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SECTION 7 Problems of Oxygenation: Perfusion

may not regularly use his or her continuous positive airway

pressure device at night causing poorly controlled hypertension
and ultimately an exacerbation of HF.
NURSING DIAGNOSES
Priority nursing diagnoses for the patient with HF include, but
are not limited to, those presented in NCP 35-1.

PLANNING
The overall goals for the patient with HF include (1) a decrease
in symptoms (e.g., shortness of breath, fatigue), (2) a decrease
in peripheral edema, (3) an increase in exercise tolerance, (4)
compliance with the medical regimen, and (5) no complications
related to HF.

NURSING CARE PLAN 35-1

Patient with Heart Failure
NURSING DIAGNOSIS

Excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to cardiac failure as
evidenced by rapid weight gain, edema, adventitious breath sounds, oliguria, and patients statement, My ankles are so
swollen
Experiences reduction or absence of edema and stable baseline weight

PATIENT GOAL
OUTCOMES (NOC)
Fluid Balance

Stable body weight _____

Peripheral pulses _____
Serum electrolytes _____
BP _____
CVP _____
24-hour I/O balance _____

Measurement Scale

1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

INTERVENTIONS (NIC) AND RATIONALES

Hypervolemia Management
Administer prescribed diuretics, as appropriate, to treat hypervolemia.
Monitor for therapeutic effect of diuretic (e.g., increased urine output, decreased CVP/PAWP, and
decreased adventitious breath sounds) to assess response to treatment.
Monitor potassium levels after diuresis to detect excessive electrolyte loss.
Weigh patient daily and monitor trends to evaluate effect of treatment.
Monitor intake and output to assess fluid status.
Monitor respiratory pattern for symptoms of respiratory difficulty to detect pulmonary edema.
Monitor hemodynamic status, including CVP, MAP, PAWP, if available, to evaluate effectiveness
of therapy.
Monitor changes in peripheral edema to assess response to treatment.

Ascites _____
Neck vein distention _____
Peripheral edema _____
Adventitious breath sounds

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

NURSING DIAGNOSIS

Impaired gas exchange related to increased preload and alveolar-capillary membrane changes as evidenced by abnormal
arterial blood gases, hypoxemia, dyspnea, tachypnea, tachycardia, restlessness, and patients statement, I am so short
of breath
Maintains adequate O2/carbon dioxide exchange at the alveolar-capillary membrane to meet O2 needs of the body

PATIENT GOAL
OUTCOMES (NOC)
Respiratory Status: Gas Exchange

INTERVENTIONS (NIC) AND RATIONALES

Respiratory Monitoring

Monitor rate, rhythm, depth, and effort of respirations to evaluate changes in respiratory status.
Auscultate breath sounds, noting areas of decreased/absent ventilation and presence of adventitious
sounds to detect presence of pulmonary edema.
Monitor for increased restlessness, anxiety, and air hunger to detect increasing hypoxemia.

Cognitive status _____

Ease of breathing _____
O2 saturation _____
PaO2 _____

Measurement Scale

1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

Dyspnea with exertion _____

Dyspnea at rest _____
Restlessness _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

Oxygen Therapy
Administer supplemental O2 as ordered to maintain O2 levels.
Monitor the O2 liter flow and position of O2 delivery device to ensure O2 is adequately delivered.
Change O2 delivery device from mask to nasal prongs during meals as tolerated to sustain O2 levels
while eating.
Monitor the effectiveness of O2 therapy to identify hypoxemia and establish range of O2 saturation.

Positioning
Position to alleviate dyspnea (e.g., semi-Fowlers position), as appropriate, to improve ventilation by
decreasing venous return to the heart and increasing thoracic capacity.

ADLs, Activities of daily living; BP, blood pressure; CVP, central venous pressure; I/O, intake and output; HF, heart failure; MAP, mean arterial pressure; PaO2, partial pressure of oxygen
in arterial blood; PAWP, pulmonary artery wedge pressure.

CHAPTER 35 Heart Failure

811

NURSING CARE PLAN 35-1contd

Patient with Heart Failure
NURSING DIAGNOSIS

Activity intolerance related to fatigue secondary to cardiac insufficiency and pulmonary congestion as evidenced by dyspnea,
shortness of breath, weakness, increase in heart rate on exertion, and patients statement, I feel too weak to do anything
Will achieve a realistic program of activity that balances physical activity with energy-conserving activities

PATIENT GOAL
OUTCOMES (NOC)
Activity Tolerance

Pulse rate with activity _____

O2 saturation with activity _____
Respiratory rate with activity _____
Systolic BP with activity _____
Diastolic BP with activity _____
Electrocardiogram findings _____
Skin color _____
Ease of performing ADLs _____

Measurement Scale

1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

INTERVENTIONS (NIC) AND RATIONALES

Energy Management
Encourage alternate rest and activity periods to reduce cardiac workload and conserve energy.
Provide calming diversionary activities to promote relaxation to reduce O2 consumption and to relieve
dyspnea and fatigue.
Monitor patients O2 response (e.g., pulse rate, cardiac rhythm, and respiratory rate) to self-care or nursing activities to determine level of activity that can be performed.
Teach patient and caregiver techniques of self-care that will minimize O2 consumption (e.g., selfmonitoring and pacing techniques for performance of ADLs).

Activity Therapy
Collaborate with occupational, physical, and/or recreational therapists to plan and monitor activity/
exercise program.
Determine patients commitment to frequency and/or range of activities/exercise to provide patient
with obtainable goals.

NURSING DIAGNOSIS

Decreased cardiac output related to altered contractility, altered preload, and/or altered stroke volume as evidenced by
decreased ejection fraction, increased CVP, decreased peripheral pulses, jugular vein distention, orthopnea, S3 and S4 sounds,
and oliguria
Maintains adequate blood pumped by the heart to meet metabolic demands of the body

PATIENT GOAL
OUTCOMES (NOC)
Cardiac Pump Effectiveness

Ejection fraction _____

Systolic BP _____
Peripheral pulses _____
Urinary output _____

Measurement Scale

1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

INTERVENTIONS (NIC) AND RATIONALES

Cardiac Care
Perform a comprehensive appraisal of peripheral circulation (e.g., check peripheral pulses, edema,
capillary refill, color, and temperature of extremity) to determine circulatory status.
Note signs and symptoms of decreased cardiac output to detect changes in status.
Monitor fluid balance (e.g., I/O and daily weight) to evaluate renal perfusion.
Monitor for cardiac dysrhythmias to detect cardiac decompensation.
Monitor for dyspnea, fatigue, tachypnea, and orthopnea to identify involvement of respiratory system.
Instruct patient and caregivers on activity restriction and progression to allay fears and anxiety.

Neck vein distention _____

Abnormal heart sounds _____
Dysrhythmia _____
Dyspnea _____

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

NURSING DIAGNOSIS

Deficient knowledge related to lack of information about disease process as evidenced by questions about the disease
and patients statement, I dont know why I keep getting sick
Describes disease process and rationales for dietary, medication, and exercise regimen

PATIENT GOAL
OUTCOMES (NOC)
Knowledge: Disease Process

Description of specific disease

process _____
Description of complications _____
Description of signs and symptoms _____
Descriptions of measures to minimize
disease progression _____
Descriptions of precautions to prevent
complications _____
Measurement Scale
1 = None
2 = Limited
3 = Moderate
4 = Substantial
5 = Extensive

INTERVENTIONS (NIC) AND RATIONALES

Teaching: Disease Process
Appraise the patients current level of knowledge related to specific disease process to identify needed
areas of teaching.
Describe common signs and symptoms of the disease so patient will know signs and symptoms to
report to health care provider.
Instruct the patient and caregiver on measures to prevent/minimize side effects of treatment for the
disease so patient may be able to decrease number of acute episodes of HF.

Teaching: Prescribed Diet

Appraise the patients and caregivers current level of knowledge about prescribed diet to assess areas
needing additional instruction.

Teaching: Prescribed Medication

Review patients knowledge of medications to determine where further teaching is needed.
Include the caregiver in teaching to provide support for the patient.