Cardiovascular Disorders
Nursing Care Plan for Patients with Congestive Heart Failure
Nursing Diagnosis
Decreased Cardiac Output related to impaired contractility and increased preload/after load
Maintaining Adequate Cardiac Output
. 1. Place patient at physical and emotional rest to reduce work of heart.
a. Provide rest in semi recumbent position or in armchair in air- conditioned environment reduces work of heart, increases heart reserve, reduces blood pressure, decreases work of respiratory muscles and oxygen utilization, improves efficiency of heart contraction; recumbency promotes diuresis by improving renal perfusion.
b. Provide bedside commode to reduce work of getting to bathroom and for defecation.
c. Provide for psychological rest emotional stress produces vasoconstriction, elevates arterial pressure, and speeds the heart.
1. Promote physical comfort.
2. Avoid situations that tend to promote anxiety/agitation.
3. Offer careful explanations and answers to the patient s questions.
2. Evaluate frequently for progression of left ventricular failure.
Take frequent blood pressure readings.
Observe for lowering of systolic pressure.
Note narrowing of pulse pressure.
c. Note alternations in strong and weak pulsations.
3. Auscultation heart sounds frequently.
a. Note presence of S3 or S4 gallop (S3 gallop is a significant indicator of congestive heart failure).
b. Monitor for premature ventricular beats.
4. Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature of skin, facial pallor, poor capillary refill of nail beds.
Administer pharmacotherapy as directed.
5. Monitor clinical response of patient with respect to relief symptoms (lessening dyspnea and orthopnea, decrease in crackles, relief of peripheral edema).
Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures
Nursing Goals & Interventions
1. Raise head of bed 20 to 30 cm (8-10 in) reduces venous
return to heart and lungs; alleviates pulmonary congestion.
a. Support lower arms with pillows to eliminate weight on shoulder muscle
b. Sit orthopneic patient on side of bed with feet support chair, head and arms resting on an over-the-bed table, lumbosacral area supported with pillows.
2. Auscultate lung fields every 4 hours for crackles and
wheezes in dependent lung fields (fluid accumulates in areas affected by gravity).
A. Mark with water-soluble ink the level on the patient s where adventitious breath sounds are heard.
B. Use markings for comparative assessment during changes in tours of duty with other nursing personnel.
3. Observe for increased rate of respirations (could be indicative of falling arterial pH).
4. Observe for Cheyne—Stokes respirations (may occur in elderly because of a decrease in cerebral perfusion stimulating a neurogenic response).
5. Position the patient every 2 hours (or encourage the patient to change position frequently) to help prevent atelectasis and
pneumonia.
6. Encourage deep-breathing exercises every 1 to 2 hours to
avoid atelectasis.
7. Offer small, frequent feedings to avoid excessive gastric
filling and abdominal distention with subsequent elevation of diaphragm that causes decrease in lung capacity.
8. Administer oxygen as directed.