Heart Failure - List of Nursing Diagnosis and Interventions

Nursing Diagnosis for Congestive Heart Failure (CHF)
  1. Decrease Cardiac Output related to :
    • Changes in myocardial contractility or inotropic changes
    • Changes in frequency, rhythm, cardiac conduction
    • Structural changes (eg, valve abnormalities, ventricular aneurysm)
  2. Activity Intolerance related to :
    • Weakness, weakness
    • Changes in vital signs, dysritmia
    • Dyspnea
    • Pale
    • Sweating
  3. Excess Fluid Volume related to
    • The reduced glomerular filtration rate (decrease in cardiac output) or increased production of ADH and sodium and water retention.
  4. Risk for Impaired Skin Integrity related to
    • Bed rest
    • Edema, decreased tissue perfusion.

    Nursing Intervention For Heart Failure
    1. Assess cardiovascular status, vital sign and hemodynamic variable to detect signs of reduced cardiac output.
    2. Assess respiratory status to detect increasing fluid in the lungs and respiratory failure.
    3. Keep the client in semi-fowler's position to increase chest expansion and improve ventilation.
    4. Administer medication as prescribed, to enhance cardiac performance and reduce excess fluids.
    5. Administer oxygen to enhance arterial oxygenation.
    6. Measure and record intake and output, Intake greater than output may indicated fluid retention.
    7. Monitor laboratory to detect electrolyte imbalances, renal failure, and impaired cardiac circulation.
    8. Provide suctioning, if necessary assist with turning and encourage coughing and deep breathing to prevent pulmonary complication.
    9. Restrict oral fluid to avoid worsening the client's condition.
    10. Weigh the client daily to detect fluid retention. A weight gain of 2lb (0,9 kg) in 1 day or 5 lb (2,3 kg) in 1 week indicates fluid gain.
    11. Measure and record the client's abdominal girth. An increased in abdominal girht suggests worsening fluid retention and right-sided heart failure.
    12. Make sure the client maintains a low-sodium diet to reduce fluid accumulation.
    13. Encourage the client to express feelings, such as a fear of dying to reduce anxiety.
    Source :
    http://articlesofnursing.blogspot.com/
    http://nandanursingdiagnosis.blogspot.com