2. 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.
3. 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.
4.
5. 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).
6. TYPES OF CONGESTIVE HEART FAILURE
Right 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.
7. 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.
8. 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.
9. 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
10. 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
11. 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
12. 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.
13. 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)
15. 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 breathing
Fatigue (tiredness)
Swelling in the ankles, feet, legs,
abdomen, and veins in the neck
19. 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).
20. 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.
21. 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.
22. 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
24. MEDICAL MANAGEMENT
Early 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 symptoms
Stopping the heart failure from getting worse
Increasing lifespan and improving your quality of
life.
25. 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.
26. 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.
27. 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.
28. 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.
29. 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.
30. 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.
31. 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).
32. 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 Drugs
Sympathomimetics
▫ Dopamine
▫ Dobutamine
33. 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.
34. 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.
35. NURSING MANAGEMENT
Nursing 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).
36. 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)
37. 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).
38. 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.
39. 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.
40. 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).
41. NURSING INTERVENTIONS Contd…
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.
42. NURSING INTERVENTIONS Contd…
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)
43. 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.
44. NURSING INTERVENTIONS Contd…
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
45. 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.
46. 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
47. 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.
49. 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.
