Congestive Heart Failure Nursing Guide 2026
Part of the ICU Emergencies Hub — browse every related guide in one place.
This article was created with AI assistance.
CHF affects 6.5 million Americans and is the most common reason for hospital readmission in patients ≥65. Every discharge without thorough patient education = a likely readmission within 30 days.
HFrEF vs HFpEF
| Feature | HFrEF (Heart Failure with Reduced EF) | HFpEF (Heart Failure with Preserved EF) |
|---|
| EF (Ejection Fraction) | <40% | ≥50% |
| Pathophysiology | Dilated, weak ventricle; poor systolic function (pump failure) | Stiff, non-compliant ventricle; poor diastolic filling |
| Causes | CAD, MI, cardiomyopathy, valvular disease | Hypertension (#1), diabetes, obesity, atrial fibrillation |
| Treatment | ACEi/ARB + beta-blocker + diuretics + ARNI (sacubitril/valsartan); SGLT2i, aldosterone antagonists | Rate control + diuretics; SGLT2i now proven beneficial; fewer mortality-reducing drugs |
| BNP/NT-proBNP | Elevated; used to diagnose and monitor severity | May be elevated but often less elevated than HFrEF |
Nursing Assessment
Signs & Symptoms
| Left-Sided CHF (Pulmonary Congestion) | Right-Sided CHF (Systemic Congestion) |
|---|
| Dyspnea on exertion; orthopnea (SOB when supine) | Peripheral edema (bilateral, pitting, dependent) |
| Paroxysmal nocturnal dyspnea (wakes gasping) | JVD (jugular venous distension) |
| Crackles (rales) at lung bases | Hepatomegaly (liver congestion) |
| S3 gallop (ventricular filling sound) | Ascites (advanced right failure) |
| Reduced SpO2; tachycardia; tachypnea | Weight gain from fluid retention |
| Frothy, pink sputum (pulmonary edema) | Anorexia, nausea (gut congestion) |
Key Assessment Parameters
- Daily weight: Same time, same scale, same clothing; early morning before eating
- Intake and output: Strict I&O; fluid restriction typically 1.5–2L/day
- Edema: Grade 1+ (trace) to 4+ (severe pitting to knee); measure circumference
- Lung sounds: Crackles that clear or worsen; new S3 indicates fluid overload
- BNP/NT-proBNP: Rising = worsening heart failure; BNP >100 pg/mL or NT-proBNP >300 pg/mL suggests HF
- Renal function: Creatinine and BUN — diuresis can cause pre-renal azotemia
NYHA Classification
| Class | Functional Limitation |
|---|
| I | No limitation; ordinary activity does not cause symptoms |
| II | Slight limitation; comfortable at rest; ordinary activity causes fatigue/dyspnea |
| III | Marked limitation; comfortable at rest; less than ordinary activity causes symptoms |
| IV | Unable to carry any activity without symptoms; symptoms at rest |
Fluid & Weight Management
Weight is the most sensitive early indicator of fluid retention. Patients gain 5–10 lbs of fluid before developing visible edema or shortness of breath. Daily weights catch this early.
- Daily weight: document and trend; report weight gain >2 lbs in 1 day or >5 lbs in 1 week to MD
- Sodium restriction: 2,000 mg/day (2g sodium diet); teach patient to read labels
- Fluid restriction: typically 1.5–2L/day; include ALL fluids (IV, ice chips, medications)
- Elevate head of bed 30–45° for orthopnea; elevate lower extremities for edema (if not in acute pulmonary edema)
- Semi-Fowler's or high Fowler's during acute dyspnea: reduces venous return, eases breathing
CHF Medications
| Drug | Class | Key Nursing Points |
|---|
| Furosemide (Lasix) | Loop diuretic | Monitor K+ (hypokalemia); I&O; daily weight; potassium supplementation often needed; hearing loss with rapid IV infusion |
| Spironolactone/Eplerenone | Aldosterone antagonist (K-sparing diuretic) | Monitor K+ (hyperkalemia risk); avoid in renal failure; breast tenderness (spironolactone) |
| Lisinopril/Enalapril (ACEi) | ACE Inhibitor | Monitor K+, creatinine, BP; hold if bilateral renal artery stenosis; dry cough (switch to ARB); hypotension first dose |
| Losartan/Valsartan (ARB) | Angiotensin Receptor Blocker | Same monitoring as ACEi; no cough; do NOT combine with ACEi (risk of hyperkalemia, hypotension) |
| Carvedilol/Metoprolol succinate (BB) | Beta-Blocker | Do NOT start in acute decompensation; start low and go slow; hold if HR <55 or SBP <90 |
| Sacubitril/Valsartan (Entresto) | ARNI | Replaces ACEi in HFrEF; 36-hour washout if switching from ACEi; monitor BP; significant mortality reduction |
| Digoxin | Cardiac glycoside | Rate control in A-fib with CHF; narrow therapeutic index; check apical pulse before giving; toxicity: N/V, bradycardia, yellow vision |
| Empagliflozin/Dapagliflozin (SGLT2i) | SGLT2 inhibitor | New evidence in CHF (both HFrEF and HFpEF); reduces HF hospitalizations; genital yeast infections; monitor glucose |
Patient Teaching
CHF readmission within 30 days triggers Medicare penalties. Every discharge is a teaching opportunity. Poor adherence to the five pillars below drives 50%+ of readmissions.
The Five Pillars of CHF Self-Management
- Daily weight: Every morning, same time, same scale; call MD if +2 lbs in 1 day or +5 lbs in 1 week
- Sodium restriction: ≤2,000 mg/day; read ALL labels; restaurant food is high sodium
- Fluid restriction: Typically 1.5–2L/day; count ALL fluids; track on paper
- Medication adherence: Take ALL heart medications daily; do NOT skip diuretics when going out ("water pill" is not optional)
- Warning signs: When to call MD (weight gain, new swelling, worsening SOB); when to call 911 (severe SOB, chest pain, unresponsiveness)
Acute Decompensated CHF (ADHF)
Pulmonary edema = life-threatening. Patient is drowning in their own fluid. This is a respiratory emergency requiring immediate intervention.
Priority Actions for Pulmonary Edema
- Position: high Fowler's (90°) immediately — reduces venous return and work of breathing
- Oxygen: NRB mask or CPAP/BiPAP for SpO2 <90%; intubation if no improvement
- IV furosemide: 40–80 mg IV push (or 2.5x home dose); diuresis begins within 10 min
- Nitroglycerin: IV drip reduces preload and afterload; monitor BP closely (can cause severe hypotension)
- Morphine: 2–4 mg IV reduces anxiety and preload (now controversial; use per MD order)
- Call rapid response or transfer to ICU if no improvement
LMNOP for pulmonary edema: Lasix, Morphine (controversial), Nitrates, Oxygen, Position (upright).
NCLEX High-Yield Points
- S3 gallop = hallmark of heart failure (ventricular filling sound); S4 = hypertensive/stiff ventricle
- Daily weight: call MD if +2 lbs/day or +5 lbs/week
- Furosemide: monitor K+ (causes hypokalemia); diuretic timing matters (give in AM to avoid nocturia)
- ACEi side effect: dry cough (switch to ARB if intolerable)
- Do NOT start beta-blocker in acute decompensated CHF — wait until stable
- Pulmonary edema positioning: high Fowler's (90°) immediately
- Left-sided CHF → lung symptoms (crackles, SOB); right-sided CHF → body symptoms (edema, JVD, hepatomegaly)
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