Nursing Care Plan Assignment: CHF Patient Scenario with NANDA Diagnoses
Assignment Overview
This BSN-level nursing care plan assignment showcases a complete congestive heart failure (CHF) case study for NUR 320: Adult Health Nursing. The sample demonstrates how to analyze patient assessment data, prioritize NANDA nursing diagnoses, write measurable outcomes, and map NIC interventions with evidence-based rationales that align with current American Heart Association (AHA) guidelines.
Course: NUR 320 – Adult Health Nursing | Author: Registered Nurse Educator | Instructor: Prof. L. Andrews, MSN, RN | Date: January 12, 2025
Key Care Plan Components
- Comprehensive Assessment: Subjective complaints, objective findings, cardiac lab values, and telemetry interpretation for CHF.
- Prioritized NANDA-I Diagnoses: Decreased cardiac output, impaired gas exchange, and excess fluid volume with defining characteristics.
- SMART Outcomes: Patient-centered goals for ventilation, activity tolerance, and self-management within 24-72 hours.
- NIC Interventions & Rationales: Medication management, oxygen therapy, fluid restriction, and patient education supported by current research.
- Evaluation & Documentation: Progress notes, reassessment data, and interdisciplinary communication for safe discharge planning.
Introduction
Congestive heart failure nursing care plans are frequently assigned in adult health courses because they evaluate a student’s ability to synthesize assessment data, lab trends, and pathophysiology into prioritized nursing actions. This paper walks through a CHF patient scenario using the nursing process and ANA documentation standards.
Patient Assessment Summary
Mr. J., a 66-year-old male with a history of coronary artery disease, presents to the telemetry unit after experiencing shortness of breath and orthopnea. Assessment reveals jugular vein distention, +3 pitting edema in both legs, S3 gallop, and bibasilar crackles. Vital signs: BP 162/94 mmHg, HR 108 bpm, RR 26/min, SpO2 88% on room air, weight gain of 5.4 lb in three days. Labs show BNP 1,240 pg/mL, serum sodium 130 mEq/L, and potassium 3.4 mEq/L.
- Subjective Data: “I wake up gasping for air,” reports paroxysmal nocturnal dyspnea, fatigue with minimal exertion.
- Objective Data: Crackles in lower lobes, diminished breath sounds, abdominal distention, decreased urine output.
- Diagnostics: Chest X-ray indicating pulmonary congestion; echocardiogram EF 30%.
Priority NANDA Diagnoses
- Decreased Cardiac Output related to impaired myocardial contractility as evidenced by dyspnea, tachycardia, and reduced ejection fraction.
- Impaired Gas Exchange related to alveolar-capillary membrane changes secondary to pulmonary congestion as evidenced by SpO2 88% and crackles.
- Excess Fluid Volume related to compromised regulatory mechanisms as evidenced by edema, weight gain, and elevated BNP.
Goals and Expected Outcomes
- Patient will maintain SpO2 ≥ 94% on 2 L/min nasal cannula within 24 hours.
- Patient will verbalize three strategies to monitor fluid status (daily weights, edema checks, sodium restriction) before discharge.
- Patient will demonstrate stable cardiac rhythm and report improved activity tolerance within 48 hours.
Nursing Interventions & Rationales
- Monitor hemodynamics: Continuous telemetry, frequent vital signs, strict I&O to evaluate response to diuretics (supports NOC: Cardiac Pump Effectiveness).
- Administer prescribed medications: IV furosemide, ACE inhibitor, and beta-blocker per CHF protocol to reduce preload and afterload.
- Provide oxygen therapy: Titrate nasal cannula, position in high Fowler’s, encourage incentive spirometry to optimize gas exchange.
- Implement fluid and sodium restrictions: Collaborate with dietitian to maintain 2 g sodium diet and 1.5 L fluid limit; educate patient on label reading.
- Teach self-management behaviors: Daily weight log, recognition of worsening symptoms, medication adherence, follow-up appointments.
Medication & Interdisciplinary Collaboration
Consulted cardiology and pharmacy to review medication titration. Coordinated with respiratory therapy for oxygen weaning and physical therapy for energy conservation techniques. Verified patient understanding of anticoagulation therapy and scheduled home health nursing for post-discharge monitoring.
Evaluation & Documentation
After 36 hours the patient maintained SpO2 95% on 1 L/min oxygen, weight decreased by 2.1 lb, lungs clear to auscultation mid-lobe, and edema reduced to +1. Education documentation reflected teach-back accuracy on medication regimen and sodium restriction. Care plan updated to address long-term heart failure clinic referral.