16+ Heart Failure Nursing Care Plans

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16+ Heart Failure Nursing Care Plans

Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body.
Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood volume.
Heart failure is not a disease itself, instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.
Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure.

Nursing Care Plans

Nursing care for patients with heart failure includes support to improve heart pump function by various nursing interventions, prevention and identification of complications, and providing a teaching plan for lifestyle modifications.
Here are 16+ nursing care plans (NCP) for patients with Heart Failure:

1. Decreased Cardiac Output

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands of the body.
Nursing Diagnosis
  • - Decreased Cardiac Output
May be related to
  • - Altered myocardial contractility/inotropic changes
  • - Alterations in rate, rhythm, electrical conduction
  • - Structural changes (e.g., valvular defects, ventricular aneurysm)
Possibly evidenced by
  • - Increased heart rate (tachycardia), dysrhythmias, ECG changes
  • - Changes in BP (hypotension/hypertension)
  • - Extra heart sounds (S3, S4)
  • - Decreased urine output
  • - Diminished peripheral pulses
  • - Cool, ashen skin; diaphoresis
  • - Orthopnea, crackles, JVD, liver engorgement, edema
  • - Chest pain
Desired Outcomes
  • - Patient will display vital signs within acceptable limits, dysrhythmias absent/controlled, and no symptoms of failure (e.g., hemodynamic parameters within acceptable limits, urinary output adequate).
  • - Patient will report decreased episodes of dyspnea, angina.
  • - Patient will Participate in activities that reduce cardiac workload.
Nursing InterventionsRationale
Auscultate apical pulse, assess heart rate, rhythm. Document dysrhythmia if telemetry is available.Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and atrial fibrillation (AF) are common dysrhythmias associated with HF, although others may also occur.Note: Intractable ventricular dysrhythmias unresponsive to medication suggest ventricular aneurysm.
Note heart sounds.S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3and S4), produced as blood flows into noncompliant chambers. Murmurs may reflect valvular incompetence.
Palpate peripheral pulses.Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post tibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans (strong beat alternating with weak beat) may be present.
Monitor BP.In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate, and profound hypotension may occur.
Inspect skin for pallor, cyanosis.Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases.
Monitor urine output, noting decreasing output and concentrated urine.Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent.
Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression.May indicate inadequate cerebral perfusion secondary to decreased cardiac output.
Encourage rest, semirecumbent in bed or chair. Assist with physical care as indicated.Physical rest should be maintained during acute or refractory HF to improve efficiency of cardiac contraction and to decrease myocardial oxygen demand/ consumption and workload.
Provide quiet environment: explain therapeutic management, help patient avoid stressful situations, listen and respond to expressions of feelings.Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate.
Provide bedside commode. Have patient avoid activities eliciting a vasovagal response (straining during defecation, holding breath during position changes).Commode use decreases work of getting to bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function.
Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase activity as tolerated.Decreases venous stasis, and may reduce incidence of thrombus or embolus formation.
Check for calf tenderness, diminished pedal pulses, swelling, local redness, or pallor of extremity.Reduced cardiac output, venous pooling, and enforced bed rest increases risk of thrombophlebitis.
Withhold digitalis preparation as indicated, and notify physician if marked changes occur in cardiac rate or rhythm or signs of digitalis toxicity occur.Incidence of toxicity is high (20%) because of narrow margin between therapeutic and toxic ranges. Digoxin may have to be discontinued in the presence of toxic drug levels, a slow heart rate, or low potassium level.
Administer supplemental oxygen as indicated.Increases available oxygen for myocardial uptake to combat effects of hypoxia.
Administer medications as indicated:
  • Diuretics: furosemide (Lasix), ethacrynic acid (Edecrin), bumetanide (Bumex), spironolactone (Aldactone).
Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in patients with stages I and II HF. In general, type and dosage of diuretic depend on cause and degree of HF and state of renal function. Preload reduction is most useful in treating patients with a relatively normal cardiac output accompanied by congestive symptoms. Loop diuretics block chloride reabsorption, thus interfering with the reabsorption of sodium and water.
  • Vasodilators: nitrates (Nitro-Dur, Isordil);
  • arterial dilators: hydralazine (Apresoline);
  • combination drugs:prazosin (Minipress);
Vasodilators are the mainstay of treatment in HF and are used to increase cardiac output, reducing circulating volume (venodilators) and decreasing SVR, thereby reducing ventricular workload. Note: Parenteral vasodilators (Nitroprusside) are reserved for patients with severe HF or those unable to take oral medications.
  • ACE inhibitors: benazepril (Lotensin), captopril (Capoten), lisinopril (Prinivil), enalapril (Vasotec), quinapril (Accupril), ramipril (Altace), moexipril (Univasc).
ACE inhibitors represent first-line therapy to control heart failure by decreasing ventricular filling pressures and SVR while increasing cardiac output with little or no change in BP and heart rate.
  • Angiotensin II receptor antagonists: eprosartan (Teveten), irbesartan (Avapro), valsartan (Diovan);
Antihypertensive and cardioprotective effects are attributable to selective blockade of AT1(angiotensin II) receptors and angiotensin II synthesis.
  • - Digoxin (Lanoxin)
Increases force of myocardial contraction when diminished contractility is the cause of HF, and slows heart rate by decreasing conduction velocity and prolonging refractory period of the atrioventricular (AV) junction to increase cardiac efficiency /output.
  • Inotropic agents: amrinone (Inocor), milrinone (Primacor), vesnarinone (Arkin-Z);
These medications are useful for short-term treatment of HF unresponsive to cardiac glycosides, vasodilators, and diuretics in order to increase myocardial contractility and produce vasodilation. Positive inotropic properties have reduced mortality rates 50% and improved quality of life.
  • Beta-adrenergic receptor antagonists: carvedilol (Coreg), bisoprolol (Zebeta), metoprolol (Lopressor);
Useful in the treatment of HF by blocking the cardiac effects of chronic adrenergic stimulation. Many patients experience improved activity tolerance and ejection fraction.
  • - Morphine sulfate.
Decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety.
  • - Antianxiety agents and sedatives.
Promote rest, reducing oxygen demand and myocardial workload.
  • - Anticoagulants: low-dose heparin, warfarin (Coumadin).
May be used prophylactically to prevent thrombus and embolus formation in presence of risk factors such as venous stasis, enforced bed rest, cardiac dysrhythmias, and history of previous thrombotic episodes.
Administer IV solutions, restricting total amount as indicated. Avoid saline solutions.Because of existing elevated left ventricular pressure, patient may not tolerate increased fluid volume (preload). Patients with HF also excrete less sodium, which causes fluid retention and increases myocardial workload.
Monitor and replace electrolytes.Fluid shifts and use of diuretics can alter electrolytes (especially potassium and chloride), which affect cardiac rhythm and contractility.
Monitor serial ECG and chest x-ray changes.ST segment depression and T wave flattening can develop because of increased myocardial oxygen demand, even if no coronary artery disease is present. Chest x-ray may show enlarged heart and changes of pulmonary congestion.
Measure cardiac output and other functional parameters as indicated.Cardiac index, preload, afterload, contractility, and cardiac work can be measured noninvasively by using thoracic electrical bioimpedance (TEB) technique. Useful in determining effectiveness of therapeutic interventions and response to activity.
Monitor laboratory studies:
  • - BUN, creatinine.
Elevation of BUN or creatinine reflects kidney hypoperfusion.
  • - Liver function studies (AST, LDH).
May be elevated because of liver congestion and indicate need for smaller dosages of medications that are detoxified by the liver.
  • - Prothrombin time (PT), activated partial thromboplastin time (aPTT) coagulation studies.
Measures changes in coagulation processes or effectiveness of anticoagulant therapy.
  • - Prepare for insertion and maintenance of pacemaker, if indicated.
May be necessary to correct bradydysrhythmias unresponsive to drug intervention, which can aggravate congestive failure and/or produce pulmonary edema.
Prepare for surgery as indicated:
  • - Valve replacement, angioplasty, coronary artery bypass grafting (CABG).
Heart failure due to ventricular aneurysm or valvular dysfunction may require aneurysmectomy or valve replacement to improve myocardial contractility/ function. Revascularization of cardiac muscle by CABG may be done to improve cardiac function.
  • - Cardiomyoplasty.
Cardiomyoplasty, an experimental procedure in which the latissimus dorsi muscle is wrapped around the heart and electrically stimulated to contract with each heartbeat, may be done to augment ventricular function while the patient is awaiting cardiac transplantation or when transplantation is not an option.
  • - Transmyocardial revascularization.
Other new surgical techniques include transmyocardial revascularization (percutaneous [PTMR]) using CO2 laser technology, in which a laser is used to create multiple 1-mm diameter channels in viable but underperfused cardiac muscle.
Assist with mechanical circulatory support system, such as IABP or VAD, when indicated.An intra-aortic balloon pump (IABP) may be inserted as a temporary support to the failing heart in the critically ill patient with potentially reversible HF. A battery-powered ventricular assist device (VAD) may also be used, positioned between the cardiac apex and the descending thoracic or abdominal aorta. This device receives blood from the left ventricle (LV) and ejects it into the systemic circulation, often allowing patient to resume a nearly normal lifestyle while awaiting heart transplantation. With end-stage HF, cardiac transplantation may be indicated.

2. Activity Intolerance

Activity Intolerance: Insufficient physiologic or physiological energy to endure or complete required or desired activity.
Nursing Diagnosis
  • - Activity intolerance
May be related to
  • - Imbalance between oxygen supply/demand
  • - Generalized weakness
  • - Prolonged bedrest/immobility
Possibly evidenced by
  • - Weakness, fatigue
  • - Changes in vital signs, presence of dysrhythmias
  • - Dyspnea
  • - Pallor, diaphoresis
Desired Outcomes
  • - Participate in desired activities; meet own self-care needs.
  • - Achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity.
Nursing InterventionsRationale
Check vital signs before and immediately after activity, especially if patient is receiving vasodilators, diuretics, or beta-blockers.Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.
Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor.Compromised myocardium and/or inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue.
Assess for other causes of fatigue (treatments, pain, medications).Fatigue is a side effect of some medications (beta-blockers, tranquilizers, and sedatives). Pain and stressful regimens also extract energy and produce fatigue.
Evaluate accelerating activity intolerance.May denote increasing cardiac decompensation rather than overactivity.
Provide assistance with self-care activities as indicated. Intersperse activity periods with rest periods.Meets patient’s personal care needs without undue myocardial stress and excessive oxygen demand.
Implement graded cardiac rehabilitation program.Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption.
Assist patient with ROM exercises. Check regularly for calf pain and tenderness.To prevent deep vein thrombosis due to vascular congestion.

3. Excess Fluid Volume

Excess Fluid Volume: Increased isotonic fluid retention
Nursing Diagnosis
  • - Fluid Volume, excess
May be related to
  • - Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention
Possibly evidenced by
  • - Orthopnea, S3 heart sound
  • - Oliguria, edema, JVD, positive hepatojugular reflex
  • - Weight gain
  • - Hypertension
  • - Respiratory distress, abnormal breath sounds
Desired Outcomes
  • - Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, vital signs within acceptable range, stable weight, and absence of edema.
  • - Verbalize understanding of individual dietary/fluid restrictions.
Nursing InterventionsRationale
Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night and/or during bed rest.
Monitor and calculate 24-hour intake and output (I&O) balance.Diuretic therapy may result in sudden increase in fluid loss (circulating hypovolemia), even though edema or ascites remains.
Maintain chair or bed rest in semi-Fowler’s position during acute phase.Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis.
Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care. Ice chips can be part of fluid allotment.Involving patient in therapy regimen may enhance sense of control and cooperation with restrictions.
Weigh daily. Frequently monitor blood urea nitrogen, creatinine, and serum potassium, sodium, chloride, and magnesium levels.Documents changes edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in excessive fluid shifts and weight loss.
Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema (check for pitting); note presence of generalized body edema (anasarca).Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet and ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually results in systemic tissue edema.
Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated.Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility (including bed rest) are cumulative stressors that affect skin integrity and require close supervision/ preventive interventions.
Auscultate breath sounds, noting decreased and/or adventitious sounds (crackles, wheezes). Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough.Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute left-sided HF. RHF’s respiratory symptoms (dyspnea, cough, orthopnea) may have slower onset but are more difficult to reverse.
Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom.May indicate development of complications (pulmonary edema and/or embolus) and differs from orthopnea paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention.
Monitor BP and central venous pressure (CVP)Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, HF.
Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation.Visceral congestion (occurring in progressive HF) can alter intestinal function.
Provide small, frequent, easily digestible meals.Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/ prevent abdominal discomfort.
Measure abdominal girth, as indicated.In progressive RHF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites).
Encourage verbalization of feelings regarding limitations.Expression of feelings may decrease anxiety, which is an energy drain that can contribute to feelings of fatigue.
Palpate abdomen. Note reports of right upper quadrant pain and tenderness.Advancing HF leads to venous congestion, resulting in abdominal distension, liver engorgement (hepatomegaly), and pain. This can alter liver function and prolong drug metabolism.
Administer medications as indicated:
  • Diuretics: furosemide (Lasix), bumetanide (Bumex) Thiazides
Signs of potassium and sodium deficits that may occur because of fluid shifts and diuretic therapy. Increases rate of urine flow and may inhibit reabsorption of sodium/ chloride in the renal tubules.
  • Diuretics with potassium-sparing agents: spironolactone (Aldactone)
Promotes diuresis without excessive potassium losses.
  • Potassium supplements: K-Dur
Replaces potassium that is lost as a common side effect of diuretic therapy, which can adversely affect cardiac function.
Maintain fluid and sodium restrictions as indicated.Reduces total body water and prevent fluid reaccumulation.
Consult with dietitian.May be necessary to provide diet acceptable to patient that meets caloric needs within sodium restriction.
Monitor chest x-ray.Reveals changes indicative of resolution of pulmonary congestion.
Assist with rotating tourniquets and/or phlebotomy, dialysis, or ultrafiltration as indicated.Although not frequently used, mechanical fluid removal rapidly reduces circulating volume, especially in pulmonary edema refractory to other therapies

4. Risk for Impaired Gas Exchange

Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
Nursing Diagnosis
  • - Risk for Impaired Gas Exchange
Risk factors may include
  • - Alveolar-capillary membrane changes, e.g., fluid collection/shifts into interstitial space/alveoli
Possibly evidenced by
  • [Not applicable]
Desired Outcomes
  • - Demonstrate adequate ventilation and oxygenation of tissues by ABGs/oximetry within patient’s normal ranges and free of symptoms of respiratory distress.
  • - Participate in treatment regimen within level of ability/situation.
Nursing InterventionsRationale
Auscultate breath sounds, noting crackles, wheezes.Reveals presence of pulmonary congestion and collection of secretions, indicating need for further intervention.
Instruct patient in effective coughing, deep breathing.Clears airways and facilitates oxygen delivery.
Encourage frequent position changes.Helps prevent atelectasis and pneumonia.
Maintain chair or bed rest, with head of bed elevated 20–30 degrees, semi-Fowler’s position. Support arms with pillows.Reduces oxygen demands and promotes maximal lung inflation.
Place patient in Fowler’s position and give supplemental oxygen.To help patient breath more easily and promote maximum chest expansion.
Graph graph serial ABGs, pulse oximetry.Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF. Note: In patients with abnormal cardiac index, research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%.
Administer supplemental oxygen as indicated.Increases alveolar oxygen concentration, which may reduce tissue hypoxemia.
Administer medications as indicated:
  • Diuretics: furosemide (Lasix)
Reduces alveolar congestion, enhancing gas exchange.
  • Bronchodilators: aminophylline
Increases oxygen delivery by dilating small airways, and exerts mild diuretic effect to aid in reducing pulmonary congestion.

5. Risk for Impaired Skin Integrity

Risk for Impaired Skin Integrity: At risk for altered epidermis and/or dermis [The integumentary system is the largest multifunctional organ of the body.]
Nursing Diagnosis
  • - Risk for impaired Skin Integrity
Risk factors may include
  • - Prolonged bedrest
  • - Edema, decreased tissue perfusion
Possibly evidenced by
  • [Not applicable]
Desired Outcomes
  • - Maintain skin integrity.
  • - Demonstrate behaviors/techniques to prevent skin breakdown.
Nursing InterventionsRationale
Inspect skin, noting skeletal prominences, presence of edema, areas of altered circulation, or obesity and/or emanciation.Skin is at risk because of impaired peripheral circulation, physical immobility, and alterations in nutritional status.
Provide gentle massage around reddened or blanched areas.Improves blood flow, minimizing tissue hypoxia. Note: Direct massage of compromised area may cause tissue injury.
Encourage frequent position changes, assist with active and passive range of motion (ROM) exercises.Reduces pressure on tissues, improving circulation and reducing time any one area is deprived of full blood flow.
Provide frequent skin care: minimize contact with moisture and excretions.Excessive dryness or moisture damages skin and hastens breakdown.
Check fit of shoes and slippers and change as needed.Dependent edema may cause shoes to fit poorly, increasing risk of pressure and skin breakdown on feet.
Avoid intramuscular route for medication.Interstitial edema and impaired circulation impede drug absorption and predispose to tissue breakdown and development of infection.
Provide alternating pressure, egg-crate mattress, sheepskin elbow and heel protectors.Reduces pressure to skin, may improve circulation.

6. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
Nursing Diagnosis
  • - Knowledge deficient [Learning Need] regarding condition, treatment regimen, self care, and discharge needs
May be related to
  • - Lack of understanding/misconceptions about interrelatedness of cardiac function/disease/failure
Possibly evidenced by
  • - Questioning
  • - Statements of concern/misconceptions
  • - Recurrent, preventable episodes of HF
Desired Outcomes
  • - Identify relationship of ongoing therapies (treatment program) to reduction of recurrent episodes and prevention of complications.
  • - List signs/symptoms that require immediate intervention.
  • - Identify own stress/risk factors and some techniques for handling.
  • - Initiate necessary lifestyle/behavioral changes.
Nursing InterventionsRationale
Discuss normal heart function. Include information regarding patient’s variance from normal function. Explain difference between heart attack and HF.Knowledge of disease process and expectations can facilitate adherence to prescribed treatment regimen.
Reinforce treatment rationale. Include SOs in teaching as appropriate, especially for complicated regimens such as dobutamine infusion home therapy when patient does not respond to customary combination therapy or cannot be weaned from dobutamine, or those awaiting heart transplant.Patient may believe it is acceptable to alter postdischarge regimen when feeling well and symptom-free or when feeling below par, which can increase the risk of exacerbation of symptoms. Understanding of regimen, medications, and restrictions may augment cooperation with control of symptoms.Home IV therapy requires a significant commitment by caregivers to troubleshoot infusion pump, change dressing for peripherally inserted central catheter (PICC) line, monitor I&O and signs and symptoms of HF.
Encourage developing a regular home exercise program, and provide guidelines for sexual activity.Promotes maintenance of muscle tone and organ function for overall sense of well-being. Changing sexual habits may be difficult (sex in morning when well rested, patient on top, inclusion of other physical expressions of affection) but provides opportunity for continuing satisfying sexual relationship.
Discuss importance of being as active as possible without becoming exhausted and of rest between activities.Excessive physical activity or overexertion can further weaken the heart, exacerbating failure, and necessitates adjustment of exercise program.
Discuss importance of sodium limitation. Provide list of sodium content of common foods that are to be avoided and limited. Encourage reading of labels on food and drug packages.Dietary intake of sodium of more than 3 grams per day can offset effect of diuretic. Most common source of sodium is table salt and obviously salty foods, although canned soups, luncheon meats, and dairy products also may contain high levels of sodium.
Refer to dietitian for counseling specific to individual dietary customs.Identifies dietary needs, especially in presence of nausea vomiting and resulting wasting syndrome (cardiac cachexia). Eating six small meals and using liquid dietary supplements and vitamin supplements can limit inappropriate weight loss.
Review medications, purpose, and side effects. Provide both oral and written instructions.Understanding therapeutic needs and importance of prompt reporting of side effects can prevent occurrence of drug-related complications. Anxiety may block comprehension of input or details, and patient/ SO may refer to written material at later date to refresh memory.
Recommend taking diuretic early in morning.Provides adequate time for drug effect before bedtime to prevent interruption of sleep.
Instruct and receive return demonstration of ability to take and record daily pulse and blood pressure and when to notify health care provider: parameters above or below preset rate, changes in rhythm and regularity.Promotes self-monitoring of drug effect. Early detection of changes allows for timely intervention and may prevent complications, such as digitalis toxicity.
Explain and discuss patient’s role in control of risk factors (smoking, unhealthy diet) and precipitating or aggravating factors (high-salt diet, inactivity, overexertion, exposure to extremes in temperature).Adds to body of knowledge, and permits patient to make informed decisions regarding control of condition and prevention of complications. Smoking potentiates vasoconstriction; sodium intake promotes water retention or edema formation; improper balance between activity and rest and exposure to temperature extremes may result in exhaustion and/or increased myocardial workload and increased risk of respiratory infections. Alcohol can depress cardiac contractility. Limitation of alcohol use to social occasions or maximum of 1 drink per day may be tolerated unless cardiomyopathy is alcohol-induced (requiring complete abstinence).
Review signs and symptoms that require immediate medical attention: rapid and significant weight gain, edema, shortness of breath, increased fatigue, cough, hemoptysis, fever.Self-monitoring increases patient responsibility in health maintenance and aids in prevention of complications, e.g., pulmonary edema, pneumonia. Weight gain of more than 3 lb in a week requires medical adjustment of diuretic therapy. Note: Patient should weigh self daily in morning without clothing, after voiding and before eating.
Provide opportunities for patient and SO to ask questions, discuss concerns, and make necessary lifestyle changes.Chronicity and debilitating nature of HF often exhausts coping abilities and supportive capacity of both patient and SO, leading to depression.
Discuss general health risks (such as infection), recommending avoidance of crowds and individuals with respiratory infections, obtaining yearly influenza immunization and one-time pneumonia immunization.This population is at increased risk for infection because of circulatory compromise.
Stress importance of reporting signs and symptoms of digitalis toxicity: development of gastrointestinal (GI) and visual disturbances, changes in pulse rate and rhythm, worsening of heart failure.Early recognition of developing complications and involvement of healthcare provider may prevent toxicity.
Identify community resources and support groups and visiting home health nurse as indicated. Encourage participation in an outpatient cardiac rehabilitation program.May need additional assistance with self-monitoring, home management, especially when HF is progressive.
Discuss importance of advance directives and of communicating plan and wishes to family and primary care providers.Up to 50% of all deaths from heart failure are sudden, with many occurring at home, possibly without significant worsening of symptoms. If patient chooses to refuse life-support measures, an alternative contact person (rather than 911) needs to be designated, should cardiac arrest occur.

7. Decreased Cardiac Output

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands of the body.
The heat fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased therefore decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness
Assessment
The patient may manifest the following:
  • - Pale conjunctiva, nail beds, and buccal mucosa
  • - irregular rhythm of pulse
  • - bradycardia
  • - generalized weakness
Diagnosis
  • - Decreased cardiac output r/t [altered heart rate and rhythm] AEB [bradycardia]
Planning
  • - Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.
  • - Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.
Nursing InterventionsRationale
Assess for abnormal heart and lung sounds.Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.
Monitor blood pressure and pulse.Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the renin-angiotensin mechanism.
Assess mental status and level of consciousness.The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
Assess patient’s skin temperature and peripheral pulses.Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
Monitor results of laboratory and diagnostic tests.Results of the test provide clues to the status of the disease and response to treatments.
Monitor oxygen saturation and ABGs.Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
Implement strategies to treat fluid and electrolyte imbalances.Decreases the risk for development of cardiac output due to imbalances.
Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
Encourage periods of rest and assist with all activities.Reduces cardiac workload and minimizes myocardial oxygen consumption.
Assist the patient in assuming a high Fowler’s position.Allows for better chest expansion, thereby improving pulmonary capacity.
Teach patient the pathophysiology of disease, medicationsProvides the patient with needed information for management of disease and for compliance.
Reposition patient every 2 hoursTo prevent occurrence of bed sores
Instruct patient to get adequate bed rest and sleepTo promote relaxation to the body
Instruct the SO not to leave the client unattendedTo ensure safety and reduce risk for falls that may lead to injury
Evaluation
  • - After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.
  • - After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

8. Excess Fluid Volume

Excess Fluid Volume: Increased isotonic fluid retention
When blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and renin is released into the bloodstream. Renin interacts with angiotensinogen to produce angiotensin I. When angiotensin I contacts ACE, it is converted to angiotensin II, a potent vasoconstrictor. Angiotensin II increases arterial vasoconstriction, promote release of norepinephrine from sympathetic nerve endings, and stimulates the adrenal medulla to secrete aldosterone, which enhances sodium and water absorption. Stimulation of the renin-angiotensin system causes plasma volume to expand and preload to increase.
Assessment
The patient may manifest the following:
  • - Edema of extremities
  • - Difficulty of breathing
  • - Crackles
  • - Change in mental status
  • - Restlessness and anxiety
Diagnosis
  • - Excessive Fluid volume related to decreased cardiac output and sodium and water retention
Planning & Desired Outcomes
  • - Patient will verbalize understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.
  • - Patient will demonstrate adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema.
Nursing InterventionsRationale
Establish rapportTo gain patient’s trust and cooperation
Monitor and record VSTo obtain baseline data
Assess patient’s general conditionTo determine what approach to use in treatment
Monitor I&O every 4 hoursI&O balance reflects fluid status
Weigh patient daily and compare to previous weights.Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess.
Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum productionWhen increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema
Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic.Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular reabsorption of sodium Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.
Follow low-sodium diet and/or fluid restrictionThe client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.
Encourage or provide oral care q2Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatic pressure exceeds interstitial pressure, fluids leak out of the capillaries and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart.
Obtain patient history to ascertain the probable cause of the fluid disturbance.May include increased fluids or sodium intake, or compromised regulatory mechanisms.
Monitor for distended neck veins and ascitesIndicates fluid overload
Evaluate urine output in response to diuretic therapy.Focus is on monitoring the response to the diuretics, rather than the actual amount voided
Assess the need for an indwelling urinary catheter.Treatment focuses on diuresis of excess fluid.
Institute/instruct patient regarding fluid restrictions as appropriate.This helps reduce extracellular volume

9. Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.
In ischemic heart disease, atherosclerosis develops in the coronary arteries, causing them to become narrowed or blocked. When a coronary artery is blocked, blood flow to the area of the heart supplied by that artery is reduced. If the remaining blood flow is inadequate to meet the oxygen demands of the heart, the area may become ischemic and injured and myocardial infarction may result. Neural pain receptors are stimulated by local mechanical stress resulting from abnormal myocardial contraction.
Assessment
Patient may manifest the following
  • - Difficulty of breathing
  • - Chest pain
  • - Restlessness
Diagnosis
  • - Acute Pain
Planning & Desired Outcomes
  • - Patient’s pain will be decreased.
  • - Patient will demonstrate activities and behaviors that will prevent the recurrence of pain.
Nursing InterventionsRationale
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Administer or assist with self-administration of vasodilators, as ordered.The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
Assess the response to medications every 5 minutesAssessing response determines effectiveness of medication and whether further interventions are required.
Provide comfort measures.To provide non pharmacological pain management.
Establish a quiet environment.A quiet environment reduces the energy demands on the patient.
Elevate head of bed.Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Teach patient relaxation techniques and how to use them to reduce stress.Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.

10. Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
Due to decreased cardiac output, there is decreased preload and stroke volume thus there is decreased blood pumped out from the blood. Decrease in stroke volume decreases perfusion throughout the body.
Assessment
  • - Pale conjunctiva, nail beds, and buccal mucosa
  • - Generalized weakness
  • - Chest pain
  • - Difficulty of breathing
  • - Abnormal pulse rate and rhythm
  • - Bradycardia
  • - Altered BP readings
  • - With pitting edema on both forearms and hands
  • - Bipedal pitting edema
Diagnosis
  • - Ineffective tissue perfusion related to decreased cardiac output.
Planning & Desired Outcomes
  • - Patient will demonstrate behaviors to improve circulation.
  • - Display vital signs within acceptable limits, dysrhythmias absent/controlled,and no symptoms of failure
Nursing InterventionsRationale
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Administer or assist with self administration of vasodilators, as ordered.The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
Assess the response to medications every 5 minutes.Assessing response determines effectiveness of medication and whether further interventions are required.
Give beta blockers as ordered.Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.
Establish a quiet environment.A quiet environment reduces the energy demands on the patient.
Elevate head of bed.Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered.Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain.
Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by physician.These enzymes elevate in the presence of myocardial infarction at differing times and assist in ruling out a myocardial infarction as the cause of chest pain.
Assess cardiac and circulatory status.Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.
Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.Notes abnormal tracings that would indicate ischemia.
Teach patient relaxation techniques and how to use them to reduce stress.Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.
Reposition the patient every 2 hoursTo prevent bedsores
Instruct patient on eating a small frequent feedingsTo prevent heartburn and acid indigestion

11. Hyperthermia

Hyperthermia: Body temperature elevated above normal range.
Presence of microorganisms stimulates the release of pyrogen from the leukocytes resetting the body’s thermostat to febrile level and then there would be activation of the hypothalamus, which will result in increase in epinephrine and norepinephrine, vasoconstriction of cutaneous vessels. The heat will be produced as peripheral vasodilation results in skin flushing and skin is warm to touch.
Assessment
Patient may manifest the following:
  • - Pale palpebral
  • - Conjunctiva and nail beds
  • - Warm to touch
  • - Weakness
  • - Increased in body temperature
  • - Fluid or electrolyte imbalance
  • - Diaphoresis
  • - Hot flushed skin
Diagnosis
  • - Hyperthermia RT increased metabolic rate secondary to pneumonia
Planning & Desired Outcomes
  • - Patient’s temperature will be on normal level.
Nursing InterventionsRationale
Assess vital signs, the temperature.Vital signs provide more accurate indication.
Monitor and record all sources of fluid loss such as urine, vomiting and diarrhea.For potential fluid and electrolyte losses.
Performed tepid sponge bath.To promote heat loss by evaporation and conduction.
Maintain bed rest.To reduce metabolic demands and oxygen consumption.
Remove excess clothing and covers.Decreases warmth and increase evaporative cooling.
Increase fluid intake.To prevent dehydration.
Provide adequate nutrition, a high caloric diet.The meet the metabolic demands.
Control environmental temperature.To prevent an increase in body temperature and prevent shivering of the patient.
Adjust cooling measures on the basis of physical response.Shivering, which burns calories and increases metabolic rate in order to produce heat.
Provide information regarding normal temperature and control.This is especially necessary for patients with conditions at risk for hyperthermia.
Explain all treatments.Patients’ S.O. needs to be oriented.
Administer antipyretics as ordered.To decrease body temperature.
Control excessive shivering with medications such as Chlorpromazine and Diazepam if necessary.Shivering increases metabolic rate and body temperature.
Provide ample fluids by mouth or intravenously as ordered.If the patient is dehydrated or diaphoretic, fluid loss contributes to fever.
Provide oxygen therapy in extreme cases as ordered.Hyperthermia increases metabolism.

12. Ineffective Breathing Pattern

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation
Ineffective Breathing Pattern occurs when there is presence of spasm and inflammation of the lung tissue and parenchyma , these results in inability of the pt to move air in and out of the lungs as needed to maintain adequate tissue oxygenation and perfusion.
Assessment
Patient may manifest the following:
  • - weakness
  • - rales on BLF
  • - productive cough
  • - frothy sputum
  • - pursed lip breathing
  • - tachypnea
Diagnosis
  • - Ineffective breathing pattern related to fatigue and decreased lung expansion and pulmonary congestion secondary to CHF
Planning & Desired Outcomes
  • - Patient’s respiratory pattern will be effective without causing fatigue
Nursing InterventionsRationale
Establish rapportTo gain comfort feelings form the pt and pts SO
Monitor VSTo gain baseline data
Inspect thorax for symmetry of respiratory movementDetermines adequacy of breathing
Observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory phase and use of accessory musclesIdentifies increased work of breathing
Measure tidal volume and vital capacityIndicates volume of air moving in and out of lungs
Assess emotional responseDetects use of hyperventilation as a causative factor
Position patient in optimal body alignment in semi- fowler’s position for breathing
Assist patient to use relaxation techniquesReduces muscle tension, decreases work of breathing

13. Activity Intolerance

Activity Intolerance: Insufficient physiologic or physiological energy to endure or complete required or desired activity.
As heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the body’s needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries
Assessment
  • - Weakness
  • - Limited range of motion
  • - Abnormal pulse rate and rhythm
Diagnosis
  • - Activity intolerance r/t imbalance O2 supply and demand
Planning & Desired Outcomes
  • - Patient will use identified techniques to improve activity intolerance
  • - Patient will report measurable increase in activity intolerance
Nursing InterventionsRationale
Establish RapportTo gain clients participation and cooperation in the nurse patient interaction
Monitor and record Vital SignsTo obtain baseline data
Assess patient’s general conditionTo note for any abnormalities and deformities present within the body
Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changesPrevents straininga nd overexertion which may aggravate symptoms
Instruct client in unfamiliar activities and in alternate ways of conserve energyConserves energy and promote safety
Encourage patient to have adequate bed rest and sleepRelaxes the body and promotes comfort
Provide the patient with a calm and quiet environmentProvides relaxation
Assist the client in ambulationPrevents risk for falls that could lead to injury
Note presence of factors that could contribute to fatigueFatigue affects both the client’s actual and perceived ability to participate in activities
Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipmentDetermines current status and needs associated with participation in needed or desired activities
Give client information that provides evidence of daily or weekly progressSustains motivation of client
Encourage the client to maintain a positive attitudeEnhances sense of well being
Assist the client in a semi-fowlers positionPromotes easy breathing
Elevate the head of the bedMaintains an open airway
Assist the client in learning and demonstrating appropriate safety measuresPrevents injuries
Instruct the SO not to leave the client unattendedAvoids risk for falls
Provide client with a positive atmosphereHelps minimize frustration and rechannel energy
Instruct the SO to monitor response of patient to an activity and recognize the signs and symptomsIndicates need to alter activity level

14. Ineffective Airway Clearance

Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increase in RR will also be expected as a compensatory mechanism of the body due to obstructed airways.
Assessment
Patient may manifest the following:
  • - Rales
  • - Productive cough
  • - Difficulty of breathing
Diagnosis
  • - Ineffective airway clearance related to retained secretions
Planning & Desired Outcomes
  • - Patient will be able to establish and maintain airway patency

15. Impaired Gas Exchange

Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
The exchange in oxygenation and carbon dioxide gases is impeded due to the obstruction caused by the accumulation of bronchial secretions in the alveoli. Oxygen cannot diffuse easily.
Assessment
  • - Productive cough
  • - Rales on auscultation
  • - Difficulty of breathing
  • - Pale conjunctiva, nail beds and buccal mucosa
  • - Fatigue
  • - Metabolic acidosis
  • - Circumoral cyanosis
Diagnosis
  • - Impaired gas exchange related to inflammation of airways and accumulation of fluid in the alveoli
Planning & Desired Outcomes
  • - Patient will be able to demonstrate improvement in gas exchange
Nursing InterventionsRationale
Monitor and record vital signsTo obtain baseline data
Observe color of skin, mucous membranes and nail beds, noting presence of peripheral cyanosis.Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/ chills
Elevate head of bed and encourage frequent position changes.To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation
Keep back dry.To avoid coughing
Promote adequate rest periodsRest will prevent fatigue and decrease oxygen demands for metabolic demands
Change position q 2 hrs.To promote drainage of secretions
Keep environment allergen freeTo reduce irritant effects on airways
Suction secretions PRNTo clear airway when secretions are blocking the airway.
Administer oxygen therapy as ordered.O2 therapy is indicated to increase oxygen saturation

16. Fatigue

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
Heart failure is a physiologic state in which the heart cannot pump enough blood to meet the metabolic demands of the body. Since the patient has inadequate cardiac output, it can lead to hypoxic tissue and slowed removal of metabolic wastes, which in turn cause the patient to tire easily.
Assessment
Patient may manifest:
  • - Weakness
  • - Limited range of motion
Diagnosis
  • - Fatigue
Planning & Desired Outcomes
  • - Patient will report improved sense of energy
Nursing InterventionsRationale
Review medication regimen.Certain medications are known to cause or exacerbate fatigue.
Assess vital signs.To evaluate fluid status and cardiopulmonary response to activity.
Determine presence or degree of sleep disturbances.Fatigue can be a consequence of sleep deprivation.
Obtain client descriptions of fatigue.To assist in evaluating impact on client’s life.
Ask client to rate fatigue.To determine degree of fatigability.
Note daily energy patterns.Helpful in determining pattern or timing of activity.
Establish realistic activity goals with client and encourage forward movement.Enhances commitment to promoting optimal outcomes.
Plan interventions to allow individually adequate rest periods.To maximize participation.
Assist with self-care needs and ambulation.To conserve energy for other tasks.
Avoid exposure to temperature and humidity extremesHas negative impact on energy level.
Instruct client in ways to monitor responses to activity and significant signs or symptoms.Indicate the need to alter activity level
Promote overall health measuresTo promote energy
Provide supplemental oxygen, as indicated.Presence of hypoxemia reduces oxygen available for cellular uptakes and contributes to fatigue.
Assist client to identify appropriate coping behaviors.Promote sense of control and improves self-esteem.

17. Other Nursing Care Plans

Additional nursing diagnoses for heart failure:
  1. Activity intolerance —poor cardiac reserve, side effects of medication, generalized weakness.
  2. Deficient Fluid Volume or Excess Fluid Volume — changes in glomerular filtration rate, diuretic use, individual fluid/salt intake.
  3. Impaired Skin Integrity —decreased activity level, prolonged sitting, presence of edema, altered circulation.
  4. Therapeutic Regimen: ineffective management—complexity of regimen, economic limitations.
  5. Impaired Home Maintenance — chronic/debilitating condition, insufficient finances, inadequate support systems.
  6. Self-Care Deficit — decreased strength/endurance, depression.
References and Sources : nurseslabs.com

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