Heart Failure (CHF) Nursing Care Plan

A nursing care plan for congestive cardiac failure (CCF, also called congestive heart failure or CHF) addresses the problems heart failure causes: fluid overload, breathlessness and low oxygen levels, limited activity, and difficulty managing a complicated treatment plan at home. A typical plan includes the nursing diagnoses Excessive fluid volume, Impaired gas exchange, Decreased activity tolerance and Ineffective health self-management, each with measurable outcomes and nursing interventions. Daily weights, lung assessment, diuretic monitoring and discharge teaching are at the center of the plan.

This guide explains the heart failure basics you need for care planning, the signs of left- and right-sided failure, current NANDA-I labels, a filled care plan table, a daily weight tracking sheet and the red flags that need escalation. It follows the 2022 AHA/ACC/HFSA guideline for the management of heart failure where it applies to nursing care.

Heart Failure Basics for Care Planning

Heart failure is a clinical syndrome in which the heart cannot fill or pump well enough to meet the body's needs at normal filling pressures. Blood and fluid back up behind the weakened side of the heart, which causes congestion, and organs receive less blood flow, which causes fatigue and low exercise tolerance. The StatPearls review of heart failure covers the causes, the most common being coronary artery disease and hypertension.

Classification by Ejection Fraction

The 2022 guideline classifies heart failure by left ventricular ejection fraction (LVEF), as summarized by the American College of Cardiology:

Stages and Functional Class

The guideline uses four stages. Stage A is "at risk" (for example, hypertension or diabetes without heart changes), Stage B is "pre-heart failure" (structural heart disease without symptoms), Stage C is symptomatic heart failure, and Stage D is advanced heart failure. The New York Heart Association (NYHA) class describes symptoms with activity: class I has no limitation, class II has slight limitation, class III has marked limitation with less than ordinary activity, and class IV has symptoms at rest. Stages only move forward, but NYHA class can improve with treatment, so the NYHA class is the one to record when you evaluate activity outcomes.

Left vs Right Heart Failure: Signs to Assess

Where the fluid backs up depends on which side of the heart is failing. Left-sided failure congests the lungs. Right-sided failure congests the veins of the body. Left-sided failure is the most common cause of right-sided failure, so many patients show both patterns. The Open RN Health Alterations chapter on heart failure includes a comparison table you can use for revision.

Nursing Assessment for Heart Failure

• Daily weight: same scale, same time (usually morning after voiding and before breakfast), similar clothing. Weight is the most practical measure of fluid change.
• Intake and output: strict measurement during diuresis, including urine output after each diuretic dose.
• Breathing: rate, effort, SpO2, lung sounds (crackles), cough, and how many pillows the patient needs to sleep (orthopnea). Ask about waking up breathless at night.
• Circulation and fluid: blood pressure, heart rate and rhythm, extra heart sounds, jugular vein distention, edema in the legs or sacrum, capillary refill and skin temperature.
• Perfusion: mental status, fatigue, dizziness and urine output, which can fall when cardiac output drops.
• Laboratory data: sodium, potassium, magnesium, creatinine and BUN, and natriuretic peptide (BNP or NT-proBNP) if ordered.
• Self-care: how the patient takes medicines, weighs themselves, limits sodium, and recognizes symptoms, and who helps at home.

Record these findings in the same order every shift so that trends are easy to compare.

Nursing Diagnosis for Heart Failure: Current NANDA-I Labels

The NANDA International 2024–2026 edition changed several labels used in heart failure care plans. The most important change is that Decreased cardiac output (00029), a label used in earlier editions, was retired, because experts judged it to be outside the scope of independent nursing practice. Risk for decreased cardiac output (00240) remains. Many textbooks and instructors still use Decreased cardiac output, so follow your course rubric and note the edition you used.

There is no single nursing diagnosis heart failure care plans must use; choose the labels your assessment data support. For a hospitalized patient with congestion, Excessive fluid volume and Impaired gas exchange usually come first, because breathing and fluid overload are the immediate threats. For help writing the full statements, see our guides to common nursing diagnoses and nursing diagnosis examples with PES statements.

Nursing Care Plan for Congestive Cardiac Failure: Filled Example

The patient below is hypothetical. A 74-year-old woman with HFrEF (LVEF 30%) and NYHA class III symptoms is admitted with acute decompensated heart failure. She has gained 2.5 kg (about 5.5 lb) in five days after several salty restaurant meals and has run out of her diuretic. She has 2+ pitting edema to the knees, crackles in both lung bases and an SpO2 of 89% on room air, and she sleeps on three pillows. She becomes breathless walking to the bathroom. She lives with her husband and does not weigh herself at home.

Use this as a model for the structure, not as a template to copy. Your assessment data, goals and evaluation must match your own patient. A typical nursing care plan CHF assignment also asks for the pathophysiology in your own words and a rationale for each intervention with a source. Our guide on how to write a nursing care plan explains each column, and the guide to nursing concept maps shows how to link these diagnoses visually.

Key Nursing Interventions Explained

Monitoring Diuretic Therapy

Loop diuretics are the main treatment for congestion. After each dose, record the urine output and watch for dizziness, low blood pressure, muscle cramps and changes in potassium, magnesium and creatinine. Weigh the patient before breakfast each day so the provider can judge the response and adjust the dose.

Supporting Guideline-Directed Medical Therapy

For HFrEF, the 2022 guideline recommends four medicine classes together: a renin-angiotensin system inhibitor (preferably an angiotensin receptor-neprilysin inhibitor, or ARNi), an evidence-based beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. Nursing responsibilities include:

• Checking blood pressure and heart rate before each dose and following hold parameters.
• Monitoring potassium and kidney function, especially with mineralocorticoid receptor antagonists and renin-angiotensin system inhibitors.
• Flagging an ACE inhibitor and an ARNi on the same medication list, since an ARNi must not be started within 36 hours of the last ACE inhibitor dose.
• Teaching patients not to stop beta-blockers abruptly and that some tiredness can occur when doses are increased.
• Teaching patients to avoid NSAIDs such as ibuprofen and naproxen unless the provider approves, because the American Heart Association lists them among drugs that can cause or worsen heart failure.

Sodium and Fluid Limits

The 2022 guideline says that, for patients with symptomatic heart failure, avoiding excessive sodium intake is reasonable to reduce congestion, but it does not set one number for everyone. Fluid restriction is not routine for every patient, and the guideline describes its benefit as uncertain even in advanced heart failure with low blood sodium. Follow the provider's order and teach the specific limits the patient has been given, rather than generic numbers.

Daily Weight and Fluid Tracking

Teaching patients to weigh themselves every day and act on changes is one of the most useful nursing interventions in heart failure, because weight often rises before breathlessness gets worse. The American Heart Association's Self-Check Plan for HF Management tells patients to contact their care team for a sudden weight gain of more than 2 to 3 pounds in 24 hours or 5 pounds in a week. Some programs use different numbers, so always teach the thresholds the patient's own provider sets.

When you teach the sheet, ask the patient to show you how they would fill in a day and what they would do if the weight rose by 3 pounds overnight. This is the teach-back method, which is also a popular topic for evidence-based practice projects. See the heart failure readmission question in our PICOT question examples.

Red Flags in Heart Failure

Escalate promptly, and use SBAR when you call, for any of the following:

• Increasing shortness of breath at rest, inability to lie flat, or falling SpO2 despite oxygen.
• Pink, frothy sputum or rapidly worsening crackles, which can signal acute pulmonary edema.
• Chest pain, new irregular heart rhythm, fainting or a heart rate outside ordered limits.
• New confusion, cool clammy skin, low blood pressure or falling urine output, which can mean poor perfusion.
• Potassium or creatinine results outside the normal range after diuretic or medicine changes.

Getting Help with a Heart Failure Care Plan

Heart failure care plans are common in medical-surgical and critical care courses and in clinical paperwork. If you would like feedback on a nursing care plan for heart failure, including your diagnoses, SMART outcomes or rationales, our nursing homework help service provides tutoring and review from nursing writers. Use any outside help in line with your school's academic integrity policy.

Frequently Asked Questions

What Is the Priority Nursing Diagnosis for Heart Failure?

In acute decompensated heart failure, Impaired gas exchange and Excessive fluid volume are usually the priorities because breathing and fluid overload are the immediate threats. Once the patient is stable, Ineffective health self-management becomes the focus for preventing readmission.

Is Decreased Cardiac Output Still a NANDA-I Diagnosis?

It was retired in the 2024–2026 edition. Risk for decreased cardiac output (00240) remains. If your instructor or textbook still uses Decreased cardiac output, follow the rubric and mention which edition you used.

What Should a Nursing Care Plan for CHF Include?

It should include assessment data, three to five prioritized nursing diagnoses, SMART outcomes, nursing interventions with rationales, and an evaluation of each outcome. Most heart failure plans cover fluid balance, breathing, activity and self-management teaching.

How Much Weight Gain Should Patients with Heart Failure Report?

The American Heart Association's patient self-check plan uses more than 2 to 3 pounds in 24 hours or 5 pounds in a week. The patient's own provider may set different numbers, and those take priority.

What Is the Difference Between Left- and Right-Sided Heart Failure?

Left-sided failure backs fluid into the lungs, causing breathlessness, orthopnea and crackles. Right-sided failure backs fluid into the body, causing leg edema, jugular vein distention, weight gain and abdominal swelling. Many patients have both.

Should Every Heart Failure Patient Be on a Fluid Restriction?

No. The 2022 guideline does not recommend routine fluid restriction, and its benefit is uncertain even in advanced heart failure. Teach patients the limit their own provider has ordered, if any.