CHF Nursing Care Plan

Nursing Diagnosis 1: Fluid Volume Excess

Fluid Volume Excess related to Congestive Heart Failure (CHF) exacerbation; classified by ejection fraction as HFrEF (LVEF ≤ 40%), HFmrEF (41–49%), or HFpEF (≥ 50%) as evidenced by Bilateral 2+ pitting lower-extremity edema; Worsening shortness of breath at rest; Bibasilar crackles on auscultation; Elevated BNP > 400 pg/mL; Weight gain > 2 kg in 48 hours.

Interventions

• Monitor and document daily weights at the same time, on the same scale, in the same garments.
• Auscultate breath sounds in all lung fields at intervals matched to clinical acuity and facility protocol; document presence and distribution of crackles.
• Assess peripheral edema location, pitting grade (1–4+), and symmetry per facility protocol.
• Maintain strict intake and output (I&O); calculate net 24-hour balance per facility protocol.
• Monitor BNP, electrolytes (K⁺, Mg²⁺, Na⁺), and renal function (BUN, Cr) per provider order.
• Assess for JVD with head of bed at 30–45° per facility protocol.
• Administer prescribed loop diuretics as ordered per provider direction, pharmacy guidance, and facility protocol.
• Position the patient in semi-Fowler’s to high-Fowler’s as tolerated and per facility protocol.
• Support the ordered fluid restriction (commonly 1.5–2 L/day in decompensation) per provider order and facility protocol.
• Administer ordered K⁺ and Mg²⁺ replacement per provider direction and facility protocol when levels are below ordered parameters.
• Coordinate with the dietitian for a low-sodium diet (commonly ≤ 2 g/day) per provider order and facility protocol.
• Teach the patient daily weights at home (same time, same scale, same garments); contact the provider for a gain of > 2 lb (1 kg) overnight or > 5 lb in a week, or as instructed by the provider.
• Educate the patient and family on reading food labels for sodium content per provider direction.
• Teach the importance of consistent diuretic dosing per provider direction (commonly in the morning) and using a marked container to track fluid intake.
• Notify the provider for UOP < 30 mL/hr for 2 consecutive hours, weight gain > 2 kg in 48 hours, new orthopnea, or any rapid clinical change.
• Coordinate referral to home health for post-discharge weight and medication monitoring per facility protocol.

Outcome: Weight, I&O, and perfusion indicators are monitored and reported within ordered parameters; Peripheral edema, lung sounds, and JVD are reassessed and trended per facility protocol; BNP trend (when ordered) is documented and reported to the provider team.

Nursing Diagnosis 2: Impaired Gas Exchange

Gas Exchange Impairment related to Congestive Heart Failure (CHF) exacerbation; classified by ejection fraction as HFrEF (LVEF ≤ 40%), HFmrEF (41–49%), or HFpEF (≥ 50%) as evidenced by Dyspnea with minimal exertion; Orthopnea; Bibasilar crackles; SpO₂ below ordered parameters on room air; Increasing supplemental oxygen requirement.

Interventions

• Monitor SpO₂ continuously and document the trend per facility protocol.
• Assess respiratory rate, depth, effort, accessory-muscle use, and breath sounds at intervals matched to clinical acuity and facility protocol.
• Auscultate breath sounds in all lung fields per facility protocol.
• Monitor and report ABG values per provider order; flag pH < 7.30, PaO₂ < 60 mmHg, or rising PaCO₂.
• Observe for signs that may reflect worsening cerebral hypoxia: restlessness, confusion, behavioral change, cyanosis, tachycardia, or tachypnea.
• Administer supplemental oxygen as ordered and titrate within provider parameters to support SpO₂ within the ordered range; escalate stepwise (NC, high-flow NC, non-rebreather, BiPAP, intubation) per facility protocol.
• Position the patient in high-Fowler’s or with HOB elevated 30–45° as tolerated and per facility protocol.
• Coach diaphragmatic and pursed-lip breathing techniques when the patient is alert and able to participate.
• Encourage incentive spirometry per facility protocol when the patient is alert and able to participate.
• Suction the airway as needed and per facility protocol when secretions are excessive and the patient’s cough is ineffective.
• Anticipate and prepare for non-invasive ventilation (BiPAP) or intubation per facility protocol when work of breathing or oxygenation is worsening despite optimized therapy.
• Teach pursed-lip and diaphragmatic breathing techniques the patient can use independently when dyspneic.
• Educate the patient on activity pacing and energy-conservation techniques.
• Educate the patient and family on early signs of worsening dyspnea that should prompt 911 or emergency evaluation: severe SOB at rest, chest pain, new confusion, cyanosis, or pink frothy sputum.
• Notify the provider for SpO₂ below ordered parameters despite oxygen titration, new orthopnea at < 30° HOB, pink frothy sputum, or any rapid clinical change.
• Coordinate with respiratory therapy for advanced airway and ventilation support per facility protocol when non-invasive measures are not maintaining ordered parameters.

Outcome: Patient maintains SpO₂ within ordered parameters with the lowest support that meets the goal; Respiratory rate stays within ordered parameters with no accessory-muscle use; ABG findings are monitored and reported per facility protocol.

Nursing Diagnosis 3: Activity Intolerance

Activity Intolerance related to Congestive Heart Failure (CHF) exacerbation; classified by ejection fraction as HFrEF (LVEF ≤ 40%), HFmrEF (41–49%), or HFpEF (≥ 50%) as evidenced by Dyspnea with minimal exertion (commonly < 10 ft ambulation); Patient-reported fatigue and weakness; Requires standby assist with ambulation; HR rise disproportionate to clinical state with minimal exertion; Poor sleep due to orthopnea or nocturnal diuresis.

Interventions

• Monitor vital signs (HR, BP, RR, SpO₂) before, during, and after activity per facility protocol.
• Assess patient-reported dyspnea on a 0–10 scale before and after activity.
• Assess sleep quality and duration daily; identify orthopnea or nocturnal awakening as contributors.
• Observe for signs of overexertion: pallor, diaphoresis, chest pain, syncope, palpitations.
• Assist with ADLs as needed; cluster cares to allow uninterrupted rest periods.
• Collaborate with physical therapy on a progressive mobility plan per facility protocol, starting with short supervised activity.
• Pause activity per facility protocol when vital signs cross ordered thresholds (commonly SBP drop > 20 mmHg, HR rise > 20% above resting, SpO₂ falling below ordered parameters, new chest pain, new dysrhythmia, or syncope) and notify the provider.
• Provide rest periods between activities and after ADLs per facility protocol.
• Educate on energy-conservation techniques: pace activities, prioritize tasks, sit while performing tasks when possible.
• Teach the patient to recognize their personal dyspnea threshold and to rest before reaching it.
• Educate on the value of consistent activity at tolerated levels rather than prolonged bed rest.
• Coordinate with physical therapy and occupational therapy for outpatient cardiac rehabilitation referral per provider order.
• Notify the provider for new or worsening exertional dyspnea, chest pain, or syncope.

Outcome: Patient reports decreased fatigue when clinical state permits; Patient ambulates within ordered parameters with the appropriate level of assistance; HR and BP return toward baseline within the expected window after activity per facility protocol.

Nursing Diagnosis 4: Impaired Cardiac Output

Cardiac Output Alteration related to Congestive Heart Failure (CHF) exacerbation; classified by ejection fraction as HFrEF (LVEF ≤ 40%), HFmrEF (41–49%), or HFpEF (≥ 50%) as evidenced by Jugular venous distention (JVD); S₃ gallop on auscultation; Decreased peripheral perfusion (cool extremities, capillary refill > 3 sec); Urine output < 0.5 mL/kg/hr; Patient-reported fatigue and dyspnea.

Interventions

• Monitor cardiac rhythm continuously and document any new arrhythmias.
• Assess apical and peripheral pulses for rate, rhythm, and quality per facility protocol.
• Check capillary refill, skin temperature, and color per facility protocol.
• Monitor urine output hourly via Foley catheter when ordered; notify the provider for UOP < 30 mL/hr (or < 0.5 mL/kg/hr) for 2 consecutive hours.
• Assess level of consciousness, orientation, and behavior per facility protocol.
• Auscultate heart sounds for a new S₃ or S₄ gallop per facility protocol.
• Administer prescribed cardiac medications (loop diuretic, beta-blocker, ACE-I/ARB/ARNI, MRA, SGLT2 inhibitor) as ordered per provider direction, pharmacy guidance, and facility protocol.
• Recheck HR and BP before each cardiac medication dose; hold and notify the provider per facility hold parameters (commonly HR below ordered parameters or SBP < 90 mmHg).
• Maintain reliable IV access per facility protocol for potential vasoactive medication administration.
• Administer ordered vasoactive support (e.g., norepinephrine, dobutamine) as ordered per provider direction and facility protocol when initiated; monitor MAP, rhythm, urine output, peripheral perfusion, and signs of extravasation.
• Provide adequate rest periods between care activities.
• Teach the patient to recognize and report signs of worsening cardiac output: increased fatigue, new confusion, decreased UOP, dizziness, or syncope.
• Educate on medication adherence and on contacting the provider before stopping any cardiac medication, including HF-indicated beta-blockers.
• Escalate per facility protocol for findings consistent with cardiogenic shock (e.g., persistent SBP < 90 mmHg or below ordered parameters, mottling, new confusion, UOP < 0.5 mL/kg/hr) and notify the provider team and rapid response per facility policy.
• Coordinate cardiology consultation per provider order for evaluation of advanced HF therapies when symptoms are refractory.

Outcome: Urine output, perfusion, and vital signs are monitored and reported within ordered parameters; Extremities are reassessed for warmth, color, and capillary refill per facility protocol; Mental status is reassessed and changes are reported promptly.

Nursing Diagnosis 5: Anxiety

Anxiety related to Congestive Heart Failure (CHF) exacerbation; classified by ejection fraction as HFrEF (LVEF ≤ 40%), HFmrEF (41–49%), or HFpEF (≥ 50%) as evidenced by Patient verbalization of fear of dying or worsening; Restlessness, inability to sit still; Tachycardia disproportionate to clinical state; Orthopnea and the felt experience of breathlessness; Sleep disturbance.

Interventions

• Assess anxiety level using a 0–10 scale at the start of every shift and PRN.
• Identify the patient’s stated triggers (breathlessness, monitor alarms, fear of dying, sleep disturbance).
• Observe for physical signs of anxiety: tachycardia out of proportion to clinical state, restlessness, hand-wringing, hypervigilance.
• Assess sleep quality and contributors (alarms, lighting, frequent interventions, orthopnea, anxiety) daily.
• Provide a calm, reassuring presence; speak clearly and at a measured pace.
• Explain procedures and findings in plain, patient-friendly terms before performing them.
• Cluster cares to allow uninterrupted rest periods when clinical state permits.
• Limit non-essential nighttime stimuli (overhead lights, loud conversations, unnecessary alarms) per facility protocol.
• Facilitate family presence per facility policy.
• Teach diaphragmatic breathing and grounding techniques the patient can use independently.
• Educate the patient and family on what the alarms mean and what is and is not clinically concerning.
• Teach progressive muscle relaxation as a sleep-onset aid.
• Coordinate with chaplaincy, social work, or psych services per facility protocol when anxiety persists or worsens despite non-pharmacologic measures.
• Notify the provider for severe or persistent anxiety unresponsive to non-pharmacologic measures.

Outcome: Patient verbalizes decreased anxiety; Patient demonstrates use of at least one coping strategy; HR consistent with clinical state.

Congestive heart failure (CHF) is a clinical syndrome in which the heart cannot pump or fill adequately to meet the body’s metabolic demands. Left-sided failure produces pulmonary congestion: dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and crackles. Right-sided failure produces systemic venous congestion: peripheral edema, JVD, hepatomegaly, and ascites. Biventricular failure presents with both.

Modern HF is classified by ejection fraction. HFrEF (LVEF ≤ 40%) reflects systolic dysfunction with eccentric ventricular remodeling and is the form with the richest mortality-reducing therapy (the four GDMT pillars: ARNI or ACE-I/ARB, beta-blocker, MRA, SGLT2 inhibitor). HFpEF (LVEF ≥ 50%) reflects diastolic dysfunction with concentric hypertrophy and stiff ventricles that fail to relax; congestion is similar but GDMT options are narrower — SGLT2 inhibitors carry a Class I indication (EMPEROR-Preserved, DELIVER), ARNI a Class IIb signal (PARAGON-HF), MRA a Class IIb signal, and diuretics support volume control. HFmrEF (41–49%) is generally treated more like HFrEF per current guidance.

As cardiac output drops, the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system activate, driving fluid retention and vasoconstriction that further increase myocardial workload, producing a self-reinforcing cycle of progressive cardiac remodeling and clinical deterioration. Common etiologies include ischemic, hypertensive, valvular, and cardiomyopathic disease. Stage A–D (ACC/AHA) and NYHA I–IV functional class anchor risk stratification and prognosis. Acute decompensated CHF can deteriorate rapidly to cardiogenic pulmonary edema or shock; the nursing role is to recognize early signs, support ordered therapy safely, monitor response and adverse effects, and escalate concerns to the provider team per facility protocol.

• EF classification: HFrEF ≤ 40 / HFmrEF 41–49 / HFpEF ≥ 50
• SpO₂ target: Within ordered parameters (commonly ≥ 92% on RA)
• Daily weights: Same time, same scale, same garments
• Fluid limit: Per provider order (commonly ≤ 2 L/day in decompensation)
• Sodium limit: Per provider order (commonly ≤ 2 g/day)

• Makic, M. B. F., & Martinez-Kratz, M. R. (Eds.). (2023). Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier.
• Heidenreich, P. A., Bozkurt, B., Aguilar, D., et al. (2022). 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation, 145(18), e895–e1032.