Heart failure is a chronic, progressive condition. It occurs when the heart is unable to pump effectively and produce enough cardiac output to successfully perfuse the rest of the body’s tissues and organs. An individual can have right-sided or left-sided heart failure as well as systolic or diastolic heart failure.
Left-sided heart failure is also known as Congestive Heart Failure (CHF). In CHF, the heart is either unable to contract completely or fill completely during relaxation. It can lead to an inadequate amount of blood pumping out of the heart. Thereby, backing up into the right side and then ultimately to the lungs and throughout the body causing congestion.
Systolic heart failure means the heart is not able to contract completely and affects its ability to pump blood out of the heart.
Diastolic heart failure means the heart is unable to relax fully between heartbeats and allows the appropriate amount of blood into the ventricle.
In this post, we’ll formulate a sample nursing care plan for a patient with Congestive Heart Failure (CHF) based on a hypothetical case scenario.
A 74-year old Hispanic male presents to the Emergency Department with complaints of increased dyspnea, reduced activity tolerance, ankle swelling, and weight gain in recent days. He has a known history of hypertension and heart failure. He reports over the past 3 days his shortness of breath, particularly with activity, has increased significantly.
He is also now using 3 pillows to sleep at night instead of his usual 1 pillow, and he has experienced a 10-pound weight gain in 3 days. He states he is now only able to ambulate 1 block before needing to stop and rest whereas in the past he could walk half a mile.
The nurse notes dyspnea upon minimal excretion with position changes. Upon physical assessment his breathing is shallow and labored, respiratory rate is 30 breaths per minute, heart rate 115 beats per minute, oxygen saturation 83% on room air, blood pressure 179/98 mm Hg, he has +4 pitting edema in bilateral lower extremities, and crackles are heard in his lung fields throughout.
The patient’s lab work reveals an elevated BNP level of 954pg/mL and a chest x-ray shows pulmonary congestion. The last echocardiogram in the patient’s chart (completed 3 months prior) showed an Ejection Fraction (EF) of 40%.
The patient is to be admitted to the hospital for Acute Exacerbation of Congestive Heart Failure (CHF).
The main assessment findings the nurse should be aware of for this patient begin with his vital signs, all of which are listed are abnormal.
The patient has labored, tachypneic, breathing. He is also tachycardic and has a decreased oxygen saturation. This demonstrates to the nurse that the patient is not hemodynamically stable and the main goal is stabilizing the patient’s respiratory status.
In addition, the nurse should also note the reported weight gain and visibly apparent edema. These assessment findings are able to help the nurse critically think and identify a potential list of differential diagnoses prior to lab and imaging results becoming available.
When assessing this patient, the nurse will want to remember ABCs (airway, breathing, circulation) of care. The patient’s airway is protected and he is able to breathe on his own.
However, his breathing is compromised due to excessive fluid. Therefore, that becomes the priority for the patient and the nurse should begin by improving his oxygen saturation and breathing status.
Once the patient’s breathing status is stabilized the next likely task will be to diuresis the patient. In doing this, it will help to remove additional fluid thereby improving his oxygen and breathing capability further.
Subjective Data:
Objective Data:
Impaired gas exchange related to fluid overload as evidenced by labored, tachypneic breathing, decreased oxygen saturation, crackles in lung fields, pitting edema, congestion on chest x-ray.
Short-term goal
To increase oxygen saturation ≥92% prior to transfer from ED and admission to hospital floor unit
| Interventions | Rationales |
| Administer supplemental oxygen therapy with continuous oxygen saturation monitoring | Supplemental oxygen will increase alveolar oxygen concentration |
| Maintain chair/bedrest | Rest will reduce the body’s oxygen demands and consumption |
| Position patient into Semi-Fowler’s position | Positioning will allow for maximal lung expansion and inflation |
Long-term goal
To decrease excess fluid by 10 pounds by discharge to return patient to baseline dry weight
Nursing Interventions with Rationales