The heart fails to pump effectively, causing decreased perfusion forward of the failure and fluid back behind the failure. Heart failure can be left-sided, right-sided, or both. When both sides are failing, it is called congestive heart failure (CHF). Heart failure is measured by ejection fraction. Normally functioning hearts have an ejection fraction of 55-75%. Anything less than 50% is concerning for heart failure.
Any issue with the cardiovascular system could potentially cause CHF (or put the patient at a much higher risk for CHF), such as myocardial infarction, coronary artery disease, hypertension, cardiomyopathy, valve disorders, arrhythmias, etc. Also any other comorbidities such as diabetes, thyroid issues, HIV, etc. contribute to heart failure occurring. If the CHF is acute, it may have been caused by a virus, infection, or blood clot.
maximized cardiac functionality as well as decreased stress on the cardiovascular system.
Congestive Heart Failure (CHF) Nursing Care Plan
- Difficulty in Breathing
- Heart palpitations or feeling like the heart is racing.
- Reports significant weight gain or loss
- Peripheral edema
- Crackles in the lung bases
- Pink, frothy sputum
- SOB with exertion
- ↓ SpO2
- Possible Atrial Fibrillation on ECG
- ↓ LOC
- Signs of decreased perfusion
- ↓ pulses
- Cool, clammy skin
- Slow cap refill
- Possible cyanosis or dusky skin
Nursing Interventions and Rationales
- Monitor heart rhythm get a 12 lead ECG
- Patients with CHF will have a low voltage ECG after peripheral edema is resolved the ECG gains voltage again and becomes more of a normal looking ECG.
- Patients may also have Atrial Fibrillation – a condition in which the atria quiver instead of contracting – this can lead to the development of heart failure.
- May also see signs of current or previous ischemia or infarction.
Water follows salt! The patient has too much fluid on board and needs to get rid of it, restricting the sodium helps with this. This means educating the patient on dietary changes that need to happen and be adhered to.
- 300-600 mg of salt per serving.
- Avoid processed foods or lunch meats
- Do not add salt to meals
Caution with a salt substitute in renal insufficiency – it is made with potassium chloride and can raise the patient’s K+!
- Monitor BNPNormal range: <100 pg/mL
Brain natriuretic peptide (BNP): is a hormone made by the heart. When the heart is stressed or working hard to pump blood, it releases BNP.
- Assess respiratory function:
- Listen to breath sounds
- Monitor O2 saturation
- Apply O2 as needed
Fluid can back up into the lungs and cause shortness of breath, especially upon exertion. Be careful about laying these patients flat as you can put them in respiratory distress. Place the patient on O2 as needed to help them keep their O2 levels adequate – usually above 92% or as ordered by the provider.
- Administer diuretics:
- Furosemide (Lasix)
- Bumetanide (Bumex)
- Hydrochlorothiazide (Microzide)
- Spironolactone (Aldactone)
We need to get all this fluid out of the patient… The best way to do this is to administer diuretics. The FIRST thing you do BEFORE you administer a diuretic has a pee plan. Do not under any circumstances administer a diuretic without a bathroom plan. And a word to the wise, have a backup plan. Meaning if you have an independent patient with functioning arms and a strong call light finger, I still would set up a bedside commode just.in.case. I walk them to the bathroom or assist them in any way needed, but it is possible that they do not know how urgent their situation is and you can clean up pee, but you can’t clean up that patient’s dignity. Diuretics work on different parts of the nephrons. The goal of diuretics is to help the kidneys rid the body of salt (notice I didn’t say sodium (Na+)?) and fluids. It is important to note for every Na+ molecule there is a compound of one water (H20) that follows it. Psssst: potassium is a salt, too… There are three kinds of diuretics: Loop, Thiazide, and potassium-sparing.
- Loop: works on the loop of Henle and excretes Na+, K+, and Ca-. Water follows. (Yikes! Watch your patient’s electrolytes!)
- Thiazide: Works on the distal convoluted tubule and blocks the Na+/Cl- symporter (which reabsorbs…you guessed it Na+ and Cl-). This symporter is responsible for about 5% of Na+ reabsorption. So monitor your patient’s sodium and chloride. Oh, and your K+…Why? Because K+, Cl- and Na+ have direct relationships!
- Potassium-Sparing: Works on the Na+/K+ pumps in the collecting ducts of the kidney by blocking the effects of aldosterone at that site. Aldosterone has the collecting ducts reabsorbing Na+ and thus water, and for every Na+ absorbed, one molecule of K+ is excreted. So this diuretic does the opposite of that, saves a K+, and excretes a Na+ and H20.
Most commonly used diuretics in congestive heart failure are loop and sometimes thiazides are used with loop diuretics:
- Furosemide: Loop
- Bumetanide: Loop
- Hydrochlorothiazide: Thiazide
- Strict intake and output (I&O’s)
These patients should only have around 8 cups of fluid or just slightly under 2 liters of fluid per day. This can change per patient and per doctor recommendation, so make sure to get a goal from the physician. Strict I&O means measuring every drop that goes in or out of that patient.
- Teach patient to drink one cup at a time and to report how many they’ve had
- Put a hat in the toilet if the patient has bathroom privileges
- Be familiar with common beverage options and their volumes (juice, milk, coffee cup, etc.)
Edema is caused by volume overload due to congestion within the system. Worsening edema can indicate worsening heart failure. Edema is measured by pressing over a bony prominence, usually the top of the foot or the tibia, and is charted by a number and whether the skin bounces back or stays pitted (called pitting edema).
- Non-pitting – doesn’t stay pitted
- +1: mild indent, 2mm
- +2: Moderate indent, 4mm
- +3: Deep indent, 6mm
- +4: Very deep indent, 8mm
Daily weights should be done at the same time of the day, same clothes (or none), same scale. A weight gain of 1 kg is equivalent to 1 L of fluid – notify HCP for a gain of 2 lbs in a day or 5 lbs in a week.
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell