10 Congestive Heart Failure Nursing Care Plans

Assessment

Planning

Nursing Interventions

Rationale

Evaluation

• with pale conjunctiva, nail beds and buccal mucosa
• irregular rhythm of pulse
• bradycardic
• pulse rate of 34 beats/min
• generalized weakness

1. Assess for abnormal heart and lung sounds.
2. Monitor blood pressure and pulse.
3. Assess mental status and level of consciousness.
4. Assess patient’s skin temperature and peripheral pulses.
5. Monitor results of laboratory and diagnostic tests.
6. Monitor oxygen saturation and ABGs.
7. Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
8. Implement strategies to treat fluid and electrolyte imbalances.
9. Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.
10. Encourage periods of rest and assist with all activities.
11. Assist the patient in assuming a high Fowler’s position.
12. Teach patient the pathophysiology of disease, medications
13. Reposition patient every 2 hours
14. Instruct patient to get adequate bed rest and sleep
15. Instruct the SO not to leave the client unattended

1. Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.
2. Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.
3. The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
4. Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
5. Results of the test provide clues to the status of the disease and response to treatments.
6. Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
7. Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
8. Decreases the risk for development of cardiac output due to imbalances.
9. Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
10. Reduces cardiac workload and minimizes myocardial oxygen consumption.
11. Allows for better chest expansion, thereby improving pulmonary capacity.
12. Provides the patient with needed information for management of disease and for compliance.
13. To prevent occurrence of bed sores
14. To promote relaxation to the body
15. To ensure safety and reduce risk for falls that may lead to injury

Assessment

Planning

Interventions

Rationale

Evaluation

• Edema on extremities
• DOB
• Crackles heard on both lung fields

Patient may manifest:

• Change in mental status (lethargy or confusion)
• Restlessness and anxiety

1. Establish rapport
2. Monitor and record VS
3. Assess patient’s general condition
4. Monitor I&O every 4 hours
5. Weigh patient daily and compare to previous weights.
6. Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production
7. Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic.
8. Follow low-sodium diet and/or fluid restriction
9. Encourage or provide oral care q2
10. Obtain patient history to ascertain the probable cause of the fluid disturbance.
11. Monitor  for distended neck veins and ascites
12. Evaluate urine output in response to diuretic therapy.
13. Assess the need for an indwelling urinary catheter.
14. Institute/instruct patient regarding fluid restrictions as appropriate.

1. To gain patient’s trust and cooperation
2. To obtain baseline data
3. To determine what approach to use in treatment
4. I&O balance reflects fluid status
5. Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess.
6. When increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema
7. Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular absorption of sodium Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.
8. The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.
9. Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatis pressure exceeds interstitial pressure, fluids leak out of ht ecpaillaries and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart.
10. May include increased fluids or sodium intake, or compromised regulatory mechanisms.
11. Inidicates fluid overload
12. Focus is on monitoring the response to the diuretics, rather than the actual amount voided
13. Treatment focuses on diuresis of excess fluid.
14. This helps reduce extracellular volume.

Assessment

Planning

Interventions

Rationale

Evaluation

• (+) DOB
• with a rate of 7 out of 10
• with complaints of chest pain unprovoked

Patient may manifest:

• Restlessness

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

1. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
2. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
3. Assessing response determines effectiveness of medication and whether further interventions are required.
4. To provide nonpharmacological pain management.
5. A quiet environment reduces the energy demands on the patient.
6. Elevation improves chest expansion and oxygenation.
7. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
8. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
9. In some case
   , the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.

Assessment

Planning

Interventions

Rationale

Evaluation

• with pale conjunctiva, nail beds and buccal mucosa
• (+)chest pain
• (+) DOB
• Generalized weakness
• Abnormal pulse rate and rhythm
• Bradycardic
• Altered BP readings.
• With pitting edema on both forearms and hands
• Bipedal pitting edema

1. Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
2. Administer or assist with self administration of vasodilators, as ordered.
3. Assess the response to medications every 5 minutes.
4. Give beta blockers as ordered.
5. Establish a quiet environment.
6. Elevate head of bed.
7. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
8. Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered.
9. Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by physician.
10. Assess cardiac and circulatory status.
11. Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.
12. Teach patient relaxation techniques and how to use them to reduce stress.
13. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
14. Reposition the patient every 2 hours
15. Instruct patient on eating a small frequent feedings

1. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
2. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
3. Assessing response determines effectiveness of medication and whether further interventions are required.
4. Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.
5. A quiet environment reduces the energy demands on the patient.
6. Elevation improves chest expansion and oxygenation.
7. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
8. Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain.
9. These enzymes elevate in the presence of myocardial infarction at differing times and assist in ruling out a myocardial infarction as the cause of chest pain.
10. Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.
11. Notes abnormal tracings that would indicate ischemia.
12. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
13. In some case
    , the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.
14. To prevent bed sores
15. To prevent heartburn and acid indigestion

Assessment

Planning

Interventions

Rationale

Evaluation

• Pale palpebral
• Conjunctiva and nail beds
• Warm to touch
• Weakness
• Temperature of 38.9 ^oC

Patient may manifest:

• Fluid or electrolyte imbalance
• Diaphoresis
• Hot flushed
• skin

1. Assess vital signs, the temperature.
2. Monitor and record all sources of fluid loss such as urine, vomiting and diarrhea.
3. Performed tepid sponge bath.
4. Maintain bed rest.
5. Remove excess clothing and covers.
6. Increase fluid intake.
7. Provide adequate nutrition, a high caloric diet.
8. Control environmental temperature.
9. Adjust cooling measures on the basis of physical response.
10. Provide information regarding normal temperature and control.
11. Explain all treatments.
12. Administer antipyretics as ordered.
13. Control excessive shivering with medications such as Chlorpromazine and Diazepam if necessary.
14. Provide ample fluids by mouth or intravenously as ordered.
15. Provide oxygen therapy in extreme cases as ordered.

1. Vital signs provide more accurate indication.
2. For potential fluid and electrolyte losses.
3. To promote heat loss by evaporation and conduction.
4. To reduce metabolic demands and oxygen consumption.
5. Decreases warmth and increase evaporative cooling.
6. To prevent dehydration.
7. The meet the metabolic demands.
8. To prevent an increase in body temperature and prevent shivering of the patient.
9. Shivering, which burns calories and increases metabolic rate in order to produce heat.
10. This is especially necessary for patients with conditions at risk for hyperthermia.
11. Patients’ S.O. needs to be oriented.
12. To decrease body temperature.
13. Shivering increases metabolic rate and body temperature.
14. If the patient is dehydrated or diaphoretic, fluid loss contributes to fever.
15. Hyperthermia increases metabolism.

Assessment

Planning

Interventions

Rationale

Evaluation

• weakness
• rales on BLF
• productive cough
• frothy sputum

Patient may manifest:

• pursed lip breathing
• tachypnea

1. establish rapport
2. monitor VS
3. inspect thorax for symmetry of respiratory movement
4. observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory phase and use of accessory muscles
5. measure tidal volume and vital capacity
6. assess emotional response
7. position patient in optimal body alignment in semi- fowler’s position for breathing
8. assist patient to use relaxation techniques

1. to gain comfort feelings form the pt and pts SO
2. to gain baseline data
3. determines adequacy of breathing
4. identifies increased work of breathing
5. indicates volume of air moving in and out of lungs
6. detects use of hyperventilation as a causative factor
7. optimizes diaphragmatic contraction
8. reduces muscle tension, decreases work of breathing
9. facilitates deep breathing

Assessment

Planning

Interventions

Rationale

Evaluation

• generalized weakness
• limited range of motion as observed
• abnormal pulse rate and rhythm
• (+) DOB

1. Establish Rapport
2. Monitor and record Vital Signs
3. Assess patient’s general condition
4. Adjust client’s daily activities and reduce intensity of level. Discontinue  activities that cause undesired psychological changes
5. Instruct client in unfamiliar activities and in alternate ways of conserve energy
6. Encourage patient to have adequate bed rest and sleep
7. Provide the patient with a calm and quiet environment
8. Assist the client in ambulation
9. Note presence of factors that could contribute to fatigue
10. Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
11. Give client information that provides evidence of daily or weekly progress
12. Encourage the client to maintain a positive attitude
13. Assist the client in a semi-fowlers position
14. Elevate the head of the bed
15. Assist the client in learning and demonstrating appropriate safety measures
16. Instruct the SO not to leave the client unattended
17. Provide client with a positive atmosphere
18. Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms

1. To gain clients participation and cooperation in the nurse patient interaction
2. To obtain baseline data
3. To note for any abnormalities and deformities present within the body
4. To prevent strain and overexertion
5. To conserve energy and promote safety
6. to relax the body
7. to provide relaxation
8. to prevent risk for falls that could lead to injury
9. fatigue affects both the client’s actual and perceived ability to participate in activities
10. to determine current status and needs associated with participation in needed or desired activities
11. to sustain motivation of client
12. to enhance sense of well being
13. to promote easy breathing
14. to maintain an open airway
15. to prevent injuries
16. to avoid risk for falls
17. to help minimize frustration and rechannel energy
18. to indicate need to alter activity level

Assessment

Planning

Interventions

Rationale

Evaluation

• with productive cough yellowish in color
• presence of rales upon auscultation
• (+) DOB
• with pale conjunctiva, nail beds and buccal mucosa

1. Monitor and record vital signs.
2. Assess patient’s condition.
3. Monitor respirations and breath sounds, noting rate and sounds.
4. Position head properly
5. Position appropriately and discourage use of oil-based products around nose.
6. Auscultate breath sounds and assess air movement.
7. Encourage deep breathing and coughing exercises
8. Elevate head of bed and encourage frequent position changes.
9. Keep back dry and loosen clothing
10. Observed for signs and symptoms of infection.
11. Instruct patient have adequate rest periods and limit activities to level of activity intolerance.
12. Give expectorants and bronchodilators as ordered.
13. Suction secretions PRN
14. Administer oxygen therapy and other medications as ordered.

1. To obtain baseline data
2. To know the patient’s general condition
3. To determine respiratory distress and accumulation of secretions.
4. To open or maintain open airway.
5. To prevent vomiting with aspiration into lungs.
6. To ascertain status and note progress.
7. To maxixmize effort
8. To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation
9. To promote comfort and adequate ventilation
10. To identify infectious process and promote timely intervention.
11. Rest will prevent fatigue and decrease oxygen demands for metabolic demands
12. To further mobilize secretions
13. To clear airway when secretions are blocking the airway
14. Indicated to increase oxygen saturation.

Assessment

Planning

Interventions

Rationale

Evaluation

• productive cough yellowish in color
• presence of rales upon auscultation
• (+) DOB
• Tachypnic AEB RR= 27bpm
• with pale conjunctiva, nail beds and buccal mucosa
• fatigue

Patient may manifest:

• Metabolic acidosis
• Circum-oral cyanosis

1. Monitor and record vital signs
2. Observe color of skin, mucous membranes and nail beds, noting presence of peripheral cyanosis.
3. Elevate head of bed and encourage frequent position changes.
4. Keep back dry.
5. Promote adequate rest periods
6. Change position q 2 hrs.
7. Keep environment allergen free
8. Suction secretions PRN
9. Administer oxygen therapy as ordered.

1. To obtain baseline data
2. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/ chills
3. To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation
4. To avoid coughing
5. Rest will prevent fatigue and decrease oxygen demands for metabolic demands
6. To promote drainage of secretions
7. To reduce irritant effects on airways
8. To clear airway when secretions are blocking the airway.
9. O2 therapy is indicated to increase oxygen saturation

Assessment

Planning

Interventions

Rationale

Evaluation

• Generalized weakness
• (+) DOB
• Limited range of motion

1. Review medication regimen.
2. Assess vital signs.
3. Determine presence or degree of sleep disturbances.
4. Obtain client descriptions of fatigue.
5. Ask client to rate fatigue.
6. Note daily energy patterns.
7. Establish realistic activity goals with client and encourage forward movement.
8. Plan interventions to allow individually adequate rest periods.
9. Assist with self-care needs and ambulation.
10. Avoid exposure to temperature and humidity extremes
11. Instruct client in ways to monitor responses to activity and significant signs or symptoms.
12. Promote overall health measures
13. Provide supplemental oxygen, as indicated.
14. Assist client to identify appropriate coping behaviors.

1. Certain medications are known to cause or exacerbate fatigue.
2. To evaluate fluid status and cardiopulmonary response to activity.
3. Fatigue can be a consequence of sleep deprivation.
4. To assist in evaluating impact on client’s life.
5. To determine degree of fatigability.
6. Helpful in determining pattern or timing of activity.
7. Enhances commitment to promoting optimal outcomes.
8. To maximize participation.
9. To conserve energy for other tasks.
10. Has negative impact on energy level.
11. Indicate the need to alter activity level
12. To promote energy
13. Presence of hypoxemia reduces oxygen available for cellular uptakes and contributes to fatigue.
14. Promote sense of control and improves self-esteem.