Nursing Diagnoses : Heart Failure

  • Nursing Diagnoses
    • Impaired gas exchange related to increased preload and alveolar-capillary membrane changes
    • Decreased cardiac output related to altered contractility, altered preload, and/or altered stroke volume
    • Excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to heart failure
    • Activity intolerance related to imbalance between O2 supply and demand secondary to cardiac insufficiency and pulmonary congestion
  • Nursing planning
    • Overall Goals
      • Decrease in symptoms
      • Decrease in peripheral edema
      • Increase in exercise tolerance
      • Compliance with the treatment regimen
      • No complications related to HF
  • Nursing intervention
    • Monitor respiratory status
    • Administer oxygen therapy
    • Semi-Fowler’s position
    • Monitor hemodynamic status
    • Daily weights
    • I and O
    • Administer prescribed drugs
    • Monitor edema
    • Alternate rest with activity
    • Provide diversionary activities
    • Monitor response to activity
    • Collaborate with OT/PT
    • Reduce anxiety
    • Evaluate support system
    • Patient teaching
      • Signs and symptoms of HF exacerbations – what to do/report
      • Importance of early detection
      • Can have positive outlook with chronic health problem if treatment plan is followed
      • Drug therapy
        • Expected actions
        • Signs of drug toxicity
        • How to take HR and what to report
        • Signs and symptoms of hypokalemia and hyperkalemia
        • BP monitoring as needed
      • Dietary therapy
        • Dietary therapy
        • Written plan
        • Reading labels for sodium
        • No added salt
        • Daily weights
        • Smaller, more frequent meals
      • Activity/rest
        • Energy-conserving and energy-efficient behaviors
        • Exercise training (cardiac rehab)
        • Increase gradually
        • Avoid heat and cold extremes
        • Rest after exertion
        • Avoid emotional upsets
      • Ongoing monitoring
        • Know FACES
        • Reappearance of symptoms
        • What to report
          • Weight gain of 3 lb (1.4 kg) in 2 days, or 3-5 lb (2.3 kg) in a wk
          • Difficulty breathing, especially with activity or when lying lat
          • Waking up breathless at night
          • Frequent dry, hacking cough, especially when lying down
          • Fatigue, weakness
          • Swelling of ankles, feet, or abdomen. Swelling of face or difficulty breathing (if taking ACE inhibitors)
          • Nausea with abdominal swelling, pain, and tenderness
          • Dizziness or fainting
        • Regular follow-up
        • Support group
      • Health promotion
        • Vaccinations
          • Annual flu vaccination
          • Pneumococcal vaccine
        • Reduce risk factors
    • Ambulatory Care
      • Explain to patient and caregiver physiologic changes that have occurred
      • Assist patient to adapt to both physiologic and psychologic changes
      • Include patient and caregiver(s) in overall care plan
  • Nursing evaluation
    • Monitoring to assess outcomes and prevent/ limit future hospitalizations
      • Vital signs
      • Weight
      • Pulse oximetry
      • Dyspnea
    • Home health nurses can be essential
    • Can use electronic monitoring