nutritional management, particularly a low-sodium diet, is crucial in heart failure to manage fluid retention and symptoms.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements or Imbalanced Nutrition: More Than Body Requirements related to dietary choices and heart failure needs.

Nursing Interventions:

1. Assess the patient’s ability to comply with dietary sodium restriction considering preferences, culture, and nutritional needs.
2. Educate the patient about the importance of a low-sodium diet (no more than 2 g/day).
3. Monitor the patient’s adherence to the low-sodium diet and assess for dietary indiscretions.
4. Involve family members in supporting the patient’s adherence to the low-sodium diet.
5. Collaborate with a dietitian or nutritionist for comprehensive nutritional guidance.
6. Evaluate the patient’s response to the low-sodium diet, including symptom resolution and weight management.

10. Maintaining Skin Integrity & Preventing Pressure Ulcers

Patients with heart failure are at increased risk for skin breakdown due to edema, impaired circulation, and immobility.

Nursing Diagnosis: Risk for Impaired Skin Integrity related to edema, immobility, and poor circulation.

Nursing Interventions:

1. Inspect skin, noting skeletal prominences, edema, altered circulation, obesity/emaciation.
2. Check the fit of shoes and slippers and change as needed due to edema.
3. Provide gentle massage around reddened or blanched areas to improve blood flow.
4. Encourage frequent position changes and assist with active and passive ROM exercises to reduce pressure and improve circulation.
5. Provide frequent skincare: minimize moisture and excretions.
6. Avoid intramuscular route for medication due to edema and impaired circulation.
7. Provide alternating pressure, egg-crate mattress, sheepskin elbow, and heel protectors to reduce pressure.

11. Managing Decreased Tolerance to Activity and Fatigue

Activity intolerance and fatigue are common in heart failure. Nursing interventions focus on promoting safe activity and managing fatigue.

Nursing Diagnosis: Activity Intolerance related to imbalance between oxygen supply and demand.

Nursing Interventions:

1. Check vital signs before and immediately after activity, especially if the patient receives vasodilators, diuretics, or beta-blockers, monitoring for orthostatic hypotension.
2. Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, and pallor.
3. Assess for other causes of fatigue (treatments, pain, medications).
4. Identify factors that could affect activity level and motivation.
5. Monitor and evaluate the patient’s response to activities.
6. Consider the use of the 6-minute walk test (6MWT) to determine physical ability.
7. Assist in identifying and overcoming barriers to physical activity.
8. Encourage daily physical activity within tolerance.
9. Collaborate with the provider and patient to develop a personalized exercise schedule.
10. Provide guidelines for safe physical activity. Start slow and low.
11. Evaluate accelerating activity intolerance as it may denote cardiac decompensation.
12. Promote adherence to exercise training, consider cardiac rehabilitation referral.
13. Assist with self-care activities as necessary. Encourage independence within prescribed limits.
14. Slow the pace of care and provide adequate rest before and after exertion.
15. Organize nursing care activities to allow rest periods.
16. Implement a graded cardiac rehabilitation program.
17. Adjust daily activities and reduce intensity level. Discontinue activities causing undesired changes.
18. Encourage adequate bed rest and sleep; provide a calm and quiet environment.
19. Initiate interventions and safeguards to promote safety and prevent risk for injury during activity.
20. Encourage the client to maintain a positive attitude; provide evidence of progress.

12. Reducing Anxiety, Fear and Improving Coping

Anxiety and fear are common emotional responses to heart failure. Nursing interventions aim to provide support and improve coping mechanisms.

Nursing Diagnosis: Anxiety related to changes in health status and uncertainty about prognosis.

Nursing Interventions:

1. Assess for restlessness and anxiety as potential indicators of hypoxia from pulmonary congestion.
2. Promote physical comfort and provide psychological support.
3. Assess physical reactions to anxiety.
4. Administer oxygen during acute events.
5. Validate observations by asking the patient, “Are you feeling anxious now?”
6. Recognize awareness of the patient’s anxiety.
7. Interact with patients in a calm, peaceful manner.
8. Encourage the patient to express fears, feelings regarding the condition.
9. Identify present and past measures that the patient uses to cope with fear.
10. Assess for factors contributing to a sense of powerlessness.
11. Assess for feelings of apathy, hopelessness, and depression.
12. Evaluate the patient’s decision-making competence.
13. Know situations/interactions that may add to the patient’s sense of powerlessness.
14. Appraise the impact of powerlessness on the patient’s physical condition.
15. Assess the role illness plays in the patient’s sense of powerlessness.
16. Evaluate the results of the information given on the patient’s feelings and behavior.
17. Encourage a calm and quiet environment.
18. Familiarize patients with the environment and new experiences or people as needed.
19. Administer oxygen during the acute stage.
20. When the patient displays anxiety, promote physical comfort and psychological support.
21. Converse using simple language and brief statements.
22. When the patient is comfortable, teach ways to control anxiety and avoid anxiety-provoking situations.
23. Assist in identifying factors that contribute to anxiety.
24. Help patient determine precipitants of anxiety that may indicate interventions.
25. Screen for depression, which often accompanies or results from anxiety.
26. Allow the patient to talk about anxious feelings and examine anxiety-provoking situations.
27. Assist the patient in developing new anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization).
28. Avoid unnecessary reassurance; this may increase undue worry.
29. Intervene when possible to eliminate sources of anxiety.
30. Explain all activities, procedures, and issues that involve the patient; use non-medical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the patient’s understanding.
31. Educate patient and family about the symptoms of anxiety.
32. Teach patients to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of the procedure.
33. Maintain a relaxed and accepting demeanor while communicating with the patient.
34. Use simple language and easy-to-understand statements regarding diagnostic procedures and treatment regimens.
35. Provide patients and significant others with emotional support.
36. Allow the patient to have rest periods.
37. Listen actively to patients often.
38. Encourage the patient to identify strengths.
39. Provide the patient with decision-making opportunities with increasing frequency and significance.
40. Help the patient in reexamining negative perceptions of the situation.
41. Provide encouragement and praise while identifying the patient’s progress.
42. Assist the patient in differentiating between factors that can be controlled and those that cannot.
43. Avoid using coercive power when approaching the patient.
44. Eliminate the unpredictability of events by allowing adequate preparation for tests or procedures.
45. Support in planning and creating a timetable to manage increased responsibility in the future.
46. Provide safety measures within the home when indicated (e.g., alarm system, safety devices in showers, bathtubs).

13. Initiating Health Teaching and Patient Education

Patient education is crucial for adherence to treatment regimens and improving long-term outcomes in heart failure.

Nursing Diagnosis: Deficient Knowledge related to heart failure management and self-care.

Nursing Interventions:

1. Discuss normal heart function and explain the patient’s variance from normal function, differentiating between heart attack and heart failure.
2. Reinforce treatment rationale. Include significant others in teaching, especially for complex regimens like home dobutamine therapy.
3. Encourage developing a regular home exercise program, and provide guidelines for sexual activity.
4. Discuss the importance of being as active as possible without exhaustion and rest between activities.
5. Discuss the importance of sodium limitation. Provide a list of high-sodium foods and encourage label reading.
6. Refer to a dietitian for individualized dietary counseling.
7. Review medications, purpose, and side effects. Provide oral and written instructions.
8. Recommend taking diuretics early in the morning.
9. Instruct and receive return demonstration of ability to take and record daily pulse and blood pressure and when to notify the provider.
10. Explain and discuss the patient’s role in controlling risk factors (smoking, unhealthy diet) and aggravating factors (high-salt diet, inactivity, overexertion, temperature extremes).
11. Review signs and symptoms that require immediate medical attention: rapid weight gain, edema, shortness of breath, increased fatigue, cough, hemoptysis, fever.
12. Provide opportunities for patients and significant others to ask questions, discuss concerns, and make lifestyle changes.
13. Discuss general health risks (such as infection) and recommend avoidance of crowds, influenza and pneumonia immunizations.
14. Stress the importance of reporting signs and symptoms of digitalis toxicity.
15. Identify community resources and support groups and visiting home health nurses as indicated.
16. Discuss the importance of advance directives and communicating wishes to family and providers.
17. Assess patients with underlying coronary artery disease for coronary artery revascularization.
18. Identify high-risk patients for life-threatening dysrhythmias and consider ICD placement.
19. Evaluate patients not responding to standard therapy for cardiac resynchronization therapy (CRT).
20. Monitor patients receiving ultrafiltration for severe fluid overload.
21. Consider referral for cardiac transplantation in end-stage heart failure patients.
22. Provide nursing surveillance for older male patients receiving diuretics to monitor for bladder distention.
23. Address the unique symptoms and challenges of older adults with heart failure.

Evaluation

Patient outcomes are evaluated based on:

• Demonstrated tolerance for increased activity.
• Maintenance of fluid balance.
• Reduced anxiety.
• Sound decision-making regarding care and treatment.
• Adherence to self-care regimen.

Discharge and Home Care Guidelines

• Patient education. Comprehensive teaching on medication management, low-sodium diets, activity recommendations, smoking cessation, and recognizing worsening heart failure symptoms.
• Encourage questions for clarification and enhanced understanding.

Discharge Goals

• Cardiac output adequate for individual needs.
• Complications prevented or resolved.
• Optimum level of activity and functioning attained.
• Disease process, prognosis, and therapeutic regimen understood.
• Plan in place to meet needs after discharge.

Documentation Guidelines

• Assessment findings.
• Intake & Output fluid balance.
• Degree of fluid retention.
• Results of laboratory tests and diagnostic studies.
• Response to interventions, teachings, and actions performed.
• Progress toward desired outcomes.

Recommended Resources

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health

See Also

Other nursing care plans for cardiovascular system disorders.

References and Sources

First published on July 14, 2013.