Congestive heart failure is a condition in which the heart is unable to pump blood effectively. This can lead to shortness of breath, fluid accumulation in the lungs, and edema (swelling) of the legs or other parts of the body. The nurse’s role in caring for patients with CHF is to monitor for signs and symptoms related to congestive heart failure and provide interventions aimed at preventing complications from developing.
Congestive Heart Failure Nursing Diagnosis
1 Ineffective airway clearance related to an accumulation of secretions.
Patients with CHF may have difficulty breathing and shortness of breath. They may experience chest congestion, wheezing, dyspnea and/or feeling of impending suffocation. Ineffective airway clearance related to an accumulation of secretions can lead to a buildup of mucus in the lungs that make it difficult for oxygen to enter the bloodstream.
When a patient’s blood flow is decreased due to heart failure, this causes less blood flow through the lungs and reduces their ability to breathe properly by clearing out excess fluid from the respiratory tract (nose, throat and windpipe). This results in increased amounts of secretions such as sputum or phlegm which can be difficult or impossible for patients who have weakened respiratory muscles due to chronic injury caused by fluid accumulation within their lungs or bronchi (tubes leading into airways).
2 Ineffective breathing pattern related to a decreased respiratory rate.
Respiratory rate is the number of breaths a person takes in one minute. It’s measured by counting how many times your patient breathes in one minute, and you can do this with a watch or by counting out loud. A normal respiratory rate is 12-20 breaths per minute (bpm). In patients with CHF, respiratory rate may be decreased due to difficulty breathing through the narrowed airways caused by edema or other interstitial lung disease. To monitor this condition, check your patient’s respiratory status every shift—especially if they have symptoms such as shortness of breath or fatigue—and keep track of what changes when you note an increase/decrease in their respiratory status over time
3 Fatigue related to the inability of the heart to pump blood effectively.
Fatigue is a common symptom of CHF, and it can result from a number of factors. Often, it’s caused by the fact that your heart cannot pump blood effectively to supply oxygen to your tissues. The lack of oxygen in your blood results in shortness of breath and may also cause you to feel dizzy or lightheaded.
If you have CHF, it’s important for you to understand the symptoms and risks associated with this condition so that you can take action quickly when necessary.
4 Risk for ineffective cardiac tissue perfusion related to decreased perfusion of oxygen and nutrients to body tissues.
Ineffective Cardiac Tissue Perfusion Related to Decreased Perfusion of Oxygen and Nutrients to Body Tissues
Risk for ineffective cardiac tissue perfusion related to decreased perfusion of oxygen and nutrients to body tissues. Ineffective cardiac tissue perfusion may be a result of several factors: acute or chronic changes in heart function, autonomic nervous system dysfunction or failure, decreased systemic blood pressure, reduced venous return from the extremities (secondary to decreased venous tone), low cardiac output states (e.g., hypotension), sustained tachycardia or bradycardia, respiratory acidosis and alkalosis. The patient with this condition is at increased risk for the development of other health problems such as pulmonary edema if compensatory mechanisms are not functioning well enough.
5 Risk for diminished cardiac output related to decreased ability of the heart muscle to contract.
For example, the heart may not be able to contract forcefully enough to pump blood through the body. This is known as congestive heart failure. The lungs may also be affected by the condition, causing shortness of breath and fatigue.
Heart failure can occur in people of all ages, though it is most common in adults over 55 years old or those who have had a previous heart attack. People with diabetes are also at increased risk for developing this condition because diabetes affects the way their bodies use sugar and other nutrients that help keep the heart healthy.
6 Nursing interventions and monitoring are important in CHF.
Nursing interventions and monitoring are important in CHF. The nurse should monitor the patient’s symptoms, cardiac status, respiratory status, fluid status, nutrition status and mental status. Nursing also includes pain management as part of nursing care plan for a patient with CHF.
In the end, CHF is a serious condition that deserves to be monitored and treated. The nursing interventions and monitoring are the most important aspects of care for patients with CHF.