Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Verbalize and demonstrate relief or control of pain or discomfort.
Demonstrate and initiate behavioral modifications of lifestyle and appropriate use of therapeutic interventions.
Nursing Care Plan Intervention with Rationale:
1. Assess for presence of pain.
Rationale: Pain, physical discomfort, or both are reported by 30% to 80% of clients with advanced HF (Walke et al, 2004). It is unknown whether pain occurs because of the HF itself, due to edema, chest fullness, and underperfused organs (Wingate, 2007).
2. Note coexisting condition(s).
Rationale: Many HF clients are elderly and have multiple chronic conditions, such as angina, arthritis, gout, back pain, claudication, and neuropathies.
3. Assess for lifestyle effects of pain, such as deconditioning, severe fatigue, weight loss or gain, sleep difficulties, and depression.
Rationale: Pain issues should be addressed and managed, when present, even though it may not be possible to determine if pain is a result of the HF itself (associated with underperfused organs) or be related to other conditions.
4. Provide anticipatory guidance.
Rationale: In client with HF in which pain is common (Wingate, 2007), educating client and significant other (SO) about when, where, and how to seek interventions or treatment may reduce limitations imposed by pain. If pain is present, pain management should be initiated.
5. Assist with treatment of underlying or coexisting conditions.
Rationale: Promotes comfort and general well-being.
6. Administer analgesics, as indicated.
Rationale: Promotes rest and relaxation and enhances ability to engage in activity.
Other possible Nursing Diagnosis for Heart Failure:
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