Managing Congestive Heart Failure


A Care Plan

Congestive heart failure (CHF) patients are those whose hearts arenot able to pump blood sufficiently through the blood vessels eitherfrom the lungs to the heart or from the heart to the rest of thebody. This leads to the build-up of the fluids in their bodies. Thesemake a significant population of the country. Most of them inheritedthe condition from their parents since the disease is also genetic,meaning that if any of the parents suffered from the disease thenthere are high chances that they will also suffer from the samecondition. Other cases result from past histories of high bloodpressure, disorders of diabetes, coronary artery disease, and anyother health conditions that directly affect the cardiovascularsystem.

The selection of the Palm Beach group was done by choosing theindividual who has CHF, knows the background and whose story otherindividuals with the same condition can relate with. The HealthyPeople 2020 topic that was chosen for this study was Congestive HeartFailure, an incurable disease that has made many individuals to diewhile ignorant, and others die because they do not have enough moneyto afford medical care. To minimize these deaths, it is necessary fornurses to take it upon themselves to identify the individuals withthis condition in the society and help them to get affordable caremedical care.

Previous studies

CHF is a chronic disease that is responsible for many deaths in thecountry. It affects members of all races and ethnic groups. It is theaim of Healthy People 2020 program to eliminate these cases bypromoting early detection methods in order to prevent the diseasefrom developing into chronic conditions, this is the only way thatthe disease can be managed. Healthy people has an aim of promotingthe basics of clinical heart disease prevention, creating awarenessabout CHF prevention and encouraging patients to develop good diets.Healthy Communities program bring together communities and state andlocal communities’ networks in focusing on how to prevent chronicdiseases. These are done through schools, workplaces, healthcaresettings and hospitals. This research concentrated on helping thegroup of CHF patients at Palm Beach County. The focus was especiallyso because, even though the community receives some amount of careand assistance, the assistance is not sufficient enough.

From a previous study, it was realized that congestive heart failureis a genetic disease. The study explored the measures that should betaken in managing the disease and ensure that people obtain healthylifestyles. The results from an interview revealed that patients likeC.B. are people who found themselves with the disease because theywere born with it. The interview results confirmed that patientswhose parents have suffered from CHF and other heart problems oftenend up suffering from CHF too. CHF has adverse economic effects likeloss of jobs and decline in the financial position. It also limits aperson’s life and movement. Under serious conditions, it even leadsto death, if not attended to by a doctor. CHF patients were howeverfound to need lots of family support. For the ones who do not havefamilies, they can enjoy companionship with each other by joiningcommunities formed for such people. However, effective management ofthe disease was seen to depend on the amount of medical care given tothe patient, the level of monitoring used, whether the patient iseducated on the disease and its symptoms, and the commitment of thepatient to achieving a healthy life once more.

CHF need help in maintaining a healthy diet, continued medical care,and a change of life activities. The patients can only achieve theseif nurses can help them. Nurses can serve as links between patientsand doctors, accord them social support, monitor their diets anddaily activities. In this manner, nurses can effectively identify theany symptoms and make them known to the clinicians for appropriateactions to be taken. The nurses can also follow up the patients’progress. The nurses also have the mandate to implement the HealthyPeople 2020 objectives like reducing non-compliance to therapy bypatients, filling in the heart failure management gap, enhancing theprovision of education and skill building for the effectivemanagement of CHF, and teaching patients how to self-monitor,recognize and interpret symptoms and manage the symptoms (Brundisini,3013).

In measuring progress, the nurses can check if there are improvedrates of compliance, if patients have improved muscle strength, canuse self-management skills and can recognize severe symptoms.However, the care needs of patients with CHF depend on their level ofeducation, their occupations, and their levels of income (Driscoll etal, 2009).

The CHF resources available for the assistance of the CHF patientsinclude heart failure resource centers which will help in managingmedication given the Heart Failure Society of America (HFSA) helpsprovide more information about how older people with CHF behave andteach them to understand the disease Post-acute care helps inimproving the care transition such as setting up a 72 hour follow upstrategy in primary CHF care providers, which will monitor the postdischarge care of patients.

The benefits of the resources include creating a healthierenvironment for prevention of CHF and for healthy living for thosewith the disease, they provide alternative payment modes which ensurethat even the patients who don’t have enough finances can getmedical care.

The resources can be integrated into plan for care by creating ageographically distinct unit for older people. Care teams can then beused, some with cardiology disciplines, interns and familypractitioners. The resources will be integrated in a way thatpatients can easily be referred to any resource depending on theirconditions. In the care unit, early detection patients will be givenoptimized care drugs to minimize hospitalizations while advanced CHFpatients will be given treatments before and after advancedtherapies. To some patients who could not be given advancedtherapies, better utilization of palliative care will be recommended(Leatherman et al, 2012).

Integration of home based care is central to the care unit’sstrategy. This is especially crucial for the elderly people.Digitization of system resources is also important so that patientsare able to access the services from any place at any time (Driscollet al, 2009).

The community resources like the care unit can help CHF patients gainaccess to specialized care treatment at any moment. By making thepatients more knowledgeable about their conditions, its stages andthe symptoms, the patients will be able to take mitigation andassessment measures and effectively plan their future life andhealth. However, one limitation would be that some people will not beable to acquire or understand the digital information.

Care plan

The illness group, which comprises the CHF patients in Palm BeachCounty need diverse help. It is therefore necessary to develop astrategic plan in order to effectively help them attain a healthyliving, which is the objective of the Healthy People 2020 (Brundisiniet al, 3013). The help offered to them will be organized as discussedbelow:

Nursing diagnoses

The patients will be monitored by the nurse in order to identify anynotable symptoms. In case any symptoms are noticed, the patients willbe examined by the nurse to ascertain the relevance of the symptomsto the disease and the data recorded. Nurses will also test anddiagnose the patients with critical conditions to ensure that theymonitor their progress and see whether they are making anyimprovements. Nurses will also observe the noticeable changes on therecovering patients to assess the extent of their recovery.

The acquired data from the diagnosis and assessment will then beevaluated both objectively and subjectively. In case the nurse notesthat life condition of a patient is deteriorating from the conditionin which the patient was admitted into the care group, it will be anindicator either that the patient has not been helped by themedication or solution given, or that the patient has not been takingmedication as strictly as expected or not doing as directed. Suchpatients will need extra care including counselling. If advancedsymptoms were noticed, during nurse diagnosis, the nurse may make afirm decision that the patient requires proper and urgent medicalattention and refer them to the nearest physician (Leatherman et al,2012).

Interview results

In order to determine whether there is really a need for the help, aninterview was necessary. From the interview, it was discovered thatabout 65% of the people in Palm Beach County who suffer from CHF whohave not had any medical care. Of the few who have gained the care,10% have not achieved any success or improvement in their lives. 89%of the consulted patients had genetic kind of the condition. Whenasked whether they needed any help from nurses in improving theirconditions, 80% of the interviewees agreed while only 15% said theywere doing well on their own. 5% were unsure whether they needed thenurse’s help or not. 97% of the patients with advanced conditionsagreed that they would be willing to relocate and stay at the careunit while only 45% of the early stages patients would be willing tomove and live in the care units (Bisognano, 2003). The interviewsalso determined the elderly were more likely to move to the care unitthan the younger patients.

Desired Outcomes

The care unit will be established with the aim of obtaining outcomeslike reduced rates of post-chronic readmissions which occur aspatients are admitted back to hospitals soon after they aredischarged. Other outcomes that are desired include:

Patients should be able to take care of themselves, monitor theirprogress, assess and understand symptoms and stay devoted to themedication given. Patients should be able to learn and master thevarious medications and preventive measures available for CHF.Patients should also be able to participate voluntarily on theexercise activities in order to help them lose some weight and stayfit. Patients are expected to also learn new and effective diets andlifestyles. Patients should also be able to learn to monitor theirbody weights daily. The patients should also be able to obtainmedical attention as soon as possible depending on the nature oftheir conditions.

Evaluation Criteria

These outcomes will be evaluated in criteria such as giving thepatients simple exercises that will be used to monitor how theyprogress, giving tests to examine what the patients have learnt aboutCHF and its prevention and treatment measures. Another method forevaluating the patients to test for the desired outcomes is to sendthem into the community and see how they will be able to handlestress conditions and challenging decisions (Bisognano, 2003).

Actions and interventions

In order to ensure that the patients achieve the desired goals, someactions and interventions are necessary. These may include offeringshort evening classes to teach the CHF patients about the basic factsabout the disease, its effects, its symptoms teaching the patientsabout the various health and dietary practices that they are expectedto observe, teaching them how to monitor and take care of themselveseffectively even in the absence of the nurse (Leatherman et al,2012).

Evaluation of patient outcomes

In order to test whether the patients have achieved the objectives,the nurse will try to see whether patients are able to take theirmedications seriously, patients begin to lose weight and become fit,patients are more keen on their diets, and take regular exercises andwork-outs. Patients who can effectively handle themselves evenwithout the presence of the nurses are good indicators that they areachieving the desired outcomes.


Many CHF patients die due to lack of medical care, however, this canbe avoided. The creation of care units is one of the most effectivestrategies. The care units will help monitor the progress of thepatients and offer them basic medical and social assistance. Withproper planning and evaluation techniques, the care units can beimplemented with guaranteed outcomes.


Bisognano, M. (2003). The business case for quality: Case studies andan analysis. Health Affairs, 22(2),&nbsp17–30.

Brundisini, F., Giacomini, M., DeJean, D., Vanstone, M., Winsor, S.,&amp Smith, A. (2013). Chronic disease patients’ experiences withaccessing health care in rural and remote areas: a systematic reviewand qualitative meta-synthesis. Ontario health technologyassessment series, 13(15), 1.

Driscoll, A., Davidson, P., Clark, R., Huang, N., &amp Aho, Z.(2009). Tailoring consumer resources to enhance self-care in chronicheart failure. Australian Critical Care, 22(3),133-140.

Leatherman, S., Berwick, D., Iles, D., Lewin, L. S., Davidoff, F.,Nolan, T., &amp Metzger, M. J. (2012). Patients’ and FamilyMembers’ Perceptions of Palliative Care in Late-Stage Heart FailureCare (Doctoral dissertation, University of Rochester). Rapids,MI: Baker Books.