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.
- Restrict sodium intake
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
- Assess respiratory function:
- Listen to breath sounds
- Monitor O2 saturation
- Apply O2 as needed
- 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.)
- Monitor swelling/edema
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
Writing a Nursing Care Plan (NCP) for Congestive Heart Failure (CHF)
A Nursing Care Plan (NCP) for Congestive Heart Failure (CHF) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.
Today, I’m going to show how to run a nursing care plan on congestive heart failure. I know that these are hard to put together and they’re overwhelming, but stay tuned. I’ll make it super easy for you.
So, of course, we are going to focus on how we write this care plan, but while doing so, you’re going to learn how to care for CHF patients, as well as how to educate them, which is super important. So, they know how to take care of themselves going home. Alright, so the cool thing about care planning is that it’s so individualized to one specific patient. We can make it as specific as we need to.
First, we start off with this subjective data. These are things that are coming from the subject or the patient, so let’s say that this gentleman comes in and he tells us that he can only get to sleep nowadays in a recliner, or maybe in a bed with like three or four pillows behind him, that is not normal. That tells us that he’s having a really hard time breathing and that’s known as orthopnea. That’s something that can be seen in CHF. Next step, he tells us that he’s really short of breath, even when he’s not doing anything super strenuous or hard. He’s finding that he is having a really hard time keeping up with his oxygen demands. That’s also not normal and that’s also associated with CHF.
Next step, we can use our nursing skills to find out more information in this objective data. So, we can listen to his lungs and determine that he has coarse crackles. That means that in his lung fields, he’s carrying some extra fluids and that’s what makes this coarse crackly sound. Some nurses might refer to this as junkie. So, that’s not good either and that tells us that the heart is not pumping fluids forward and actually some of them are backing up into the lungs. That’s where the C in congestive heart failure comes from. That’s the congestion they’re talking about. Okay, next step, we notice that his fingers and his toes are really pale and that tells us that they’re not getting good perfusion. Same with this next thing here. The capillary refill being prolonged tells us that the blood flow from the heart all the way down to the extremities, the hands and the feet, is not sufficient.
Okay, so we work our way forward into the diagnosis section. This is where we as nurses get to decide what is really going on with this patient? What are we concerned about? This is how we move forward with building our care plan. So, we noticed that he has decreased cardiac output. Some of these things from the assessment tell us that, especially these last two here, his pale fingers and toes and his capillary refill that tells us that the heart again is not pumping out to those extremities. Next step, we also can notice that he has increased fluid volume and we notice those from the respiratory symptoms. So, these crackles, the shortness of breath, not being able to sleep, laying down flat, those will have to do with the body working too hard to manage the current volume of fluid in the plan section. This is where we determine what this patient can work towards to get feeling better.
So, we can make up a few different goals here. Weight is a really, really good goal for patients who have CHF, because weight is a very sensitive indicator of how well the patient is doing and how much fluid they’re carrying around. So, we could say that the patient would participate in daily weights. That goes hand in hand with a fluid restriction. Typically, the provider will write out a fluid restriction and it will be somewhere around two liters that this patient needs to adhere to. The patient not having shortness of breath would be a huge indication that they’re doing better, right, so that’s a great goal there. They have a brisk capillary refill, so that would be something like around two seconds, instead of prolonged here, let’s say that was maybe like three or more seconds to come back. So, a brisk cap refill tells us that those fingers and toes they’re getting the blood that they need and so are all the other organs along the way. Then lastly, we always, always want our patients to understand education about all these other things that we’re working with them on in the implementation section. This is where we decide what we do as a nurse to help out our patient and if you haven’t noticed yet, there’s a trend here, right? We’re always working this way in the care plan and referring back to build the next section.
So, the nurse will support daily weights by helping to record them and teaching the patient how important it is to do this. When they go home, a lot of times, a good rule of thumb for these patients is to be doing this at the same time every day, wearing roughly the same amount of clothing too. That’s really important for when they go home. The nurse can monitor this fluid restriction and make sure that the patient’s actually adhering to it. This is something that’s really, really hard to do. Think about any time you’ve been told you can’t have something, what do you want? You want that thing they say you cannot have. So, these patients are really, really thirsty for fluid so we can help them out with monitoring their intake and output and we also can help them by giving them maybe cups of ice because when you drink a big old drink, that super easy to go down, but when you give them a cup of ice, this melts down and actually has a lot less volume than straight water or other liquids would have, but they’re still feeling like they’re getting hydrated.
Then for these next two goals, we can just monitor them more like we’re supposed to be doing as nurses, every shift, right? So, we monitor their cardiovascular and the respiratory systems, how we do that is by listening, right? We can listen to their hearts. We can listen to their lungs. We can observe how hard they’re working to breathe and we can keep on checking that cap refill on the shortness of breath and saying, Hmm, are they getting any better? Lastly, of course, we play a huge role in the education of this patient. So, we want them to feel confident that they can take care of themselves and that they can avoid hospital stays in the future because they know what they’re doing. They know how to manage this new diagnosis, right? That’s very important. So, for daily weights, this right here is important too. Also, one thing to know is that there may be a guideline for this patient to follow. So, maybe they need to call the doctor if they gain more than two pounds in one day or five pounds in one week and that tells us that, oh, they’re starting to have too many fluids on board. When you discharge a patient, there will be education like this, so they know exactly when they need to seek a provider’s care. We also, again, can help them to know why they’re doing this strict fluid restriction, because it’s really hard. I know when things are hard, they’re made easier when you understand, why, why do I have to do this? Why are you not letting me drink fluids? Well, it’s going to make your heart’s job a lot easier and you will continue to feel better and then heck, they can even monitor their own status at home. They can keep a journal of how frequently they’re feeling, shortness of breath. Does that happen when they do something really strenuous? Like they just went and mowed the lawn, or is it starting to happen more just at rest when someone is short of breath at rest, that is not a good sign, right? So, making sure they know all of this is very, very important.
The last section here is very straight forward. We’re just asking ourselves, did this work? Did they meet their goals? So, let’s say this patient was a rockstar and they met all of their goals. So, they recorded their weights every day. They complied with her fluid restriction here, check and check. They no longer have shortness of breath at rest. Their capillary refill is back to normal and they verbalize understanding of the education you’ve given them. That would be awesome. That would be a very successful care plan, right? But, let’s say that this patient actually didn’t meet one of these goals. What would we do then? What do you think we would do? Well, we would put “not met” in this section and all we have to do is reevaluate. Sometimes that means we have to go back one section. Sometimes that means we have to go all the way back here and we just fix the problem and make it so we can eventually have this met, and that’s okay. That’s part of customizing a care plan for a patient because not every patient is going to respond the exact same way.
Alright, so now you know how to do your awesome care plan. You know how to give patient care and you know how to educate these patients. We love you guys. Now, go out and be your best selves today and as always, happy nursing!