Hemodynamic ValuesGrab the Free Cheatsheet"What's the Standard Cardiac Output level?" Want a Free Hemodynamics Values Cheatsheet?

Nursing Care Plan for CHF

Pathophysiology

Fluid back up in the heart causing the heart to fail its’ functionality and pump ineffectively. Heart failure can be in the left side, right side or both. When both sides are failing, it is called congestive heart failure. Heart failure is measured by ejection fraction. Normally functioning hearts have 50% or higher ejection fractions. Anything less is concerning for heart failure.

Etiology

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, heart arrhythmias, etc. Also any other comorbidities such as diabetes, thyroid issues, HIV, etc. contribute to heart failure occurring. If the CHF is acute in nature, it may have been caused by a virus, infection, or blood clot.

Desired Outome

maximized cardiac functionality as well as decreased stress on the cardiovascular system.

Congestive Heart Failure (CHF) Nursing Care Plan

Subjective Data:

Difficulty in Breathing

 

Coughing (produces a white or pink tinged mucus)

 

Heart palpitations or feeling like the heart is racing.

Objective Data:

Leg edema

 

Crackles in the lung bases

 

Shortness of breath upon exertion

 

Confusion


Nursing Interventions and Rationales:

  1. 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.
  2. 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. Try to stay between 300-600 mg of salt in a serving. Also be aware of salt substitute and the patients K+!
  3. Monitor BNP Normal 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.
  4. Assess respiratory function: Listen to breath sounds Monitor O2 saturation
    • 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.
  5. 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 administer diuretics.

      The FIRST thing you do BEFORE you administer a diuretic is have 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 a walkie talkie 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 patients 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...

      There are three kinds of diuretics: Loop, Thiazide, and potassium sparing.

      Loop: works on the loop of henle and excretes Na+, K+, and Ca-. (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 ever 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
  6. Strict intake and output (I&O’s)
    • These patients should 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.
  7. Monitor swelling/edema
    • 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).
      +1: mild indent
      +2: Moderate indent
      +3: Deep indent
      +4: Very deep indent

References

Date Published - Jun 2, 2017
Date Modified - Jun 30, 2017