Nursing Care Plan – Congestive Heart Failure (CHF)

Congestive heart failure, or heart failure, is a condition in which the heart is unable to adequately pump blood throughout the body and/or unable to prevent blood from "backing up" into the lungs.
In most cases, heart failure is a process that occurs over time, when an underlying condition damages the heart or makes it work too hard, weakening the organ. Heart failure is characterized by shortness of breath (dyspnea) and abnormal fluid retention, which usually results in swelling (edema) in the feet and legs.

 

Pathophysiology of Congestive Heart Failure (CHF)

 CARE SETTING

Although generally managed at the community level, inpatient stay may be required for periodic exacerbation of failure/development of complications.

RELATED CONCERNS

1. Myocardial infarction
2. Hypertension
3. Cardiac surgery
4. Dysrhythmias
5. Psychosocial aspects of care
6. Patient Assessment Database

ACTIVITY/REST

May report: 

1. Fatigue/exhaustion progressing throughout the day; exercise intolerance
2. Insomnia
3. Chest pain/pressure with activity
4. Dyspnea at rest or with exertion

May exhibit: 

• Restlessness, mental status changes, e.g., anxiety and lethargy
  Vital sign changes with activity

CIRCULATION

May report: 

1. History of hypertension, recent/acute multiple MIs, previous episodes of HF, valvular heart disease, cardiac surgery, endocarditis, systemic lupus erythematosus (SLE), anemia, septic shock
2. Swelling of feet, legs, abdomen, “belt too tight” (right-sided heart failure)
3. May exhibit: BP may be low (pump failure), normal (mild or chronic HF), or high (fluid overload/ increased SVR)
4. Pulse pressure may be narrow, reflecting reduced stroke volume
5. Tachycardia (may be left- or right-sided heart failure)
6. Dysrhythmias, e.g., atrial fibrillation, premature ventricular contractions/tachycardia, heart blocks
7. Apical pulse: PMI may be diffuse and displaced inferiorly to the left
8. Heart sounds: S3 (gallop) is diagnostic of congestive failure; S4 may occur; S1 and S2 may be softened
9. Systolic and diastolic murmurs may indicate the presence of valvular stenosis or insufficiency, both atrial and ventricular.
10. Pulses: Peripheral pulses diminished; central pulses may be bounding, e.g., visible jugular, carotid, abdominal pulsations; alteration in strength of beat may be noted
11. Color ashen, pale, dusky, or even cyanotic
12. Nailbeds pale or cyanotic, with slow capillary refill
13. Liver may be enlarged/palpable, positive hepatojugular reflex
14. Breath sounds: Crackles, rhonchi
15. Edema may be dependent, generalized, or pitting, especially in extremities; JVD may be present

EGO INTEGRITY

May report: 

1. Anxiety, apprehension, fear
2. Stress related to illness/financial concerns (job/cost of medical care)

May exhibit: 

• Various behavioral manifestations, e.g., anxiety, anger, fear, irritability

ELIMINATION

May report: 

1. Decreased voiding, dark urine
2. Night voiding (nocturia)
3. Diarrhea/constipation

FOOD/FLUID

May report: 

1. Loss of appetite/anorexia
2. Nausea/vomiting
3. Significant weight gain (may not respond to diuretic use)
4. Lower extremity swelling
5. Tight clothing/shoes
6. Diet high in salt/processed foods, fat, sugar, and caffeine
7. Use of diuretics

May exhibit: 

1. Rapid/continuous weight gain
2. Abdominal distension (ascites); edema (general, dependent, pitting, brawny)
3.  Abdominal tenderness (ascites, hepatic engorgement)

HYGIENE

May report: 
Fatigue/weakness, exhaustion during self-care activities

May exhibit: 
Appearance indicative of neglect of personal care

NEUROSENSORY

May report: 
Weakness, dizziness, fainting episodes

May exhibit: 
Lethargy, confusion, disorientation
Behavior changes, irritability

PAIN/DISCOMFORT

May report: 

1. Chest pain, chronic or acute angina
2. Right upper abdominal pain (right-sided heart failure [RHF])
3. Generalized muscle aches/pains

May exhibit: 

1. Nervousness, restlessness 
2. Narrowed focus (withdrawal) 
3. Guarding behavior

RESPIRATION

May report: 

1. Dyspnea on exertion, sleeping sitting up or with several pillows
2. Cough with/without sputum production, dry/hacking—especially when recumbent
3. History of chronic lung disease
4. Use of respiratory aids, e.g., oxygen and/or medications

May exhibit: 

1. Tachypnea; shallow, labored breathing; use of accessory muscles, nasal flaring
2. Cough: Dry/hacking/nonproductive or may be gurgling with/without sputum production
3. Sputum may be blood-tinged, pink/frothy (pulmonary edema)
4. Breath sounds may be diminished, with bibasilar crackles and wheezes
5. Mentation may be diminished; lethargy, restlessness present
6. Color: Pallor or cyanosis

SAFETY

May exhibit: 

1. Changes in mentation/confusion
2. Loss of strength/muscle tone
3. Skin excoriations, rashes

SOCIAL INTERACTION

May report: Decreased participation in usual social activities

TEACHING/LEARNING

May report: 

1. Use/misuse of cardiac medications, e.g., beta-blockers, calcium channel blockers
2. Recent/recurrent hospitalizations
3. Evidence of failure to improve
4. Discharge plan
5. DRG projected mean length of inpatient stay: 5.5 days
6. Assistance with shopping, transportation, self-care needs, homemaker/maintenance tasks
7. Alteration in medication use/therapy
8. Changes in physical layout of home
9. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.
2. Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest ventricular aneurysm.
3. Sonograms (echocardiogram, Doppler and transesophageal echocardiogram): May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
4. Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.
5. Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan): Determines presence of myocardial ischemia and wall motion abnormalities.
6. Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.
7. Cardiac catheterization: Abnormal pressures are indicative and help differentiate right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some patients to determine the underlying disorder, such as myocarditis or amylodosis.
8. Liver enzymes: Elevated in liver congestion/failure.
9. Digoxin and other cardiac drug levels: Determine therapeutic range and correlate with patient response.
10. Bleeding and clotting times: Determine therapeutic range; identify those at risk for excessive clot formation.
11. Electrolytes: May be altered because of fluid shifts/decreased renal function, diuretic therapy.
12. Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
13. Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased PCO2 (late).
14. BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is indicative of renal failure.
15. Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.
16. Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional changes indicating water retention.
17. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.
18. ESR: May be elevated, indicating acute inflammatory reaction.
19. Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.

NURSING PRIORITIES

1. Improve myocardial contractility/systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

DISCHARGE GOALS

1. Cardiac output adequate for individual needs.
2. Complications prevented/resolved.
3. Optimum level of activity/functioning attained.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.