This document provides a nursing care plan for patients with congestive heart failure. It outlines several nursing diagnoses such as decreased cardiac output and impaired gas exchange. For each diagnosis, it lists goals and interventions. Interventions include placing the patient at rest, monitoring for signs of worsening heart failure, administering diuretics and monitoring fluid balance, gradually increasing activity, and providing patient education on managing their condition. The overall aim is to reduce the workload of the heart and improve oxygen delivery through non-pharmacological and pharmacological means.

1. Cardiovascular Disorders
Nursing Care Plan for Patients with
Congestive Heart Failure

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Nursing Diagnosis
Decreased Cardiac Output related to impaired
contractility and increased preload/after load
Maintaining Adequate Cardiac Output
.
1. Place patient at physical and emotional rest
to reduce work of heart.
a. Provide rest in semi recumbent position or in
armchair in air- conditioned environment
reduces work of heart, increases heart reserve,
reduces blood pressure, decreases work of
respiratory muscles and oxygen utilization,
improves efficiency of heart contraction;
recumbency promotes diuresis by improving
renal perfusion.

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b. Provide bedside commode to reduce work of
getting to bathroom and for defecation.
c. Provide for psychological rest emotional
stress produces vasoconstriction, elevates
arterial pressure, and speeds the heart.
1. Promote physical comfort.
2. Avoid situations that tend to promote
anxiety/agitation.
3. Offer careful explanations and answers to the
patient's questions.

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2. Evaluate frequently for progression of left
ventricular failure.
Take frequent blood pressure readings.
Observe for lowering of systolic pressure.
Note narrowing of pulse pressure.
c. Note alternations in strong and weak pulsations
(pulsus alternans).
3. Auscultate heart sounds frequently.
a. Note presence of S3 Or S4 gallop (S3 gallop is
a significant indicator of congestive heart
failure).
b. Monitor for premature ventricular beats.

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4. Observe for signs and symptoms of reduced
peripheral tissue
perfusion: cool temperature of skin, facial pallor, poor
capillary refill of nailbeds.
Administer pharmacotherapy as directed.
5. Monitor clinical response of patient with
respect to relief
symptoms (lessening dyspnea and orthopnea, decrease
in crackles, relief of peripheral edema).

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Impaired Gas Exchange related to alveolar
edema due to elevated ventricular pressures
Nursing Goals & Interventions
1. Raise head of bed 20 to 30 cm (8-10 in) reduces
venous
return to heart and lungs; alleviates pulmonary congestion.
a. Support lower arms with pillows to eliminate weight on
shoulder muscle
b. Sit orthopneic patient on side of bed with feet support chair,
head and arms resting on an over-the-bed table, lumbosacral
area supported with pillows.

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2. Auscultate lung fields every 4 hours for crackles and
wheezes in dependent lung fields (fluid accumulates in areas
affected by gravity).
A. Mark with water-soluble ink the level on the patient's where
adventitious breath sounds are heard.
B. Use markings for comparative assessment during changes in
tours of duty with other nursing personnel.
3. Observe for increased rate of respirations (could be indicative
of falling arterial pH).
4. Observe for Cheyne—Stokes respirations (may occur in
elderly because of a decrease in cerebral perfusion stimulating a
neurogenic response).

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5. Position the patient every 2 hours (or encourage the patient to
change position frequently) to help prevent atelectasis and
pneumonia.
6. Encourage deep-breathing exercises every 1 to 2 hours to
avoid atelectasis.
7. Offer small, frequent feedings to avoid excessive gastric
filling and abdominal distention with subsequent elevation of
diaphragm that causes decrease in lung capacity.
8. Administer oxygen as directed.

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Fluid Volume Excess related to sodium and water
retention
Restoring Fluid Balance
Administer prescribed diuretic as ordered.
2.Give diuretic early in the morning night time diuresis
3.Keep input and output record the patient may lose large
volume of fluid after a single dose of diuretic.
4.Weigh the patient daily to determine if edema is being
controlled: weight loss should not exceed 0.45 to 2
lb/day). Assess for weakness, malaise, muscle cramps
diuretic may produce hypovolemia and electrolyte
depletion namely hypokalemia. Hypokalemia may cause
weakening of cardiac contractions and may precipitate
digitalis toxicity in the form of dysrhythmias.

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6.Give oral potassium as prescribed.
7. Watch for problems associated with diuretic therapy
including disorders of hyperuricemia, volume depletion,
an( hyponatremia, magnesium depletion, hyperglycen
diabetes mellitus.
8. Watch for signs of bladder distention in the elderly
male with prostatic hyperplasia.
9. Observe for symptoms of electrolyte depletion
lassitude, apathy, mental confusion, anorexia,
decreasing urinary output, azotemia.
10.Limit intravenous fluid administration through use of
heparin lock (allows for periodic drug administration
without increasing excessive fluid intake).

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11.Monitor for pitting edema of lower extremities and sacral area.
Use "egg crate" mattress and sheepskin to prevent pressure sores
(poor blood flow and edema increase susceptibility).
12. Observe for the complications of bed rest pressure sores
(especially in edematous patients), phlebothrombosis,
pulmonary embolism.
13.Be alert to complaints of right upper quadrant abdominal pain,
poor appetite, nausea, and abdominal distention (may indicate
hepatic and visceral engorgement).
14.Monitor the patient's diet. Diet may be limited in sodium to
prevent, control, or eliminate edema; may also be limited in
calories.
15. Caution patients to avoid added salt in food and foods wit
high sodium content.

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Activity Intolerance related to oxygen supply and
demand imbalance
Improving Activity Tolerance
1.Increase the patient's activities gradually. Alter or modify
patient's activities to keep within the limits of his cardiac
reserve
2.Assist the patient with self-care activities early in the day
(fatigue sets in as day progresses).
3.Be alert to complaints of chest pain or skeletal pain during or
after activities.
to
4.Observe the pulse, symptoms, and behavioral response
activity.
a. Monitor the patient's heart rate during self-care activity

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b.Allow heart rate to decrease to preactivity level before initiating
new activity.
1. Note time lapse between cessation of activity and heart rate
(decreased stroke volume causes immediate rise in heat rate )
2.Document time lapse and revise patient care plan appropriate
(progressive increase in time lapse may be indication of increased
left ventricular failure).
3. Relieve night time anxiety and provide for rest and
sleep-with congestive heart failure have a tendency to be restless
at because of cerebral hypoxia with superimposed nitrogen
retention-
a. Give appropriate sedation—to relieve insomnia an
restlessness.

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Patient Education
1.Explain the disease process to the patient; the term
"failure" may have terrifying implications.
2.Explain the pumping action of the heart—"to move
blood through the body to provide nutrients and aid in
the removal of waste material."
Explain the difference between "heart attack" and
congestive heart failure.
Teach the signs and symptoms of recurrence. Watch
for:
report weight gain of more than 2 to 3 pounds
(0.9-1.4 kg) in a few days. Weigh at same time daily

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-Swelling of ankles, feet, or abdomen
-Persistent cough
-Tiredness; loss of appetite
- Frequent urination at night
3.Review medication regimen.
-Label all medications.
-Give written instructions concerning pharmacologic
therapy.
-Make sure the patient has a check-off system that will
show that he/she has taken medications.
-Teach the patient to take and record pulse rate and
blood pressure.

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-Inform the patient of the signs and symptoms of
adverse drug effects. If the patient is taking oral
potassium solution, it may be diluted with juice and
taken after a meal.
- Tell the patient to weigh self daily and log weight if on
diuretic therapy.
4.Review activity program. Instruct the patient as
follows:
-Increase walking and other activities gradually,
provided they do not cause fatigue and dyspnea.
-In general, continue at whatever activity level can be
maintained without the appearance of symptoms.

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-Avoid excesses in eating and drinking.
Undertake a weight reduction program until optimal
weight is reached.
-Avoid extremes in heat and cold which increase
work of the heart; air conditioning may be essential in a
hot, humid environment.
-Keep regular appointment with health care provider or
5.Restrict sodium as directed.
Give patient a booklet containing sodium content of
common foods from local chapter of American Heart
Association.

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-Give patient a written diet plan with lists of permitted and
restricted foods.
-Advice patient to look at all labels to ascertain sodium content
(antacids, laxatives, cough remedies, etc.).
-Teach the patient to rinse the mouth well after brushing tooth
cleansers and mouthwashes contains amounts of sodium.
some
Water softeners are to be avoided.
-Teach the patient that sodium is present in alkalizers, cough
remedies, laxatives, pain relievers, estrogens, and other drugs.
-Encourage use of flavorings, spices, herbs, and lemon juice.
Avoid salt substitutes in the presence of renal disease

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