Heart failure is a chronic condition in which the heart is unable to pump as effectively and efficiently as possible to meet the body’s demands. Heart failure can be right- or left-sided, as well as, systolic of diastolic in nature. Systolic heart failure is when the heart is unable to contract completely, and therefore, will not pump the appropriate amount of blood out of the heart. Diastolic heart failure is when the heart is unable to relax completely between beats likely due to cardiac muscle stiffness, which results in the heart being unable to properly fill with blood. Congestive heart failure refers to left-sided heart failure and means the left side of the heart is unable to contract and pump properly thereby resulting in a backup of blood and congestion.
Heart failure typically occurs as a result of something else (i.e. another condition/disease or possibly a medication) having already damaged the heart muscle. Conditions that could potentially damage the heart and lead to heart failure include: coronary artery disease, myocardial infarction, hypertension, heart valve disease, myocarditis, congenital heart defects, cardiac arrhythmias, or other long-term, chronic conditions that are poorly managed such as diabetes mellitus, HIV, hyperthyroidism, or hypothyroidism.
Signs and Symptoms
Patients with heart failure can display a variety of symptoms including:
- Dyspnea on exertion
- Edema in lower extremities
- Irregular heart beat
- Low exercise tolerance level
- Persistent cough
- Abdominal swelling
- Rapid weight gain
- Nausea, lack of appetite
- Decreased alertness
- Chest pain
If heart failure is left untreated it can cause additional complications for the patient including:
- Renal damage – because heart failure causes a reduction in blood flow it can result in a reduction in blood flow to the kidneys, the body’s filtering system. This can result in a buildup of toxins or medications within the body. If renal damage becomes severe enough the patient may require dialysis.
- Heart Valve Disease – the heart valves are designed to prevent blood from backflowing in the heart. When the heart is not functioning properly, the muscle becomes stiff, or pressures increase within the heart it can then cause dysfunction of the valves as well.
- Cardiac Arrhythmias – If the heart function is significantly reduced, it can increase the likelihood that a person may experience other cardiac dysrhythmias, some of which can be fatal.
- Liver Damage – The backup of fluid that can occur with heart failure can potentially put more pressure on the liver thereby causing liver dysfunction and damage.
Since heart failure is a chronic condition it will require lifetime treatment. First form of treatment is aimed at identifying any potential contributing factors and treating those (i.e. repairing a heart valve if possible). Many times, patients require multiple medications to management this condition. The table below lists the most common classes of medications used for the treatment and management of heart failure.
|Angiotensin-converting enzyme (ACE) inhibitors||ACE inhibitors relax the blood vessels which results in improved blood flow, lower blood pressures, and less strain on the cardiac muscle|
|Angiotensin II receptor blockers (ARBs)||ARBs relax the blood vessels which results in improved blood flow, lower blood pressures, and less strain on the cardiac muscle|
|Beta Blockers (BB)||BBs lower the heart rate and blood pressure which can improve heart function|
|Diuretics||Diuretics cause an increase in urination to remove excess fluid from the body|
|Aldosterone antagonists||These medications are potassium-sparing diuretics that help in the treatment of systolic heart failure|
|Inotropes||Typically given IV while hospitalized, these are designed to increase the effectiveness of the heart pumping and maintain blood pressures|
|Digoxin||Increases the strength of the heart’s contractions|
Stages of Heart Failure
There are various stages defined as classes of heart failure dependent on the symptoms the patient is experiencing. These stages along with the associated symptoms are listed below.
|Class I||No heart failure symptoms|
|Class II||Activities of daily living can be completed without difficulty; however, exertion causes shortness of breath and some fatigue|
|Class III||Difficulty in completing activities of daily living|
|Class IV||Shortness of breath occurs while resting|
Prevention is incredibly important and patients should receive proper education on how to prevent heart failure. Actions taken by the patient that can reduce the chances of developing heart failure include: quitting smoking, eating heart-healthy food items, staying active, keeping weight within the normal range for their body type, and treating and appropriately managing other health conditions (i.e. hypertension, diabetes, etc.).
Nursing Care Plans for Congestive Heart Failure
Nursing Care Plan 1
Nursing Diagnosis: Activity intolerance related to weakness, fatigue, and shortness of breath
Outcome: The patient will be able to complete activities of daily living without shortness of breath or needing to stop for rest breaks.
|Monitor vital signs before and after activity||Patients with acute CHF exacerbations can experience orthostatic hypotension due to the effects of medications, diuresis, or poor cardiac pumping function|
|Monitor patient’s cardiopulmonary response to activity||Due to compromised myocardium and an inability to increase the stroke volume with activity the patient may experience tachycardia or an increase in oxygen demands with activity; this will further increase weakness and fatigue|
|Maintain chair/bed level at Semi-Fowler’s position||Semi-Fowler’s position allows for optional usage of oxygen by the body|
|Administer supplemental oxygen as needed||Supplemental oxygen will allow patient to maintain appropriate oxygen saturation levels and minimize shortness of breath|
|Assist patient with activities of daily living as needed and allow for rest periods throughout activity||This will help to meet the patients’ needs without additional unneeded myocardial stress or excessive oxygen demands|
|Implement physical therapy and/or cardiac rehabilitation program||This will help patient to regain strength and endurance as well as improve cardiac function under stress|
Nursing Care Plan 2
Nursing Diagnosis: Decreased cardiac output related to altered contractility
Outcome: The patient will be hemodynamically stable with adequate urinary output
|Monitor vital signs||Patients often experience tachycardia even at rest to compensate for the decreased contractility of the ventricle Blood pressure may be high or low depending on the stage of heart failure the patient is in and may require medications to maintain appropriate blood pressure|
|Monitor for dysrhythmias||Patients are more prone to dysrhythmias and ectopy due to decreased contractility of the heart|
|Assess skin for pallor and cyanosis||Due to decreased cardiac output patient may then experience diminished peripheral perfusion|
|Monitor intake and output closely as well as urine appearance (i.e. concentration)||The renal system can also be affected by low cardiac output and result in the retaining of sodium and water; therefore, the patient may have a low urine output|
|Assess neurologic status and any changes in level of alertness||Decreased cerebral perfusion may result secondary to a decrease in cardiac output|
|Administer supplemental oxygen as needed||Patient may become shorter of breath due to poor blood and oxygen circulation; supplemental oxygen will assist patient in maintaining appropriate oxygen saturations|
|Administer medications as ordered (Diuretics, ACE, ARBs, beta blockers)||These medications can increase the stroke volume, improve contractility of the cardiac muscle, and reduce overall congestion|
Nursing Care Plan 3
Nursing Diagnosis: Excess fluid volume related to impaired excretion of sodium and water
Outcome: The patient will have stabilized fluid volume and return to baseline weight prior to discharge home
|Monitor intake and output closely||This will ensure patient is exerting the appropriate amount of fluid that is in line with the patient’s intake|
|Provide patient education regarding fluid restriction||Patients may require fluid restriction upon discharge home to prevent excess fluid buildup in the future; include patient in teaching so s/he can be independent with this at home and prevent further hospital admissions; also gives patient a sense of personal power in the management of their health|
|Monitor weight daily and educate patient on the importance of this||Daily weight measurements help to be aware of any potential excess fluid gain and if a change in medications or doses is required|
|Assess neck and peripheral vessels||Fluid retention may result in venous engorgement|
|Auscultate breath sounds||Patient may experience crackles or wheezes when excess fluid is present|
|Administer medications as ordered||Patients are often given diuretics to help remove excess fluid|
Nursing Care Plan 4
Nursing Diagnosis: Impaired gas exchange related to excess fluid
Outcome: Patient will maintain adequate oxygenation saturation and ventilation prior to discharge home
|Auscultate breath sounds||Patient may experience crackles, wheezes, or diminished breath sounds related to excess fluid|
|Educate patient on coughing and deep breathing exercises||This will assist patient with clearing their airway and allow for better oxygen flow and delivery throughout the body|
|Change positions frequently||This will decrease the chances of patient developing atelectasis and/or pneumonia|
|Maintain sitting in semi-Fowler’s position||This position allows for optimal oxygenation|
|Monitor pulse oximetry||This will allow nurse to be aware if additional oxygen therapy is needed|
|Administer supplemental oxygen as needed||This will allow patient to maintain adequate oxygen saturation levels|
|Monitor arterial blood gases (ABGs)||Hypoxemia can be severe and ABGs will help to determine if compensatory acid-base changes are occurring|
|Administer medications as ordered||Medication will assist in removing excess fluid and will improve oxygen saturation|
Nursing Care Plan 5
Nursing Diagnosis: At risk of ineffective health management related to chronic illness and complex treatment regimen
Outcome: Patient will identify the need for ongoing treatment program to prevent recurrent episodes of heart failure exacerbation and further complications
|Assess patient’s level of understanding and awareness of chronic illness||This will assist in determining the patient’s present knowledge level and then the nurse will be able to tailor education to meet their needs|
|Educate patient on normal heart function and patient’s personal level of heart function||Understanding the disease process can help the patient know what can be expected during the long-term treatment of the condition|
|Reinforce the rationale for treatment plan||Patients may think it is acceptable to deviate from the treatment plan once home in their own setting; reinforcing the overall treatment plan and need for it will assist in preventing additional hospitalizations|
|Educate on the importance and benefits of a regular exercise routine||This will assist patients with maintaining muscle strength and organ function as well as benefiting the patients’ mental health|
|Educate on any diet restrictions (i.e. sodium and/or fluid restriction)||Excess sodium or fluid intake can result in excess fluid throughout the body and cause acute exacerbation of CHF|
|Educate patient on medication regimen||Understanding each medication and its purpose will assist the patient in understanding the importance of taking all medications as prescribed|
|Educate patient to monitor weight daily||This will allow patient to be aware of any potential weight gain and when to call his/her MD|
|Assess patient’s support system||Management of chronic conditions can be very challenging for patients and having a strong support system can assist in better adherence to the treatment plan|
- Ackley, B.J., Ladwig, G.B., Flynn Makic M.B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook: An evidence-based guide to planning care (12th edition). Mosby.
- Blumenthal, R. & Jones, S. (2021). Congestive heart failure: Prevention, treatment, and research. https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th edition). F.A. Davis Company.
- Mayo Clinic (2021). Heart failure. https://www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148