BEE ENN COLLEGE OF NURSING

NURSING CARE PLAN

ON

CONGESTIVE HEART FAILURE

SUBMITTED TO: SUBMITTED BY:

SUBMITTED ON:

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IDENTIFICATION DATA OF THE PATIENT
HISTORY COLLECTION
I. DEMOGRAPHIC PROFILE:-
1. Name of the patient : Ms. Razia
2. Age : 32 years
3. Sex : Female
4. MRD no. : 1103487
5. Ward : 5 ( CCU )
6. Bed no. : 03
7. Language : Dogri , Urdu , Hindi
8. Religion : Muslim
9. Marital status : Married
10. Education : Illiterate
11. Occupation : Housewife
12. Address : Kathua
13. Date of admission : 01-04-2024
14. Medical diagnosis : Congestive Heart Failure
15. Date of surgery : 04-04-2024
16. Name of surgery : Coronary Artery Bypass Surgery
17. Type of Anesthesia : General Anesthesia
18. Post operative day : 1st

1. II CHIEF COMPLAINTS: Chief complaints on admission :

 Shortness of breath 1 month
 Fatigue 1 month
 Arrhythmias 1 month
 Body edema 15 days
2. Treatment taken elsewhere for the chief complaints : None
3. Reasons for admission : chest pain, shortness of breath, arrhythmias, body
edema
4. Investigations done on admission : RBS ( 141 mg )
5. Treatment given on admission :
 Inj. Pantop 40 mg IV
 Inj. Lasix 125 mg IV
6. Confirmatory diagnosis : Congestive Heart Evaluation
7. Chief complaints on day one care :
 Shortness of breath
 Fatigue
 Arrhythmias
 Body edema

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 III. HISTORY OF HEALTH STATUS:
A)Present Medical History : Chief complaints on day one care :

 Shortness of breath
 Fatigue
 Arrhythmias
 Body edema

B)Past medical History : Not Significant

C)Present Surgical History : Not significant
D)Past Surgical History : Not Significant.

IV. FAMILY HISTORY

(a) Family Tree
MALE FEMALE

Male patient Female Patient

Ram Lal(father) Sarojni( Mother)

(76 years) (72 years)
0

Mr Rahul Ratik (Brother) Ms. Razia (patient)

S. Name of family Age Sex Relationship Occupation Health Education

NO. member Status

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1 Ram Lal 76 Male Father govt. Healthy Graduate
employee

2. Sarojni 72 Female Mother House wife Healthy Uneducated

3. Rahul 40 Male Brother Private Healthy B.Com

employee

4. Ratik 35 Male Brother private job Healthy BA

private job unhealthy

5. Ms. Razia 32 Female Sister 12th pass
Begum

1. Type of family : Nuclear

2. Communicable / hereditary diseases : There is no evidence of family history.

V. Personal History :
1. Nutrition : Non vegetarian
 History of any special diet : there is no evidence of history of any special diet.
2. Sleep pattern : Insomnia
3. Elimination :
 Urinary : 5-6 times / day
Problems : There is no evidence of any urinary problems.
 Bowel : 2-3 times / day
Problems : There is no evidence of any bowel problems.

4. Hygiene :
 Brushing : Brush daily
 Material used : Tooth paste
 Bathing : 2-3 times / week
 Preference of water : Hot
5. Habits :
 Smoking : No
 Alcoholism : No
 Use of snuff : No
 Chewing tobacco : No
6. Reproductive history :
 Age at menarche : 15 yrs.
 Menstrual cycle : Regular
 No. of days / cycle : Regular

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  No. of children : 01
 Age at menopause : not significant
 Family planning adopted method : Yes ( Natural method )

VI.Socio Economic Status :

(a) Housing : Proper housing.
(b) Ventilation : Good ventilation of house.
(c) Electricity : Proper electricity (12 hours in day and night)
(d) Water supply : Using proper tap water.
(e)Income : 30,000/ month

(f)Relationship with neighbours / friend’s : Good

PHYSICAL ASSESSMENT/ EXAMINATION

I.VITAL SIGNS:
Temperature : 97.60 Fahrenheit.
Pulse : 78 beats/ minute.
Respiratory rate : 20 breaths / minute
Blood Pressure : 110/80 mmHg
O2 saturation : 95%

II.Anthropometric measurements :-

1. Height : 5 feet 2 inch

2. Weight : 52 kg

III.General Appearance
1. Appearance : Anxious
2. Body build : Well nourished
3. Orientation : Oriented
4. Level of consciousness : Conscious
5. Complexion : Fair
6. General hygiene : Good

Skin:
1. Colour : Pallor
2. Texture : Dry
3. Temperature : Warm
4. Lesions : Absent
5. Water supply : Well

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 6. Toilet facility : Own latrine
7. Drainage : Closed
8. Disposal of wastes : Burning
9. Market facility : Available
10. Medical : Available
11. Transport : Bus
12. Sensitivity : No
13. Turgor : Good

Nails :-

1. Colour : Pale
2. Texture : Smooth
3. Capillary refill : Abnormal
4. Nail bed : Clubbing

Head and face :-

1. Size and shape : Normocephalic

2. Facial feature : Symmetrical
3. Facial puffiness : Present
4. Sinuses : Tender

Hair and Scalp/Skull/face:

Colour : Black
Distribution : Generalised thinning
Hair loss : Absent
Dandruff : No dandruff
Lice : Absent

Eyes:
Vision/Visual Acuity : Not proper.
Glasses : Present
Sclera : White
Cornea and Iris : Black
Pupils : Grey coloured
Eye lashes : Normal
Lens : Biconvex
Discharge : No abnormal discharge
Pain : Absent

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Itching : Absent

Ears:
Hearing : Proper
Discharge : No abnormal discharge
Pain : Absent
Itching : Absent
Vertigo : Absent
Ringing : Absent

Nose and Sinuses

Deviated nasal septum : Patient have no deviated nasal septum.
Nostrils : Round
Discharge : Absent
Allergies : Absent
Obstruction : Absent
Pain : Absent
Epitaxies : Absent

Mouth and throat:

Tongue : Normal pink coloured
Lips : Lips pink coloured
Lesions : Absent
Bleeding : Absent
Odour : No foul smell
Tooth decay : Absent

Neck:
Stiffness : Present
Lymph nodes : Normal ( 1cm diameter)
Swelling : Absent
Pain : Absent
Thyroid : Normal (4.0- 6.0 cm)

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I. Respiratory System:
H/O Smoking : No history of smoking
Sputum (Colour) : Clear, white or Gray
Asthma : Absent
Wheezing : Absent
Haemoptysis : Absent
Inspection : Bilateral symmetrical movement of chest wall
: Palpation : No tenderness.
Percussion : Absence of fluids
Auscultation : Lung Sound is normal

II. Cardiovascular System:

H/O Hypertension : No history of hypertension.
Dyspnoea : Absent
Orthopnoea : Absent
Chest Pain : Present
Heart Sound : S1 and S2 heard
Pulse : 67 beats/ minute
Inspection : Normal shape
Palpation : Peripheral pulse is normal
Auscultation : No abnormal heart sound is heard.
Breast :-

1. Placement : Symmetrical
2. Size : Normal
3. Consistency : Soft
4. Abscess : Absent
5. Palpable lump : No
6. Nipple : Retracted
7. Areola : Round and bilaterally same

III. Gastro-Intestinal System:

Shape and Symmetry : Normal
Pain : Absent
Abdominal distension : Absent
Anorexia : Absent

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 Nausea : Present
Constipation : Absent
Vomiting : Present
Bowel sounds : Normal
Inspection : Shape and size of abdomen is normal
Palpation : Tenderness is not Present
Percussion : No abnormal fluid
Auscultation : Bowel sound is heard

IV. Genito-urinary system:

Nocturia : Absent
Dysuria : Absent
Infection : Absent
H/O Illness (or) surgery : No history of previous illness or surgery
Inspection : Shape and size kidneys are normal
Palpation : No suprapubic and bladder distension is found
Percussion : No edema is found

V. Reproductive system:
Hairs : Absent

Lesions : Absent

Vaginal prolapsed : Absent

Urinary catheter : Present

Rectum : Normal

VI. Musculo-skeletal system:

Posture : Normal
Muscular pain/cramps : Absent
Pain : Present
Swelling : Absent
Range of motion : Proper
Any deformities : Absent
Inspection : Normal muscle structure.
Palpation : No tenderness

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VII. Integumentary system:
Colour : Pale white
Texture : Eudermic
Bleeding : Absent
Discharge : Absent
Infection : Absent
VIII. Haematological System:
Hb : 12 gm/dl
Bleeding tendencies : No impaired bleeding tendencies
Any blood transfusion : Absent

IX. Neurological System:

1. Observation of mental status during history taking :-
 Behaviour : Normal
 Appearance : Depressed
 Level of alertness : Alert and oriented
 Emotional status : Anxious
 Intellect : Average
 Judgement : Moderate
 Thought process and concentration : Distracted
2. Reflexes :-
 Biceps : Normal response
 Triceps reflexes : Normal response
 Patellar reflexes : Normal response
 Achilles reflexes : Normal response
 Plantar reflexes : Normal response

INVESTIGATIONS:

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S.No. Name of investigation Patient Value Normal value Remarks
1. Haemoglobin level 9.6 gm/dl 14-16 gm/dl Decreased

2. RFT
Sr. urea 26 gm 15 – 40 mg Normal
Sr. creatinine 0.8 mg 0.6 – 1.3 mg Normal
Sr. uric acid 9.4 mg 2.6 – 7.2 mg Elevated
Sr. calcium 8.1 mg 8.5 – 10.5 mg Decreased
Sr. phosphorous 4.3 mg 8.5 – 10.5 mg Decreased
Sr. sodium 39 mEq./l 135 – 145 mEq./l Normal
Sr. potassium 4.4 mEq./l 3.5 – 5.5 mEq./l Normal
LFT
3.
Bilirubin (T) 0.4 mg/dl 0.2 – 1.0 mg/dl Normal
Bilirubin (D) 0.2 mg/dl 0.0 – 0.4 mg/dl Normal
Protein 8.0 g/dl 6.0 – 8.0 g/dl Normal
Albumin 4.0 g/dl 3.8 – 5.0 g/dl Normal
Globulin 2.5 g/dl 2.3 – 3.5 g/dl Normal
Alanine transaminase 23 u/l 4 – 36 u/l Normal
Aspartate transaminase 30 u/l 5 – 34 u/l Normal
Alkaline phosphatase 120 u/l 40 – 150 u/l Normal
Prothrombin time 0.55 I.1 or below Normal

4. RBS 141 mg up to 150 mg

Normal

OTHER INVESTIGATIONS:-
S.NO DATE INVESTIGATIONS FINDINGS
.
1. 01-04-24 X-RAY  Shown cardiomegaly grade I, II or III
 PVH, increased central systemic venous
volume, with enlargement of mediastinal
veins and pleural effusions.

2. 01-04-24 ECG  Atrial fibrillation seen frequently

 Sinus tachycardia
 ST elevation associated with Q wave

3. 01-04-24 ECHO The pumping function of heart is too low ( ejection

fraction )
4. 01-04-24 MRI The parts of heart are damaged seen specifically
5. 01-04-24 CT SCAN  Ground glass opacification
 Broncho vascular bundle thickening
 Interlobular septal thickening
Pleural effusion

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 MEDICATION CHART:

S.No Name of the Dose Route Indication Action Side Nurse’s

drug Effects responsibility

1. Inj. 10 I.V Edema , liver Loop Frequent Assess fluid

mg/m cirrhosis , diuretics urination, status Monitor
Furosemide
l kidney feeling thirsty, input and
disease dry mouth and output ratios.
Assess or
headache .
allergy.
Monitor BP
HTN
Constipation
2. I.V Anxiety Beta-
40 mg blockers Shortness of Monitor heart
Inj. Propanol Arrhythmias breath rate, rhythm
AF Fatigue Monitor BP

Stomach pain Assessing for

bradycardia.

3. Oral Acute Cough

hypertensive ACE Instruct patient
Tab. Captopril 25 mg Hypotension
crisis inhibitors to take tablet as
Flushing directed at the
Raynaud same time each
phenomenon Low blood day
Hypertension counts
Take missed
dose as soon as
4. Oral Calcium Headaches possible
Hypertension
Tab 10 mg channel Feeling dizzy Monitor BP and
Angina blockers
amlodipine pulse before
Coronary Flushing
therapy
artery Pounding
Monitor ECG
disease heartbeat
periodically
Swollen
Assess for
ankles
peripheral
edema
Assess for
dyspnoea.
Monitor EKG
5. Tab ecospirin Oral Stroke changes,
Antiplatelet
75 mg Angina Stomach upset seizures,
hallucinations.
Neuralgia Heart burn

NURSING DIAGNOSIS:

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 1. Ineffective breathing pattern related to increased fluid accumulation in the lungs
secondary to decrease contractility of the heart leading to backflow of fluid into the
lungs
2. Impaired gas exchange related to decreased oxygenation of the lungs secondary to
extravasation of fluid into the alveolar spaces
3. Decreased cardiac output related to the systolic dysfunction secondary to impaired
myocardial oxygenation
4. Ineffective peripheral tissue perfusion related to impaired myocardial contractility and
decreased oxygenation of the lungs secondary to pulmonary congestion
5. Acute chest pain related to pulmonary congestion and increased cardiac workload
secondary to ventricular dysfunction
6. Excess fluid volume related to and backflow of fluid into the peripheries secondary to
impaired ventricular contractility
7. Activity intolerance related to decreased tissue perfusion secondary to imbalance
between the oxygen supply and demand
8. Impaired nutrition less than body requirements related to impaired metabolic function
secondary to hepatomegaly
9. Risk for renal dysfunction related to decreased renal perfusion secondary to
ineffective myocardial contractility and decreased stroke volume
10. Ineffective therapeutic regimen related to the critical disease condition and need for
long term treatment and healthcare management
11. Activity intolerance related to imbalance between O 2 supply and demand secondary to
congestive heart failure
12. Knowledge deficit related to management of congestive heart failure

NURSING CARE PLAN

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Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis
Subjective Ineffective To Provide Provided To push the Breathing
data: Patient breathing maintain fowlers or fowlers or high diaphragm pattern
says that she ispattern the high fowlers fowlers position down and maintained
having related to breathing position with with cardiac create enough to some
Shortness of increased pattern cardiac table table support space in extent as
breath/dyspnoea fluid with support Continuously thoracic evidenced
Cough accumulatio normal Continuously monitored the cavity for by
Pursed lip n in the respiratory monitor the vital signs, ecg, breathing checking
breathing lungs rate, vital signs, and oxygen To identify vital signs.
Heart secondary to rhythm ecg, and saturation the cause of
palpitation decreased and oxygen Placed the client breathing
Chest pain contractility saturation saturation in well- difficulty and
Fatigue of the heart levels Place the ventilated room pain
Weakness leading to client in and restricted interventions
backflow of well- visitors To meet the
fluid into the ventilated Administered oxygen needs
lungs. room and oxygen therapy and prevent
Objective data: restricted Provided strict suffocation
on observation visitors bed rest To prevent
pt. gasps for Administer Assessed the the shortness
breath oxygen need for of breath
Tachycardia therapy intubation and Rest
Tachypnoea Provide strict ventilation decreases the
Presence of bed rest Provided oxygen
cardiac wheeze Assess the nebulizer demands and
need for therapy promotes
intubation Administered comfort
and diuretics To provide
ventilation Started with mechanical
Provide digital therapy ventilation
nebulizer Assessed the and
therapy need for oxygenate the
Administer surgical/ lungs To
diuretics invasive clear the
Start with treatments and airways and
digital prepare the ai in
therapy client for breathing To
Assess the procedure treat
need for pulmonary
surgical/ edema
invasive To promote
treatments ventricular
and prepare contractibility
the client for and improve
procedure cardiac
output
Subjective Impaired gas To Continuously Continuously To identify Adequate

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data: exchange maintain monitor the monitored the the level of gas
Patient says:related to the ECG, vital ECG, vital signs respiratory exchange
the patient is
decreased adequate signs and and oxygen functions and maintained
said that sheoxygenation gas oxygen saturation levels provide to some
is having of the lungs saturation Obtained appropriate extent as
exchange
Cough with secondary to with
levels Obtain complete blood interventions evidenced
sputum extravasatio complete counts , sr. To identify by checking
normal
Shortness of n of fluid in blood electrolytes and the o2
to the saturatio counts , sr. ABG levels hemodynami saturation.
breath
Chest pain alveolar n and electrolytes regularly c status of the
heart space . ABG and ABG Provided client and
palpitation levels levels complete bed start
Suffocation regularly rest in high interventions
Lethargy Provide fowler’s To increase
Discoloratio complete bed position with the thoracic
n of skin. rest in high head elevated to space and
fowler’s 900 improve
position with Assessed the oxygenation
Objective head elevated need for oxygen to the lungs
data: on to 900 therapy and start To improve
observation Assess the oxygen via face oxygenation
pt. Presence need for mask or insert to the lungs
of pursed lip oxygen intubation and and aid in gas
breathing therapy and mechanical exchange
Capillary start oxygen ventilation To relieve
refill time via face Provided congestion in
prolonged mask or suctioning respiratory
Presence of insert intermittently as tract
rates and intubation and when To clear
wheezes and required airway
Tachycardia mechanical Advised the To meet any
Tachypnoea ventilation client to perform emergencies
Oxygen Provide deep breathing in the event
saturation suctioning exercises of cardiac
decreased intermittentl Kept all arrest
y as and emergency To treat the
when articles at cause and
required bedside of the improve
Advise the oxygenation
patient .
client to
perform deep
breathing
exercises
Keep all
emergency
articles at
bedside of
the patient .

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 HEALTH EDUCATION

TOPIC CONTENT REMARK

Breathing exercises  Maintain the respiratory rate, rhythm  Maintained
and increase lung oxygenation respiratory rate
 Maintain the oxygen saturation
 Maintain the myocardial oxygenation
 Clear the congestion of respiratory
tract
 Enhance the lungs oxygenation

 Change the lifestyle pattern

 Decrease work load  Maintained
Lifestyle  Take proper bed rest cardiac function

 Consult diet plan and list of permitted

and restricted foods  Maintained body
 Avoid using salt when preparing weight
Diet foods or adding salt to the foods
 Eat small, frequent meals

 Take medication as prescribed by

doctor
 Do not take any medicine without
prescriptions
 Improve body
 Do not take over dose of medicines functions
Medication

 Educate the patient for regular Prevention from

Follow up care checkups and importance of follow complications
up care

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 PROGNOSIS AND CONCLUSION:
PROGNOSIS:
 One study says that people with congestive heart failure have a life span 10 yrs.
shorter than those who don’t have heart failure.
 Another study showed that the survival rates of people with chronic heart failure
were:
o 80% to 90% for one year
o 50% to 60% for five years
o 30% for 10 years
 A different study found that people who had heart failure had expected life spans
ranging from 3 to 20 years after their hospital stay, depending on various factors like
age and assigned sex at birth. It’s important to look at your specific situation when
considering your prognosis

CONCLUSION:
 Congestive heart failure is a common disabling and deadly condition. Heart failure is
associated with significantly reduced physical and mental health, resulting in a
markedly decreased quality of life. By changing lifestyle, it can be prevented and if it
already occurs early diagnosis and treatment can prevent mortality associated with it.
 Heart failure has reached epidemic proportions. Early identification of the risk factors
and initiation of appropriate therapy at early stages prevents development of heart
failure.

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BIBLIOGRAPHY:

BOOK REFERENCES:

✓ Burner and Siddharth’s ; “ Text book of medical surgical nursing ; 12 th edition volume 2 ,
page no. 1120-1125.
✓ Levis ; “ A text book of medical surgical nursing” published by Elsevier, a devision of
reed Elsevier Indian private limited , page no. 1030- 1035.
✓ Phipps’s and Monahan; “ A text book of medical surgical nursing” , publishers sehrefer,
page no. 611-613.
✓ Dr. Cheerg SN ; “ A text book of medical surgical nursing”, AVI chap publishers ; page
no. 972-980.
✓ Suresh k, Sharma. Text book of medical surgical nursing ( 10th ed.). page no.239 – 345.
Wolters kulwer publishers.

✓ Sukh pal, Kaur. . Text book of adult medical surgical nursing ( Ist ed.). page no. 350 –
357. Jaypee publishers.

✓ Wilson and Ross : “Anatomy and Physiology in Health and illness”13 th edition;
Elsevier Publishers, page no-407-409

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