Nursing Care Plan Sample: Chronic Heart Failure

Model Answer

Patient Scenario

Mr D, a 71-year-old man with a six-year history of heart failure with reduced ejection fraction (HFrEF, last recorded ejection fraction 32%) secondary to ischaemic heart disease, was admitted to a cardiology ward with a two-week history of worsening breathlessness, orthopnoea requiring three pillows, and bilateral ankle swelling. He reported a 4 kg weight gain over ten days, reduced exercise tolerance to under 50 metres, and an episode of paroxysmal nocturnal dyspnoea the night before admission. On examination he was tachypnoeic at 26 breaths per minute, oxygen saturation 91% on room air, heart rate 104 beats per minute and irregularly irregular, blood pressure 108/68 mmHg, with bibasal crackles on auscultation, a raised jugular venous pressure and pitting oedema to mid-shin bilaterally. His regular medication included bisoprolol, ramipril, furosemide and a statin; his daughter reported that he had been intermittently omitting his furosemide because it “made him need the toilet too much,” and had recently increased his salt intake at a family celebration.

His past medical history includes a myocardial infarction five years ago, type 2 diabetes, chronic kidney disease stage 3a (baseline eGFR 52 mL/min/1.73m²) and newly documented atrial fibrillation on the admission electrocardiogram. Blood tests confirmed a raised N-terminal pro-B-type natriuretic peptide (NT-proBNP) of 3,850 pg/mL, mildly deranged renal function consistent with his baseline chronic kidney disease, and a low serum sodium of 131 mmol/L, all consistent with an episode of decompensated congestive heart failure precipitated by dietary indiscretion, diuretic non-adherence and new-onset atrial fibrillation (NICE NG106, 2021). This multifactorial precipitant is clinically significant: effective care planning must address not only the acute fluid overload but the modifiable behavioural and rhythm-related contributors, or readmission is highly likely, a point returned to throughout this plan.

Mr D is a retired electrician who lives with his wife in a bungalow, and until this admission had been managing largely independently, though his wife had increasingly taken on responsibility for his medication organisation over the preceding year. He described this admission as his third in eighteen months, a pattern consistent with the literature identifying heart failure as one of the leading causes of potentially preventable readmission among older adults in the United Kingdom, and one that his consultant had previously flagged as requiring closer community support. He expressed considerable frustration at being back in hospital, describing the diuretic-related urinary frequency as “ruling my life,” a statement that proved central to shaping a genuinely person-centred self-management plan rather than a purely biomedical one.

Assessment

Assessment combined a structured Airway, Breathing, Circulation, Disability, Exposure (A–E) survey with the Activities of Living model (Roper, Logan and Tierney, 2000), reflecting the Nursing and Midwifery Council Code (2018) and the systematic clinical reasoning expected at postgraduate level.

Airway/Breathing: patent airway, tachypnoeic with bibasal crackles, saturations 91% on air, improving to 95% on 2L nasal cannula oxygen titrated to a target of 94–98% given no history of chronic obstructive pulmonary disease. Circulation: tachycardic and irregularly irregular consistent with atrial fibrillation, blood pressure at the lower end of normal reflecting reduced cardiac output, raised jugular venous pressure and cool peripheries suggestive of a degree of hypoperfusion. Disability: alert and orientated, Glasgow Coma Scale 15/15, blood glucose within acceptable range for his known diabetes. Exposure: bilateral pitting oedema to mid-shin, weight 4 kg above his documented dry weight, skin intact but taut over oedematous areas with early breakdown risk.

A NEWS2 score of 5 was calculated, prompting increased monitoring frequency (Royal College of Physicians, 2017). Further assessment addressed breathing and circulation as an activity of living (severe limitation, orthopnoea), mobilising (exercise tolerance reduced to under 50 metres, New York Heart Association Class III), eating and drinking (reduced appetite secondary to breathlessness and early satiety from hepatic congestion, alongside a diet history revealing high recent salt intake), and elimination (reduced urine output relative to fluid intake, consistent with fluid retention). A fluid balance chart and daily weight monitoring were commenced immediately. A Malnutrition Universal Screening Tool (MUST) score of 1 was recorded, and a Waterlow pressure ulcer risk score flagged him as moderate risk owing to oedema and reduced mobility, prompting proactive skin care. Critically, a structured medicines-adherence conversation, conducted non-judgementally, revealed the specific driver of his furosemide omission (urinary frequency affecting his sleep and social activity) rather than a general unwillingness to adhere, information that directly shaped the self-management diagnosis and intervention below rather than being treated as a generic “non-compliance” label. A cognitive screen was also completed given his age and the diagnostic overlap between cardiac and cognitive decline in older adults, returning a score within normal limits and confirming that his ability to engage with education and shared decision-making was not itself in question.

Nursing Diagnoses

Four prioritised nursing diagnoses were identified, ranked using a combined physiological-urgency and person-centred rationale:

1. Decreased cardiac output related to impaired ventricular contractility and new-onset atrial fibrillation, evidenced by tachycardia, hypotension relative to baseline, raised jugular venous pressure and elevated NT-proBNP (actual problem, highest priority).

2. Excess fluid volume related to sodium and water retention secondary to reduced cardiac output and dietary sodium intake, evidenced by 4 kg weight gain, bilateral oedema and reduced urine output relative to intake (actual problem, high priority).

3. Impaired gas exchange related to pulmonary congestion, evidenced by tachypnoea, bibasal crackles and oxygen saturation of 91% on air (actual problem, high priority).

4. Risk of ineffective self-management related to a complex medication regimen and unaddressed treatment burden, evidenced by reported furosemide omission linked to specific, modifiable concerns about urinary frequency (risk problem, medium priority but central to preventing recurrence).

The first three diagnoses reflect the interlinked physiological cascade of decompensated heart failure and are prioritised for immediate stabilisation; however, consistent with contemporary heart failure nursing scholarship, the fourth diagnosis is treated as equally clinically important over the admission as a whole, since unresolved self-management barriers are the single most consistently identified predictor of 30-day heart failure readmission (NICE NG106, 2021; British Heart Foundation, 2022).

The Care Plan

Evaluation and Review

Evaluation was undertaken at each nursing handover and formally reviewed at 48 and 96 hours, using NEWS2 trends, daily weight, fluid balance, oxygen requirement and self-reported symptom burden as objective and subjective markers of progress, in keeping with a critically reflective, evidence-based approach appropriate to postgraduate practice (NMC, 2018). Where goals were only partially met, for example if diuresis proved slower than anticipated or renal function deteriorated, the plan specified prompt escalation to the medical and cardiology teams for reassessment of the diuretic strategy rather than mechanical continuation of an ineffective regimen; this reflects the genuinely cyclical, rather than linear, nature of the nursing process in a complex, comorbid patient. Discharge planning was integrated from admission, involving the multidisciplinary team, the community heart failure specialist nursing service and, with Mr D’s consent, his daughter, to support a safe transition and to directly target the modifiable readmission risk identified during assessment.

By day five, Mr D’s weight had reduced by 3.6 kg toward his documented dry weight, his oxygen saturation was maintained at 96% on room air, his respiratory rate had normalised to 16 breaths per minute, and his heart rate was controlled at 78 bpm on optimised rate-control therapy, with cardiology agreeing a plan for anticoagulation given his CHA₂DS₂-VASc score. Renal function remained stable throughout diuresis, and his serum sodium had corrected to 135 mmol/L. Most significantly for longer-term outcomes, Mr D engaged constructively with the heart failure specialist nurse, agreeing a revised diuretic timing that avoided disrupting his afternoon social activities, and correctly demonstrated understanding of daily weight monitoring and the specific weight-gain threshold at which he should contact the heart failure helpline. A structured discharge summary was shared with his general practitioner and the community heart failure team, with a home visit arranged within 72 hours and cardiac rehabilitation referral initiated. Given his history of two prior admissions in eighteen months, the multidisciplinary team also agreed a shared “red flag” action plan with Mr D and his wife, specifying the exact weight-gain and symptom thresholds at which she should contact the heart failure helpline rather than waiting for a further emergency presentation, a step explicitly aimed at breaking the preventable-readmission cycle identified at the outset of this care plan. This case illustrates that in chronic heart failure, physiological stabilisation and psychosocially informed self-management planning are not sequential but interdependent components of safe, effective discharge, and that failure to address the latter is likely to reproduce the very admission the plan was designed to resolve (Roper, Logan and Tierney, 2000; NICE NG106, 2021).

References

British Heart Foundation (2022) Living With Heart Failure: A Guide for Patients and Carers. London: BHF.
British Thoracic Society (2017) Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings. London: BTS.
National Institute for Health and Care Excellence (2014) Pressure Ulcers: Prevention and Management (CG179). London: NICE.
National Institute for Health and Care Excellence (2021) Chronic Heart Failure in Adults: Diagnosis and Management (NG106). London: NICE.
National Institute for Health and Care Excellence (2021) Atrial Fibrillation: Diagnosis and Management (NG196). London: NICE.
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
Roper, N., Logan, W.W. and Tierney, A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Churchill Livingstone.
Royal College of Physicians (2017) National Early Warning Score (NEWS) 2. London: RCP.