Medical Surgical Nursing Nursing Care Plans

Heart Failure & Decreased Cardiac Output Nursing Care Plans: ADPIE Clinical Guide

ToNursing Team December 6, 2024

2 101 8 minutes read

Cardiovascular Masterclass
• Hemodynamics & NANDA-I Care Plans

Clinical Overview: Heart failure (HF) is a complex clinical syndrome resulting from structural or functional cardiac disorders that impair the ventricles’ ability to fill with or eject blood. In both acute decompensation (ADHF) and chronic maintenance, nurses play the frontline role in stabilizing hemodynamics, titrating life-saving guideline-directed medical therapy (GDMT), and managing fluid overload. This comprehensive clinical guide presents prioritized NANDA-I nursing care plans centering on Decreased Cardiac Output and Excess Fluid Volume, complete with SMART outcomes, cardiovascular pharmacology safety rules, and NCLEX board pearls.

Pathophysiology & Hemodynamics: Left vs. Right Heart Failure

To safely implement a decreased cardiac output care plan, the nurse must analyze the underlying ventricular mechanics and distinguishing clinical manifestations:

Heart Failure with Reduced Ejection Fraction (HFrEF / Systolic Failure): Left ventricular ejection fraction (LVEF) is ≤ 40%. The weakened myocardium cannot generate sufficient contraction force during systole to maintain adequate stroke volume.
Heart Failure with Preserved Ejection Fraction (HFpEF / Diastolic Failure): LVEF remains ≥ 50%, but ventricular walls are stiff, hypertrophied, and non-compliant, impairing normal diastolic ventricular filling.

Bedside Assessment: Differentiating Left vs. Right Ventricular Failure:

Clinical Parameter	Left-Sided Heart Failure (Pulmonary Congestion)	Right-Sided Heart Failure (Systemic Venous Congestion)
Pathophysiology	Blood backs up from the failing left ventricle into the left atrium and pulmonary veins, increasing pulmonary capillary wedge pressure (PCWP).	Blood backs up from the failing right ventricle into the right atrium, superior vena cava (SVC), and inferior vena cava (IVC). Most common cause: left-sided HF!
Respiratory Manifestations	Dyspnea on exertion, orthopnea (needs 2-3 pillows), Paroxysmal Nocturnal Dyspnea (PND), bilateral bibasilar crackles (rales), tachypnea, pink frothy sputum in acute pulmonary edema.	Minimal primary pulmonary symptoms; patient may report abdominal fullness and shortness of breath secondary to diaphragm elevation from severe ascites.
Cardiovascular & Systemic Signs	S3 gallop (“ventricular gallop”), displaced point of maximal impulse (PMI), weak thready pulses, cool pale extremities, prolonged capillary refill (>3 sec).	Jugular Venous Distension (JVD) at 45 degrees, dependent bilateral peripheral pitting edema (+1 to +4) in ankles/sacrum, hepatomegaly with right upper quadrant tenderness, splenomegaly, ascites.
Renal & Cognitive Findings	Oliguria during the day (decreased renal perfusion), nocturia at night (improved recumbent perfusion), confusion, restlessness, and memory loss from cerebral hypoxemia.	Anorexia, nausea, abdominal bloating, and gastrointestinal malabsorption secondary to venous congestion of the stomach and mesentery.

Core NANDA-I Nursing Diagnoses for Heart Failure

Nurses care for heart failure patients across the clinical continuum—from acute ICU infusions of inotropes to outpatient cardiology clinics. The following prioritized NANDA-I diagnoses direct clinical care:

Decreased Cardiac Output (Primary Priority): Inadequate volume of blood pumped by the heart per minute to meet the metabolic demands of the body.
Excess Fluid Volume: Increased isotonic fluid retention secondary to decreased glomerular filtration rate and hyperactivation of the Renin-Angiotensin-Aldosterone System (RAAS).
Impaired Gas Exchange: Excess fluid in the alveolar-capillary interstitial space interfering with oxygen diffusion.
Activity Intolerance: Insufficient physiological or psychological energy to endure daily activities due to tissue hypoperfusion.
Risk for Impaired Skin Integrity: Fragile, edematous dermal tissue susceptible to pressure breakdown, shearing, and venous stasis ulcers.
Ineffective Health Management: Challenges managing lifelong dietary sodium restrictions, fluid limits, daily weight logging, and complex multi-drug regimens.

Master 5-Column High-Yield Care Plan Table

The following standardized care plan provides evidence-based assessment data, measurable SMART goals, and prioritized bedside interventions with scientific rationales:

1. Assessment Data	2. Nursing Diagnosis (PES)	3. SMART Goals & Outcomes	4. Nursing Interventions & Rationales	5. Evaluation
Subjective: “I feel exhausted doing the simplest tasks, dizzy when standing up,” palpitations. Objective: Blood pressure 92/58 mmHg, apical heart rate 118 bpm, weak peripheral pulses (+1/4), S3 gallop, capillary refill 4 seconds, BNP 1,450 pg/mL, echocardiogram shows LVEF 28%.	Decreased Cardiac Output related to altered contractility, afterload, and ventricular dysfunction secondary to ischemic cardiomyopathy, as evidenced by EF 28%, hypotension, tachycardia, S3 sound, and prolonged capillary refill.	Client will maintain adequate systemic perfusion as evidenced by systolic BP ≥ 100 mmHg, apical HR 60–100 bpm, strong peripheral pulses (+2/4), and warm dry skin within 24 hours.	1. Position client in semi-Fowler’s or high-Fowler’s position. (Rationale: Decreases venous return/preload, reducing cardiac workload and easing diaphragmatic excursion). 2. Administer prescribed ACE inhibitors/ARBs or ARNI (Sacubitril/Valsartan) and Beta-blockers (Metoprolol succinate). (Rationale: Inhibits neurohormonal remodeling, decreases afterload, and improves long-term cardiac output). 3. Auscultate apical pulse for 1 full minute prior to administering Digoxin; withhold if HR < 60 bpm. (Rationale: Prevents dangerous bradyarrhythmias and toxicity). 4. Space nursing activities and implement planned rest periods. (Rationale: Prevents myocardial oxygen demand from exceeding supply).	Goal Met: BP stabilized at 106/68 mmHg, resting apical pulse 76 bpm, peripheral pulses palpable +2/4 bilaterally, capillary refill reduced to 2.5 seconds.
Subjective: “My shoes don’t fit anymore, my rings are tight, and I gained 6 pounds in 3 days.” Objective: Bilateral +3 pitting pretibial and ankle edema, JVD visible 6 cm above sternal angle at 45 degrees, abdominal distension, bibasilar fine crackles, weight increase from 72 kg to 75 kg in 72 hours.	Excess Fluid Volume related to compromised regulatory mechanisms secondary to renal hypoperfusion and sodium/water retention, as evidenced by 3 kg weight gain, +3 pitting edema, JVD, and pulmonary crackles.	Client will achieve fluid volume reduction as evidenced by diuresis > 1,500 mL/24 hr, resolution of dependent edema to ≤ +1, and baseline dry weight restoration within 48 hours.	1. Administer prescribed IV loop diuretic (Furosemide / Lasix); push slowly over 2-3 minutes (max 20 mg/min). (Rationale: Rapid IV boluses of furosemide can cause permanent ototoxicity and tinnitus). 2. Weigh patient daily at the exact same time every morning, using the same scale, after first void, wearing similar clothing. (Rationale: Weight is the most accurate bedside indicator of fluid gain or loss; 1 kg = 1,000 mL fluid). 3. Enforce prescribed 2-gram sodium restriction and fluid restriction (1,500 to 2,000 mL/day). (Rationale: Prevents hyperosmolar thirst stimulation and further vascular fluid overload). 4. Monitor serum electrolytes (potassium, sodium, magnesium) and BUN/Creatinine closely. (Rationale: Loop diuretics cause rapid renal excretion of potassium and potential hypokalemia-induced arrhythmias).	Goal Met: Diuresis of 2,800 mL in first 24 hours. Weight decreased by 2.6 kg. Dependent edema decreased to trace (+1). Serum potassium maintained at 4.2 mEq/L with oral KCl replacement.
Subjective: “I wake up choking and gasping for air 2 hours after falling asleep (PND), I have to sleep in a recliner.” Objective: SpO2 88% on room air, RR 26 breaths/min, intercostal muscle retractions, bibasilar moist crackles extending into mid-lung fields, persistent dry hacking cough.	Impaired Gas Exchange related to alveolar-capillary membrane changes secondary to pulmonary venous congestion and fluid accumulation in the lung interstitium, as evidenced by SpO2 88%, crackles, and orthopnea.	Client will maintain adequate oxygenation as evidenced by SpO2 ≥ 94% on minimal supplemental O2 and unlabored respiratory rate of 12–20 breaths/min within 4 hours.	1. Place client in high-Fowler’s position with legs dependent over the edge of the bed if hemodynamically stable. (Rationale: Venous blood pools in the lower extremities, immediately reducing venous return and pulmonary capillary hydrostatic pressure). 2. Administer humidified supplemental oxygen via nasal cannula or Venturi mask to maintain SpO2 ≥ 94%. (Rationale: Elevates alveolar PO2, driving oxygen diffusion across edematous alveolar membranes). 3. Auscultate lung sounds every 2 hours and monitor for pink, frothy sputum (cardinal sign of acute flash pulmonary edema). (Rationale: Provides early warning of respiratory collapse requiring emergent CPAP/BiPAP or mechanical ventilation).	Goal Met: SpO2 stabilized at 95% on 2 L/min NC. Respiratory rate slowed to 16 breaths/min. Crackles diminished significantly to lung bases only. Patient able to rest comfortably in semi-Fowler’s.

1. Assessment Data

2. Nursing Diagnosis (PES)

3. SMART Goals & Outcomes

4. Nursing Interventions & Rationales

5. Evaluation

Subjective: “I feel exhausted doing the simplest tasks, dizzy when standing up,” palpitations.

Objective: Blood pressure 92/58 mmHg, apical heart rate 118 bpm, weak peripheral pulses (+1/4), S3 gallop, capillary refill 4 seconds, BNP 1,450 pg/mL, echocardiogram shows LVEF 28%.

Decreased Cardiac Output related to altered contractility, afterload, and ventricular dysfunction secondary to ischemic cardiomyopathy, as evidenced by EF 28%, hypotension, tachycardia, S3 sound, and prolonged capillary refill.

Client will maintain adequate systemic perfusion as evidenced by systolic BP ≥ 100 mmHg, apical HR 60–100 bpm, strong peripheral pulses (+2/4), and warm dry skin within 24 hours.

1. Position client in semi-Fowler’s or high-Fowler’s position. (Rationale: Decreases venous return/preload, reducing cardiac workload and easing diaphragmatic excursion).

2. Administer prescribed ACE inhibitors/ARBs or ARNI (Sacubitril/Valsartan) and Beta-blockers (Metoprolol succinate). (Rationale: Inhibits neurohormonal remodeling, decreases afterload, and improves long-term cardiac output).

3. Auscultate apical pulse for 1 full minute prior to administering Digoxin; withhold if HR < 60 bpm. (Rationale: Prevents dangerous bradyarrhythmias and toxicity).

4. Space nursing activities and implement planned rest periods. (Rationale: Prevents myocardial oxygen demand from exceeding supply).

Goal Met: BP stabilized at 106/68 mmHg, resting apical pulse 76 bpm, peripheral pulses palpable +2/4 bilaterally, capillary refill reduced to 2.5 seconds.

Subjective: “My shoes don’t fit anymore, my rings are tight, and I gained 6 pounds in 3 days.”

Objective: Bilateral +3 pitting pretibial and ankle edema, JVD visible 6 cm above sternal angle at 45 degrees, abdominal distension, bibasilar fine crackles, weight increase from 72 kg to 75 kg in 72 hours.

Excess Fluid Volume related to compromised regulatory mechanisms secondary to renal hypoperfusion and sodium/water retention, as evidenced by 3 kg weight gain, +3 pitting edema, JVD, and pulmonary crackles.

Client will achieve fluid volume reduction as evidenced by diuresis > 1,500 mL/24 hr, resolution of dependent edema to ≤ +1, and baseline dry weight restoration within 48 hours.

1. Administer prescribed IV loop diuretic (Furosemide / Lasix); push slowly over 2-3 minutes (max 20 mg/min). (Rationale: Rapid IV boluses of furosemide can cause permanent ototoxicity and tinnitus).

2. Weigh patient daily at the exact same time every morning, using the same scale, after first void, wearing similar clothing. (Rationale: Weight is the most accurate bedside indicator of fluid gain or loss; 1 kg = 1,000 mL fluid).

3. Enforce prescribed 2-gram sodium restriction and fluid restriction (1,500 to 2,000 mL/day). (Rationale: Prevents hyperosmolar thirst stimulation and further vascular fluid overload).

4. Monitor serum electrolytes (potassium, sodium, magnesium) and BUN/Creatinine closely. (Rationale: Loop diuretics cause rapid renal excretion of potassium and potential hypokalemia-induced arrhythmias).

Goal Met: Diuresis of 2,800 mL in first 24 hours. Weight decreased by 2.6 kg. Dependent edema decreased to trace (+1). Serum potassium maintained at 4.2 mEq/L with oral KCl replacement.

Subjective: “I wake up choking and gasping for air 2 hours after falling asleep (PND), I have to sleep in a recliner.”

Objective: SpO2 88% on room air, RR 26 breaths/min, intercostal muscle retractions, bibasilar moist crackles extending into mid-lung fields, persistent dry hacking cough.

Impaired Gas Exchange related to alveolar-capillary membrane changes secondary to pulmonary venous congestion and fluid accumulation in the lung interstitium, as evidenced by SpO2 88%, crackles, and orthopnea.

Client will maintain adequate oxygenation as evidenced by SpO2 ≥ 94% on minimal supplemental O2 and unlabored respiratory rate of 12–20 breaths/min within 4 hours.

1. Place client in high-Fowler’s position with legs dependent over the edge of the bed if hemodynamically stable. (Rationale: Venous blood pools in the lower extremities, immediately reducing venous return and pulmonary capillary hydrostatic pressure).

2. Administer humidified supplemental oxygen via nasal cannula or Venturi mask to maintain SpO2 ≥ 94%. (Rationale: Elevates alveolar PO2, driving oxygen diffusion across edematous alveolar membranes).

3. Auscultate lung sounds every 2 hours and monitor for pink, frothy sputum (cardinal sign of acute flash pulmonary edema). (Rationale: Provides early warning of respiratory collapse requiring emergent CPAP/BiPAP or mechanical ventilation).

Goal Met: SpO2 stabilized at 95% on 2 L/min NC. Respiratory rate slowed to 16 breaths/min. Crackles diminished significantly to lung bases only. Patient able to rest comfortably in semi-Fowler’s.

Cardiovascular Pharmacology: Nursing Rules & NCLEX Safety Pearls

Drug Class & Examples	Hemodynamic Mechanism	Critical Nursing Precautions & Hold Parameters
ACE Inhibitors / ARBs (Lisinopril, Enalapril, Losartan)	Blocks Angiotensin II synthesis; promotes vasodilation and afterload reduction.	Monitor for hyperkalemia (blocks aldosterone), dry hacking cough (switch to ARB), symptomatic hypotension, and angioedema (life-threatening airway swelling).
Beta-Adrenergic Blockers (Metoprolol succinate, Carvedilol)	Inhibits chronic sympathetic overdrive; decreases heart rate and myocardial remodeling.	Start low and titrate slowly. Hold if apical pulse < 60 bpm or systolic BP < 90 mmHg. Caution in severe asthma (bronchospasm risk). May temporarily worsen HF during initial titration.
Loop Diuretics (Furosemide / Lasix, Bumetanide)	Inhibits Na+/K+/2Cl- cotransporter in ascending loop of Henle; profound diuresis.	Push IV furosemide slowly (≤ 20 mg/min) to avoid ototoxicity. Monitor daily weights, I&O, and serum potassium (hypokalemia < 3.5 mEq/L triggers fatal arrhythmias).
Cardiac Glycoside (Digoxin / Lanoxin)	Inhibits Na+/K+ ATPase; positive inotrope (increases squeeze), negative chronotrope (slows HR).	Always check apical pulse for 1 full minute; hold if HR < 60 bpm. Narrow therapeutic range (0.5 to 0.9 ng/mL). Hypokalemia significantly potentiates digoxin toxicity!

🚨 NCLEX Emergency Alert: Recognizing Digoxin Toxicity

Early signs of digoxin toxicity are predominantly gastrointestinal: anorexia, nausea, vomiting, and diarrhea. Neurological and visual signs follow: fatigue, confusion, blurred vision, and classic yellow-green halos around lights or objects. Cardiac manifestations include bradycardia, premature ventricular contractions (PVCs), and heart block. If toxicity is suspected, withhold the dose, check serum digoxin and potassium levels immediately, and prepare the antidote (Digoxin immune Fab / Digibind) as ordered.

Essential Patient Teaching & Discharge Protocol

Re-hospitalization rates for heart failure are among the highest in healthcare. To prevent readmissions, nurses must provide clear, actionable discharge education using the MAWDS framework:

M (Medications): Take all cardiac medications every day as prescribed. Never discontinue beta-blockers or diuretics abruptly, and never skip doses because you feel well.
A (Activity): Stay active daily within tolerance; balance exercise with scheduled rest periods. Avoid strenuous isometric lifting that spikes afterload.
W (Weight – Cardinal Rule!): Weigh yourself every single morning using the same scale, after urinating, before breakfast. Report a weight gain of 2 to 3 lbs in 24 hours or 5 lbs in 1 week immediately!
D (Diet): Maintain a strict low-sodium diet (≤ 2,000 mg/day). Avoid canned soups, cured meats, and frozen dinners. Do NOT use salt substitutes containing potassium without physician approval if taking ACE inhibitors or spironolactone.
S (Symptoms): Call your cardiologist or emergency services immediately if you experience worsening shortness of breath, needing more pillows to sleep, swelling in legs or abdomen, persistent cough, or dizziness.

Interactive Knowledge Check: Cardiovascular Nursing Quiz

Test your clinical mastery of heart failure management, cardiac pharmacology, and NCLEX hemodynamics with this interactive board simulator:

Question 1 of 1

Score: 0

Academic References & Evidence-Based Sources

Heidenreich, P. A., Bozkurt, B., Aguilar, D., et al. (2022). 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895–e1032.
Hinkle, J. L., & Cheever, K. H. (2022). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer Health.
Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). NANDA International Nursing Diagnoses: Definitions & Classification 2021–2023 (12th ed.). Thieme Medical Publishers.
Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (12th ed.). Elsevier.
Silvestri, L. A., & Silvestri, A. E. (2023). Saunders Comprehensive Review for the NCLEX-RN Examination (9th ed.). Elsevier.

Heart Failure & Decreased Cardiac Output Nursing Care Plans: ADPIE Clinical Guide

Pathophysiology & Hemodynamics: Left vs. Right Heart Failure

Bedside Assessment: Differentiating Left vs. Right Ventricular Failure:

Core NANDA-I Nursing Diagnoses for Heart Failure

Master 5-Column High-Yield Care Plan Table

Cardiovascular Pharmacology: Nursing Rules & NCLEX Safety Pearls

Essential Patient Teaching & Discharge Protocol

Interactive Knowledge Check: Cardiovascular Nursing Quiz

Quiz Completed!

Academic References & Evidence-Based Sources

Balanced Nursing Quiz

ToNursing Team

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Pathophysiology & Hemodynamics: Left vs. Right Heart Failure

Bedside Assessment: Differentiating Left vs. Right Ventricular Failure:

Core NANDA-I Nursing Diagnoses for Heart Failure

Master 5-Column High-Yield Care Plan Table

Cardiovascular Pharmacology: Nursing Rules & NCLEX Safety Pearls

Essential Patient Teaching & Discharge Protocol

Interactive Knowledge Check: Cardiovascular Nursing Quiz

Quiz Completed!

Academic References & Evidence-Based Sources

Balanced Nursing Quiz

ToNursing Team

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