Care Plan for Congestive Heart Failure (CHF)

Category / Primary Body System

• Cardiovascular System

Problem

• Patient is at risk for complications due to Congestive Heart Failure (CHF).

Goal

• Patient will not experience CHF exacerbation for the next 90 days.

Plan/Approach

1. Medication Management

   • Administer medications as ordered to manage CHF and prevent exacerbations.

2. Monitoring and Assessment

   • Check labs as ordered to monitor the patient's response to treatment and overall health status.
   • Monitor for signs of CHF exacerbation (e.g., increased edema, wheezing) and notify MD/RNP promptly.

3. Dietary Management

   • Provide diet as ordered, ensuring it is low in sodium and fluids if necessary to manage CHF symptoms.

4. Patient Education

   • Educate the patient about energy conservation techniques to manage fatigue and prevent overexertion.
   • Encourage rest periods during activities to allow the patient to conserve energy and avoid strain.

5. Diagnostic Monitoring

   • Check x-ray as needed to assess the patient's cardiac and pulmonary status.

6. Communication and Reporting

   • Notify MD/RNP immediately for signs of CHF exacerbation, such as increased edema or wheezing.

Rationale

1. Medication Management

   • Administering medications as prescribed helps control symptoms and prevent exacerbations of CHF.

2. Monitoring and Assessment

   • Regular lab tests and monitoring for signs of exacerbation ensure early detection and management of potential complications.

3. Dietary Management

   • A low-sodium diet helps manage fluid retention, a common issue in CHF.

4. Patient Education

   • Teaching energy conservation techniques and encouraging rest helps the patient manage symptoms and improve quality of life.

5. Diagnostic Monitoring

   • Regular x-rays can provide important information about the patient’s cardiac and pulmonary status, guiding treatment adjustments.

6. Communication and Reporting

   • Promptly reporting signs of exacerbation allows for timely interventions, reducing the risk of severe complications.

Actions

1. Medication Management

   • Administer prescribed CHF medications on schedule, monitoring for effectiveness and any side effects.
   • Document medication administration and the patient's response.

2. Monitoring and Assessment

   • Check labs as ordered, including BNP, electrolytes, kidney function tests, and document the results.
   • Monitor for signs of CHF exacerbation, such as increased edema, wheezing, shortness of breath, and notify the MD/RNP immediately if these signs are observed.

3. Dietary Management

   • Provide a heart-healthy diet as ordered, focusing on low sodium and appropriate fluid restrictions.
   • Educate the patient on dietary choices to help manage CHF symptoms.

4. Patient Education

   • Teach the patient energy conservation techniques, such as sitting while performing tasks and taking frequent breaks.
   • Encourage the patient to take rest periods during activities, and document their adherence to these recommendations.

5. Diagnostic Monitoring

   • Schedule and review chest x-rays as needed, and communicate findings with the healthcare team.

6. Communication and Reporting

   • Notify the MD/RNP of any signs of CHF exacerbation immediately, and document the communication and any actions taken.