CHF Nursing Care Plan

Pathophysiology

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 now have a Class I indication (EMPEROR-Preserved, DELIVER), ARNI a Class IIb signal (PARAGON-HF), MRA Class IIb, and diuretics for volume control. HFmrEF (41-49%) is treated more like HFrEF.

As cardiac output drops, the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system activate, causing fluid retention and vasoconstriction that further increase myocardial workload, creating a self-reinforcing cycle of progressive cardiac remodeling and clinical deterioration. Common etiologies: ischemic, hypertensive, valvular, and cardiomyopathies. Stage A-D (ACC/AHA) and NYHA I-IV functional class anchor risk stratification and prognosis.

Quick Reference

• EF classification: HFrEF ≤ 40 / HFmr 41-49 / HFpEF ≥ 50
• SpO₂ target: ≥ 92% RA
• Daily weights: Same time, same garments
• Fluid limit: ≤ 2 L/day in decompensation
• Sodium limit: ≤ 2 g/day

Common Labs

Lab	Normal range	Significance in CHF
BNP	< 100 pg/mL	> 400 = HF likely; trend response to diuresis
NT-proBNP	< 300 pg/mL	Age-adjusted cutoffs; useful in renal disease
Troponin	< 0.04 ng/mL	Rule out acute MI; mild rise common in CHF
Na+	135–145 mEq/L	Hyponatremia common; marker of poor prognosis
K+	3.5–5.0 mEq/L	Watch with diuretics + ACE-I/ARB
Mg2+	1.7–2.2 mg/dL	Loop diuretics deplete; arrhythmia risk if low
BUN / Cr	7–20 / 0.6–1.2 mg/dL	Elevated = poor renal perfusion (cardiorenal)
Hemoglobin	12–17 g/dL	Anemia worsens HF; target > 9 in most cases
ABG	pH 7.35–7.45	Respiratory acidosis if hypoventilating; check on dyspnea

Common Medications

Class	Examples	Mechanism of action	Key side effects	Nursing considerations
Loop diuretic	Furosemide (Lasix), Bumetanide	Inhibits Na+/K+/2Cl− co-transporter in loop of Henle	↓ K+, ↓ Mg2+, dehydration, ototoxicity, ↑ uric acid	Daily weights, I&O, recheck K+/Cr 4–6 h post-IV dose
ACE inhibitor	Lisinopril, Enalapril	Blocks ACE → ↓ angiotensin II → vasodilation, ↓ aldosterone	Dry cough, ↑ K+, hypotension, angioedema, ↑ Cr	BP & K+/Cr pre-dose; hold if SBP < 90; never combine with ARB
ARB	Losartan, Valsartan	Blocks AT1 receptor (downstream of ACE)	↑ K+, hypotension; cough rare (vs ACE-I)	Same monitoring as ACE-I; substitute when cough intolerable
Beta-blocker	Carvedilol, Metoprolol succinate, Bisoprolol	Blocks β1/β2 → ↓ HR, ↓ contractility, neurohormonal blockade	Bradycardia, hypotension, fatigue, bronchospasm, heart block	HR + BP pre-dose; hold for HR < 50 or SBP < 90; NEVER stop abruptly
Aldosterone antagonist	Spironolactone, Eplerenone	Blocks aldosterone → K+-sparing diuresis	↑ K+, gynecomastia (spironolactone), renal impairment	K+ weekly first month; especially watch when on ACE-I/ARB
SGLT2 inhibitor	Dapagliflozin, Empagliflozin	Inhibits renal glucose reabsorption. Class I across the EF spectrum — HFrEF (DAPA-HF, EMPEROR-Reduced), HFmrEF/HFpEF (EMPEROR-Preserved, DELIVER). Reduces hospitalization for HF + CV mortality.	Genital infections, euglycemic DKA, volume depletion	Encourage hydration; hold for surgery/illness; teach DKA signs. Works regardless of diabetes status.

Nursing Care Plan

Nursing Diagnosis 1: Fluid Volume Excess

Fluid Volume Excess related to Congestive Heart Failure (CHF) exacerbation — 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 every 4 hours; document presence and distribution of crackles.
• Assess peripheral edema location, pitting grade (1–4+), and symmetry every shift.
• Maintain strict intake and output (I&O); calculate net 24-hour balance.
• Monitor BNP, electrolytes (K⁺, Mg²⁺, Na⁺), and renal function (BUN, Cr) per provider order.
• Assess for JVD with head of bed at 30–45° every shift.
• Administer prescribed loop diuretics (IV preferred in acute decompensation) on schedule.
• Position the patient in semi-Fowler’s to high-Fowler’s as tolerated.
• Enforce fluid restriction of 1.5–2 L/day per provider order.
• Administer K⁺ and Mg²⁺ replacement per protocol when levels low.
• Coordinate with dietitian for low-sodium diet (≤ 2 g/day).
• Teach the patient daily weights at home (same time, same scale, same garments); call provider for > 2 lb (1 kg) overnight gain or 5 lb in a week.
• Educate patient and family on reading food labels for sodium content; target < 2 g/day.
• Teach the importance of consistent morning diuretic dosing and using a marked container to track fluid intake.
• Notify provider for UOP < 30 mL/hr × 2 consecutive hours, weight gain > 2 kg in 48 h, or new orthopnea.
• Coordinate referral to home health for post-discharge weight and medication monitoring.

Outcome: Weight loss of 2–3 kg within 48 hours; Reduction in peripheral edema to 1+ or less; Absence of bibasilar crackles.

Nursing Diagnosis 2: Gas Exchange Impairment

Gas Exchange Impairment related to Congestive Heart Failure (CHF) exacerbation — HFrEF (LVEF ≤ 40%), HFmrEF (41-49%), or HFpEF (≥ 50%) as evidenced by Dyspnea with minimal exertion; Orthopnea; Bibasilar crackles; SpO₂ < 92% on room air; Oxygen requirement: 2 L/min via nasal cannula.

Interventions

• Monitor SpO₂ continuously; document trend every 1–2 hours.
• Assess respiratory rate, depth, effort, and use of accessory muscles every 2 hours.
• Auscultate breath sounds in all lung fields every 4 hours.
• Monitor ABG values as ordered; report pH < 7.35 or PaO₂ < 60 mmHg.
• Observe for signs of hypoxia: restlessness, confusion, cyanosis, tachycardia, tachypnea.
• Administer supplemental oxygen as prescribed; titrate to maintain SpO₂ > 92%.
• Position patient in high-Fowler’s or with HOB elevated 30–45°.
• Coach diaphragmatic and pursed-lip breathing techniques hourly while awake.
• Encourage incentive spirometry every 1–2 hours while awake.
• Suction airway as needed if secretions are excessive and ineffective cough is present.
• Teach pursed-lip and diaphragmatic breathing techniques the patient can use independently when dyspneic.
• Educate on activity pacing and the use of energy-conservation techniques.
• Educate patient and family on early signs of worsening dyspnea requiring 911: severe SOB at rest, chest pain, confusion, cyanosis.
• Notify provider for SpO₂ < 90% despite oxygen titration, new orthopnea at < 30° HOB, or pink frothy sputum.
• Coordinate respiratory therapy consult for advanced airway support if non-invasive measures fail.

Outcome: SpO₂ ≥ 92% on room air or minimal O₂ support; Respiratory rate within 12–20 breaths/min; Decreased work of breathing, no accessory-muscle use.

Nursing Diagnosis 3: Activity Intolerance

Activity Intolerance related to Congestive Heart Failure (CHF) exacerbation — HFrEF (LVEF ≤ 40%), HFmrEF (41-49%), or HFpEF (≥ 50%) as evidenced by Dyspnea with minimal exertion (< 10 ft ambulation); Patient-reported fatigue and weakness; Requires standby assist with ambulation; HR rise from baseline 88 to 124 bpm with minimal exertion; Poor sleep due to orthopnea and nocturnal diuresis.

Interventions

• Monitor vital signs (HR, BP, RR, SpO₂) before, during, and after activity.
• 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 starting with short supervised walks.
• Stop activity if SBP drops > 20 mmHg, HR rises > 20% above resting, or SpO₂ falls < 92%.
• Provide rest periods of at least 30 minutes between activities and after ADLs.
• Educate on energy-conservation techniques: pace activities, prioritize tasks, sit while performing tasks when possible.
• Teach the patient to recognize their own dyspnea threshold and to rest before reaching it.
• Educate on the importance of consistent activity at tolerated levels rather than prolonged bed rest.
• Coordinate with physical therapy and occupational therapy for outpatient cardiac rehabilitation referral.
• Notify provider for new or worsening exertional dyspnea, chest pain, or syncope.

Outcome: Patient reports decreased fatigue; Patient ambulates 50 ft with standby assistance without dyspnea; HR returns to within 10 bpm of baseline within 5 minutes of activity cessation.

Nursing Diagnosis 4: Cardiac Output Alteration

Cardiac Output Alteration related to Congestive Heart Failure (CHF) exacerbation — 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

• Continuously monitor cardiac rhythm; document any new arrhythmias.
• Assess apical and peripheral pulses for rate, rhythm, and quality every 4 hours.
• Check capillary refill, skin temperature, and color every 4 hours.
• Monitor urine output hourly; report < 30 mL/hr × 2 consecutive hours.
• Assess level of consciousness, orientation, and behavior every 4 hours.
• Auscultate heart sounds for new S₃ or S₄ gallops.
• Administer prescribed cardiac medications (beta-blocker, ACE-I/ARB, aldosterone antagonist, SGLT2 inhibitor) on schedule.
• Recheck BP and HR before each cardiac medication dose; hold and notify provider per parameters.
• Maintain IV access for emergency vasoactive medications.
• Provide adequate rest periods between care activities.
• Teach the patient to recognize and report signs of worsening cardiac output: increased fatigue, confusion, decreased UOP, dizziness.
• Educate on medication adherence and the importance of never abruptly stopping beta-blockers.
• Escalate immediately for signs of cardiogenic shock: persistent SBP < 90 mmHg, mottling, decreased LOC, UOP < 0.5 mL/kg/hr.
• Coordinate cardiology consultation for advanced heart failure therapy evaluation if symptoms refractory.

Outcome: Urine output ≥ 0.5 mL/kg/hr; Warm and dry extremities with capillary refill < 3 sec; HR and BP within ordered parameters.

Nursing Diagnosis 5: Anxiety

Anxiety related to Congestive Heart Failure (CHF) exacerbation — 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).
• Observe for physical signs: tachycardia disproportionate to clinical state, restlessness, hand-wringing.
• Provide a calm, reassuring presence; speak clearly and at a measured pace.
• Explain procedures and findings in patient-friendly terms before performing them.
• Cluster cares to allow uninterrupted rest periods of at least 30 minutes.
• Limit nonessential stimuli at night (overhead lights, loud conversations, unnecessary alarms).
• 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 if anxiety persists or worsens.
• Notify 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.

References

• 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.