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CONGESTIVE CARDIAC FAILURE

By

Sulekha ShresthaMN 2nd Year, 11th Batch

Nursing Campus Maharajgunj

CONGESTIVE CARDIAC FAILURE

•Congestive Cardiac Failure or Heart failure Often termed "congestive heart failure" or CHF, is a global term for the physiological state which most commonly caused when cardiac output is low and the body becomes congested with fluid due to an inability of heart output to properly match venous return.

CONGESTIVE CARDIAC FAILURE Contd.•A state of circulatory congestion produced

by myocardial dysfunction.•It is the inability of the heart to pump an

adequate amount of blood to the systemic circulation to meet the metabolic demand of the body.

•It is not a disease itself but a group of manifestations related to inadequate heart performance due to any reason either muscular or valvular.

EPIDEMIOLOGY•CCF is present in 2% of persons age 40 to 59,

more than 5% of persons age 60 to 69, and 10% of persons age 70 and older.

•Prevalence is at least 25% greater among the black population than among the white population.

•More than 22 million people worldwide suffer from congestive cardiac failure. (WHO).

•CCF is the 6th leading cause of mortality in the Philippines, affecting males more often than females.

• In the context of Nepal about 15% of the population is suffering from heart diseases and the number is increasing year after year. (Nepal Health Foundation, NHF).

TYPES OF CONGESTIVE HEART FAILURERight Ventricular Failure, Left Ventricular

Failure•Because the two ventricles of the heart

represent two separate pumping systems, it is possible for one to fail alone for a short period.

•Most heart failure begins with left ventricular failure and progresses to failure of both ventricles

•Acute pulmonary edema, a medical emergency, results from left ventricular failure.

TYPES OF CONGESTIVE HEART FAILURE•Right-side heart failure occurs if the heart can't pump enough blood to the lungs for gas exchange.

• Left-side heart failure occurs if the heart can't pump enough oxygen-rich blood to the rest of the body.

•If pulmonary edema is not treated, death will occur from suffocation because the client literally drowns in his or her own fluids.

TYPES OF CONGESTIVE HEART FAILURE Forward Failure, Backward Failure•In forward failure, an inadequate output of

the affected ventricle causes decreased perfusion to vital signs.

•In backward failure, blood backs up behind the affected ventricle, causing increased pressure in the atrium behind the affected ventricle.

Systolic Failure, Diastolic Failure•Systolic failure leads to problems with

contraction and ejection of blood.•Diastolic failure leads to problems with the

heart relaxing and filling with blood.

CLASSIFICATION• Functional classification generally relies on

the New York Heart Association Functional Classification

The classes (I-IV) are:• Class I: no limitation is experienced in any

activities; there are no symptoms from ordinary activities.• Class II: slight, mild limitation of activity;

the patient is comfortable at rest or with mild exertion.• Class III: marked limitation of any activity;

the patient is comfortable only at rest.• Class IV: any physical activity brings on

discomfort and symptoms occur at rest

CAUSES•Intrinsic Causes

▫Myocardial Infarction (Blocked blood vessels supplying the heart muscle (coronary arteries), which may lead to a heart attack).

▫Cardiomyopathy (Weakened heart muscle)▫Myocarditis▫Congenital heart disease▫Valvular heart defects ▫Percarditis/cardiac tamponade▫Diseases such as hemochromatosis (iron

overload) or amyloidosis can cause stiffening of the heart muscle and impair the ventricles' capacity to relax and fill

CAUSES Contd…•Extrinsic causes

▫Systemic hypertension that results in thickening of the heart muscle (left ventricular hypertrophy).

▫Chronic obstructive pulmonary disease▫Pulmonary embolism▫Severe Anemia▫Thyrotoxicosis▫Metabolic/respiratory acidosis▫Blood volume excess/polycythemia▫Drug toxicity▫Prolonged Cardiac dysrhythmias, ▫Congenital heart diseases▫Metabolic diseases▫Infections, commonly viruses

CAUSES Contd…• There are over a hundred other less

common causes of heart failure, which include a variety of infections, exposures (such as radiation or chemotherapy), endocrine disorders (including thyroid disorders), complications of other diseases, toxic effects, and genetic predisposition.

• However, the cause of congestive heart failure is often idiopathic, or unknown. People who have diabetes are at increased risk for both ischemic and non-ischemic heart failure.

RISK FACTORS• Age o Hypertension• Physical inactivity o Diabetes• Obesity o Smoking• Metabolic syndrome o Coronary artery disease• Family history of heart failure• Enlargement of the left ventricle• Some types of valvular heart disease, including infection• High cholesterol and triglycerides• Excessive alcohol consumption• Prior heart attack• Certain exposures, such as to radiation and some types

of chemotherapy• Infection of the heart muscle (usually viral)

PATHOPHYSIOLOGY OF CCF

PATHOPHYSIOLOGY.docx

SIGN & SYMPTOMS•Heart failure is not a disease itself;

instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance.

•The most common signs and symptoms of heart failure are:

Shortness of breath or trouble breathingFatigue (tiredness)Swelling in the ankles, feet, legs,

abdomen, and veins in the neck

Causes

Jugular venous distension

External jugular vein marked by an arrow.

DIAGNOSIS•A thorough patient history may disclose

the presence of one or more of the symptoms of CCF described above. In addition, a history of significant coronary artery disease, prior heart attack, hypertension, diabetes, or significant alcohol use can be clues.

•The physical examination is focused on detecting the presence of extra fluid in the body (breath sounds, leg swelling, or neck veins) as well as carefully characterizing the condition of the heart (pulse, heart size, heart sounds, and murmurs).

DIAGNOSIS•CCF can be confused with other illnesses

that cause breathing difficulties, such as bronchitis, pneumonia, emphysema, and asthma. No single test can diagnose heart failure.

•Chest X-ray: is very helpful in identifying the buildup of fluid in the lungs. Also, the heart usually enlarges in CHF, and this may be visible on the X-ray film.

•ECG: changes may be seen. However, the ECG result may be normal in heart failure.

DIAGNOSIS Contd…• Blood tests: Low blood cell counts (anemia)

may cause symptoms much like congestive heart failure or contribute to the condition.

• Sodium, potassium, magnesium, and other electrolyte levels may be abnormal, especially if the person has been treated with diuretics and/or has kidney disease.

• Tests for kidney function.• B-type natriuretic peptide (BNP) can be

measured. This is a hormone produced at higher levels by the failing heart muscle. This is a good screening test; the levels of this hormone generally increase as the severity of heart failure worsens.

DIAGNOSIS Contd…•Echocardiography: (echo) uses sound

waves to create a moving picture of heart.•Echo also can identify size and shape of

the heart, areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and heart muscle damage caused by lack of blood flow.

•Heart catheterization allows the arteries to the heart to be visualized with angiography.

•Biopsy of the heart tissue

TREATMENT/MANAGEMENT

•MEDICAL MANAGEMENT•NURSING MANAGEMENT

MEDICAL MANAGEMENTEarly diagnosis and treatment can help people

live longer, more active lives. Treatment for heart failure will depend on the type and stage of heart failure (the severity of the condition).

• The goals of treatment:Treating the condition's underlying cause, such

as coronary heart disease(CHD), high blood pressure, or diabetes

Reducing symptomsStopping the heart failure from getting worseIncreasing lifespan and improving your quality

of life.

MEDICAL MANAGEMENT Contd…•Treatments usually include lifestyle

changes, medicines, and ongoing care. If severe heart failure, patient also may need medical procedures or surgery.

1. Lifestyle Changes•Simple changes can help feel better and

control heart failure. Heart Healthy Diet•Following a heart healthy diet is an

important part of managing heart failure. In fact, not having a proper diet can make heart failure worse.

MEDICAL MANAGEMENT Contd…•A healthy diet includes a variety of

vegetables and fruits, whole grains, fat-free or low-fat dairy products, and protein foods, such as lean meats, eggs, poultry without skin, seafood, nuts, seeds, beans, and peas.

•A healthy diet is low in sodium and solid fats (saturated fat and trans fatty acids). Too much salt can cause extra fluid to build up in the body, making heart failure worse. Saturated fat and trans fatty acids can cause unhealthy blood cholesterol levels.

MEDICAL MANAGEMENT Contd…•A healthy diet is low in added sugars and

refined grains (come from processing whole grains, which results in a loss of nutrients, such as dietary fiber). Examples of refined grains include white rice and white bread.

•A balanced, nutrient-rich diet & getting enough potassium is important. Some heart failure medicines deplete the potassium in the body. Lack of potassium can cause very rapid heart rhythms that can lead to sudden death.

MEDICAL MANAGEMENT Contd…•Potassium is found in foods like white

potatoes and sweet potatoes, greens (such as spinach), bananas, many dried fruits, and white beans and soybeans.

•It's important to drink the correct amounts and types of fluid. Drinking too much fluid can worsen heart failure.

•Patient shouldn't drink alcohol.

MEDICAL MANAGEMENT Contd…Other Life style modification:

•Taking steps to control risk factors for CHD, high blood pressure, and diabetes will help control heart failure. For example:

•Lose weight if you're overweight or obese. Work with your health care team to lose weight safely.

•Be physically active to become more fit and stay as active as possible.

•Quit smoking and avoid using illegal drugs. Also, try to avoid secondhand smoke.

•Get enough rest.

MEDICAL MANAGEMENT Contd…

Commonly used medicines:•Diuretic Therapy: To decrease cardiac

workload by reducing circulating volume and thereby reduce preload. Commonly used diuretics:

Thiazides: Chlorthiazide (Diuril)Loop diuretics: Furosemide (Lasix)Potassium-Sparing: Spironolactone

(Aldactone) •Vasodilators: To decrease afterload by

decreasing resistance to ventricular emptying.

MEDICAL MANAGEMENT Contd…

Commonly used vasodilators:Nitroprusside (Nipride)Hydralazine (Apresoline)Nifedipine Captopril (Capoten)•Beta blockers: slow heart rate and lower

blood pressure to decrease heart's workload.

•Digitalis therapy(Digoxin): Has positive inotropic (strengthens force of cardiac contractility) and negative chronotropic effects (decreases heart rate).

MEDICAL MANAGEMENT Contd…•Morphine – Because catecholamines are

released in response to the anxiety and pain associated with suffering an acute MI (increasing the workload of the heart). Morphine can be used to help reduce the pain that can be associated with congestive heart failure

•Other DrugsSympathomimetics

▫Dopamine▫Dobutamine

ONGOING CARE• Watch for signs that heart failure is getting

worse. For example, weight gain may mean that fluids are building up in body. Weigh yourself & report weight changes .

• Getting medical care for other related conditions is important. If the pt. has diabetes or high blood pressure, work up to control these conditions. Check blood sugar level and blood pressure regularly.

• Try to avoid respiratory infections like the flu and pneumonia. Get flu and pneumonia vaccines.

• Oxygen therapy (oxygen given through nasal prongs or a mask). Oxygen therapy can be given in a hospital or at home.

MEDICAL PROCEDURE OR SURGERY

As CHF worsens, lifestyle changes and medicines may no longer control the symptoms. May need a medical procedure or surgery such as, cardiac resynchronization therapy (CRT) device or an implantable cardioverter defibrillator (ICD).

• In heart failure, the right and left sides of the heart may no longer contract at the same time. This disrupts the heart's pumping. To correct this problem, CRT device (a type of pacemaker) may be implanted.

• This device helps both sides of your heart contract at the same time, which can decrease heart failure symptoms.

NURSING MANAGEMENTNursing Assessment:• Monitor vital signs/oxygenation/Neuro

status (report changes in heart and respiratory rate/patterns as well as changes in LOC).

• Daily weight (a 2.2 kg weight increase over a 1 day period is considered significant).

• Breath sounds (monitor for increased crackles, rhonchi or pulmonary congestion).

• The presence of jugular vein distention (jugular vein distention can be a sign of worsening right sided heart failure).

NURSING ASSESSMENT Contd…

• Capillary refill (if greater than 3 seconds, assess for signs of peripheral edema).

• The presence of hepatomegaly (also a sign of worsening right sided heart failure).

• The presence of ascites (also a sign of worsening right sided heart failure).

• ECG changes • Evaluate electrolyte levels (sodium,

potassium and creatinine) • Digoxin levels (if patient taking Digoxin) • Pain level (degree, quality, source, location,

onset and relieving factors)

NURSING ASSESSMENT Contd…

• Intake and Output (monitor effects of diuretic therapy and observe for signs and symptoms of either fluid overload or deficit)

• Assess degree of discomfort associated with activity (provide a proper rest/activity balance. Group nursing interventions when appropriate).

• Monitor for restless, anxious behavior and promote self care participation.

• Maintain adequate bowel function (stool softeners should be ordered to prevent constipation).

NURSING DIAGNOSIS

1. Decreased cardiac output r/t ventricular damage, ischemia and restriction secondary to fluid overload.

2. Impaired gas exchange r/t increased pulmonary interstitial fluid accumulation.

3. Altered tissue perfusion r/t imbalance between oxygen demand and supply.

4. Ineffective breathing pattern r/t imbalance between oxygen demand and supply.

NURSING INTERVENTIONS Providing Oxygenation•Administer oxygen therapy per nasal

cannula at 2-6 LPM as ordered•Evaluate ABG analysis results•Semi-Fowler’s or High-Fowler’s position

to promote greater lung expansion. Use pillows for added support.

Promoting Rest and Activity•Bed rest or limited activity may be

necessary during the acute phase.•Provide an overbed table close to the

patient to allow resting the head and arms.

NURSING INTERVENTIONS Contd…

Promoting Rest and Activity contd…•Administer Diazepam (Valium) 2-10 mg 3-

4x a day as ordered to allay apprehension•Gradual ambulation is encouraged to

prevent risk of venous thrombosis and embolism due to prolonged immobility

•Activities should progress through simple to complex.

•Assess for signs of activity intolerance (dyspnea, fatigue and increased pulse rate that does not stabilize readily).


Decreasing Anxiety•Allow verbalization of feelings• Identify strengths that can be used for

coping•Learn what can be done to decrease

anxiety•*** Anxiety causes increased

breathlessness which may be perceived by the client as an increase in the severity of the heart failure and this in turn increases anxiety.


Providing Skin Care•Edematous skin is poorly nourished and

susceptible to pressure sores•Change position at frequent intervals•Assess the sacral area regularly•Use protective devices to prevent pressure sores

Facilitating Fluid Balance•Control of sodium intake•Administer diuretics and digitalis as prescribed•Monitor I and O, weight and V/S•Dry phlebotomy (rotating tourniquets)

NURSING INTERVENTIONS Contd…Promoting Nutrition

• Provide bland, low-calorie, low-residue with vitamin supplement during acute phase

• Frequent small feedings minimize exertion and reduce gastrointestinal blood requirements

• There may be no need to severely restrict sodium intake of the client who receives diuretics.

• “No added salt” diet is prescribed. No processed foods in the diet.

Promoting Elimination• Advise to avoid straining at defecation which

involves Valsalva manoeuvre.• Administer laxative as ordered.• Encourage use of bedside commode.


Facilitating Learning• Teach the client and his family about the

disorder and self-care• Monitor S/S of recurring CHF (weight gain,

loss of appetite, dyspnea, orthopnea, edema of the legs, persistent cough and report these to the physician).

• Avoid fatigue, balance rest with activity• SFF rather than 3 large meals a day• Take prescribed medications at regular

basis• Observe regular follow-up care as directed

NURSING INTERVENTIONS Contd…In acute pulmonary edema:• High-fowler’s position• Morphine Sulfate 10-15mg/IV as ordered to allay

anxiety, reduce preload and afterlaod• O2 therapy at 40-70% by nasal cannula or face

mask• Aminophylline IV to relieve bronchospasm,

increase urinary output and increase cardiac output

• Rapid digitalization• Diuretic therapy• Dopamine and Dobutamine• Monitor serum potassium. Diuresis may result to

hypokalemia.

RESEARCH ARTICLE ON HEART FAILURE

KUMJ | VOL. 4 | NO. 3 | ISSUE 15 | JULY-SEPT, 2006

• Could garlic be an useful adjuvant therapy in adriamycin heart failure?Das RN, Poudel N

Abstract: 50 year old suffering from breast carcinoma,

treated with adriamycin developed heart failure with 22.82% ejection fraction.

Added garlic pearl to routine anti-failure measures for 9 months achieved 51.6% ejection fraction

PROGNOSIS•The prognosis depends on the patient's age,

the severity of the heart failure, the severity of the underlying heart disease and other factors.

•When congestive heart failure develops suddenly and has a treatable underlying cause, patients can sometimes return to normal heart function after treatment.

•With appropriate treatment, even individuals who develop congestive heart failure as a result of long- standing heart disease can often enjoy many years of productive life.

THANK YOU!

REFERENCES• Black, J.M., & Hawks J. H. (2009) Medical

Surgical nursing. (8th ed.). St. Louis, Missouri.• Nettina, S.M., (1998). The lipponcott manual of

nursing practice. (6th ed.). Lippincott Raven Publishers, Washinton squares, Philadelphia

• Smeltzer, S. C., Bare B.G., Hinkle J.L., Cheever K.H. (2008). Textbook of medical-surgical nursing. (11th ed.). Lippincott Williams & Wilkins, Lippincott Company.

• Potter, P.A., Perry A.G. (2005). Fundamentals of Nursing. (6th ed.). Noinda, U.P, India.

• Lobel, S., Spartto, G. (2003). The nurses drug handbook. (3rd ed.). Whiley medical New York, USA.

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