2. GENERAL OBJECTIVE
• At the end of the lecture/discussion
students should be able to acquire
knowledge on congestive cardiac
failure and its management.
3. SPECIFIC OBJECTIVES
At the end of the lecture/discussion
students should be able to:
1. Describe the anatomy of the heart.
2. Define congestive cardiac failure.
3. State the causes of congestive cardiac
failure.
4. Outline the forms of congestive cardiac
failure.
4. CONT…
8. Explain compensatory mechanisms
of congestive cardiac failure.
6. Describe the pathophysiology of
congestive cardiac failure.
7. State the signs and symptoms of
congestive cardiac failure.
5. CONT…
8. Describe the management of
congestive cardiac failure.
9. State the complications of
congestive cardiac failure.
10. Explain the health education given
on discharge.
6. INTRODUCTION
• Heart failure is as a result of undue
stress upon the heart.
• It represents failure of the heart muscle
to pump sufficient blood to meet the
body’s metabolic need.
• The acute heart failure develops swiftly
when the heart muscle suddenly fails in
its function as a pump.
7. CONT…
• The results of sudden heart failure
are shock, cardiac arrest, syncope and
sudden death.
• On the other hand heart failure which
develops slowly is known as chronic
congestive cardiac failure.
9. DEFINITION
• Congestive cardiac failure is the
inability of the heart to pump
sufficient blood to meet the needs of
the tissues for oxygen and
nutrients.(smeltzer etal, 2010).
10. CAUSES OF CONGESTIVE
CARDIAC FAILURE
• Reduced blood volume- due to
dehydration and hemorrhage, this results
in a reduction in the flow of blood to the
heart thereby reducing its cardiac output.
• Increased blood volume-this can be due
to excessive intravenous fluids, sodium
and water retention; this increases the
workload of the heart.
11. CONT…
• Valvular heart disease for example
Rheumatic heart disease- this results
in valvular stenosis or regurgitation.
• Damage to the heart muscle from
either ischaemia(myocardial
infarction) or inflammation
process(myocarditis).
12. CONT…
• Conditions like anaemia, fever,
hyperthyroidism or pregnancy that
increases the metabolic needs of the
body also increases the workload of the
heart.
• Arteriosclerotic disease-it’s a condition
characterized by hardening and loss of
elasticity of walls.
13. CONT…
• Hypertensive cardiovascular disease-
hypertension if sustained for a long
period of time causes irreversible
degenerative changes within the arterial
walls.
• Constrictive pericarditis- as a result of
infection the pericardium may become
inflamed, scarred and constricted.
14. CONT…
• Pulmonary disease for example
chronic tuberculosis causes damage
to the arteries of the lungs.
16. COMPENSATORY MECHANISM
• As heart failure develops, the body
activates neurohormonal
compensatory mechanisms.
• These mechanisms represent the
body’s attempt to cope with the
failing heart.
17. CONT…
1. Due to the reduced cardiac output
the sympathetic system is stimulated
which leads to production of
adrenaline which brings about the
fight and flight reaction.
• There is tachycardia and palpitations.
18. CONT…
2. A decrease in blood supply to the
kidneys leads to production of renin
which convents angiotensinogen to
angiotensin I.
• Angiotensin I is converted to
angiotensin II by angiotensin coverting
enzyme.
• Angiotensin II is a powerful
vasoconstrictor.
19. CONT…
• Angiotensin II also stimulates the
adrenal gland to release aldosterone
resulting in sodium and fluid
retention by renal tubules and
stimulating the antidiuretic hormone
leading to increased blood volume.
21. CONT…
• Decreased contractility results in an
increase in end-diastolic blood
volume in the ventricle, stretching
the myocardial muscle fibers and
increasing the size of the ventricle.
22. CONT…
4. Ventricular hypertrophy
• Due to the increased workload of the
heart there is abnormal proliferation
of the myocardial cells this increases
the contractility of the heart though
it’s also for a short while, as the heart
eventually fails.
23. PATHOPHYSIOLOGY
• One of the causes of heart failure is
ischaemic heart disease for example
myocardial infarction.
• When the myocardium of the left
ventricle is diseased the left ventricle will
fail to eject blood fully into the aorta to
the general circulation.
24. CONT…
• When this happens there will be a
residue of blood in the left ventricle with
each ejection.
• The residue in turn will decrease the
ventricles capacity to receive blood from
left atrium.
• This means the left atrium should work
hard to eject its blood, as a result it
hypertrophies and dilates.
25. CONT…
• If the left atrium cannot fully eject its
blood in the left ventricle, the result
is that it will be unable to receive the
full amount of incoming blood from
the pulmonary veins.
26. CONT…
• Once this happens, it leads to
congestion of the pulmonary system
and will cause symptoms that are
respiratory in nature such as
dyspnoea, Orthopnoea, paroxysmal
nocturnal dyspnoea, cough, pleural
effusion and pulmonary oedema.
27. CONT…
• The increased pressure in the pulmonary
vascular system entails that the right
ventricle should work extra hard to pump
blood into the pulmonary system against
the increased pressure.
• When this happens the right ventricle
dilates and hypertrophies in order to meet
its increased workload.
28. CONT…
• It eventually fails, this causes
engorgement of the venous system which
extends backwards to produce congestion
in the gastro intestinal tract, abdominal
viscera and the kidneys.
• This manifests as oedema, ascites, gastro
intestinal tract symptoms such as nausea
and anorexia.
29. SIGNS AND SYMPTOMS
Left sided failure
• Dyspnoea or shortness of breathe-
It results from congestion of the
patient’s lungs owing to pulmonary
engorgement.
• Orthopnoea- inability to breath well
while in recumbecy.
30. CONT…
• Paroxysmal nocturnal dyspnoea-
This is dyspnoea which awakes the
patient from sleep and forces him/her
to get out of bed to catch their
breathe. The reason is that in the
lying position there is an increase in
the venous return to the lungs causing
severe congestion.
31. CONT…
• Pleural Effusion and Pulmonary
Oedema- these are as a result of
pulmonary congestion which is so
severe that the distended capillaries
leak fluid into the interstitial and
alveolar spaces of the lungs.
32. CONT…
• Cough - the cough is productive with
large frothy blood tinged sputum.
The cough is due to irritation of the
lung tissue by the large amount of
fluids trapped in the pulmonary tree.
33. CONT…
• Decreased renal function,
• oedema and weight gain.
• Cerebral anoxia.
• Fatigue and muscular weakness
34. CONT…
Right Sided Failure
• Liver enlargement and abdominal pains
as the liver becomes congested with
venous blood, it enlarges.
• This stretches the capsule surrounding
the liver causing discomfort and the
patient may complain of consistent
aching in the right upper quadrant or
sharp pain.
35. CONT…
• Anorexia and nausea- these develop
secondary to venous congestion in
the gastro intestinal tract which delay
digestion.
37. INVESTIGATION
• Health history may reveal the
following information;
Activity intolerance.
Nocturnal paroxysmal dyspnoea.
Tachycardia.
Orthopnoea.
Family history.
38. CONT…
• Physical Assessment.
On inspection patient may appear
breathless at rest or after an activity.
Auscultation of the respiratory tract
will disclose crackles due to
pulmonary oedema.
39. CONT…
Assessment of cardiovascular system
may reveal abnormal heart sounds.
On inspection, oedema is seen in
dependent areas such as sacrum and
ankles .
40. CONT…
• Chest X-ray will show an enlarged
heart, pulmonary and venous
congestion and interstitial oedema.
• Electrocardiogram may show
evidence of a myocardial infarction
and arrhythmias.
41. CONT…
• Echocardiography with Doppler flow
studies will show cardiac structure
integrity and function.
• Arterial blood gas analysis to detect
alkalosis or acidosis.
Early heart failure usually manifests
with alkalosis due to hyperventilation
42. CONT…
Late heart failure manifests with
acidosis due to reduced oxygen
perfusion.
• Laboratory tests;
Blood Urea Nitrogen and Creatinine
for kidney function will be raised.
Liver Function Test will reveal
elevated liver enzymes.
44. MEDICAL TREATMENT
• Digoxin(cardiac glycoside) 1-1.5mg
digitalizing dose stat and 0.2mg po
daily. It can however be administered
intravenous or intramuscular only
when the patient life is threatened
otherwise digoxin is almost always
administered orally. IV/IM
digitalizing dose is 0.5-1mg.
45. CONT…
• Action: It increases the myocardial
contractility.
• Nursing Implication: Take apical
beat and withhold the medication if
less than 60 beats per minute.
• Side effects: Brandycardia and
hypotension.
46. CONT…
• Diuretics: For example furosemide
10-20mg IV stat then 20mg PO once
daily.
• Action: It promotes excretion of
sodium, water and chloride by
inhibiting their tubular re-absorption.
47. CONT…
• Side effects: Dehydration, Polyuria,
electrolyte imbalance and
hypovolaemia.
• Nursing Implication: Observe for
electrolyte abnormalities and decreased
blood pressure.
• Careful monitor intake and output and
daily weighing.
48. CONT…
• Slow K: it’s a potassium sparing
diuretic, give 600mg OD PO to
replace the potassium lost through
diuresis.
49. CONT…
• Captopril (Capoten): 12.5mg tds.
• Action: Angiotensin Converting
Enzyme inhibitor which reduces
blood pressure and afterload.
• Side Effects : Tachycardia, anorexia
and hypersensitivity rashes.
50. CONT…
• Nursing Implication: Do not
administer drug in patients with
known hypersensitivity.
• Use cautiously in patients with
impaired renal function.
51. CONT…
• Atenolol- 50 mg orally once daily.
• Action: Beta-adrenergic antagonists
(beta blockers) which reduces BP by
antagonizing beta adrenergic effects
thus counteracting vasoconstriction
and reducing renin secretion by the
kidneys.
52. CONT…
• Side Effects: Tachycardia, headache
and palpitations.
• Nursing Implications: Observe for
decreased heart rate, symptomatic
hypotension and fatigue.
53. NURSING CARE
AIMS
• To reduce myocardial workload
• To improve ventricular pump
performance.
• To promote lifestyle conducive to
cardiac health.
54. ENVIRONMENT
• The patient will be nursed in an acute
bay on a cardiac bed for easy
observation by the nursing staff.
• Maintain a calm environment to
decrease anxiety which increases the
workload of the heart.
55. CONT…
• Maintain a warm environment to
promote blood vessel dilatation and
tissue perfusion.
• There should be a cardiac table for
the patient to lean on and oxygen
source as patient can be dyspnoeic.
56. POSITION
• Nurse the patient in a fowler’s
position to relieve pulmonary
congestion and dyspnoea.
• Maintain the legs in the dependent
position as much as possible as
elevating the legs can rapidly
increases venous return.
57. REST
• Put the patient on complete bed rest to
reduce the workload of the heart and
reduce tissue demand for oxygen.
• Space nursing activities to prevent fatigue
which increases the myocardial oxygen
demand.
• Schedule rest periods in order to conserve
the patient’s energy reserves
58. CONT…
• Gradually increase activities to gain
cardiac conditioning and improve
activity tolerance.
• change the patients position whenever
necessary to make him comfortable and
allow for rest.
• Administer oxygen by naso catheter or
mask to relieve dyspnoea thereby
allowing rest.
59. PSYCHOLOGICAL CARE
• Reassure the patient that the dyspnoea
will be relieved by the position,
administration of oxygen and diuretics
to reduce the pulmonary congestion.
• Explain to the patient that he is on total
bed rest to allow the heart to rest and
that he will resume activities once
condition improves.
60. CONT…
• Explain the reason for fluid and
sodium restriction that is to reduce
body fluid retention which puts strain
on the already diseased heart.
• Allow patient to be visited by
significant others to maintain family
ties and also for the patient to feel
cared for.
61. CONT…
• Provide diversional therapy by
talking to the patient or offering him
a magazine for him to read to keep
the patients mind off the condition.
62. OBSERVATION
• Maintain strict intake and output to
avoid overloading the patient which
can put further strain on the heart.
• Weigh the patient daily on the same
scale wearing same clothes. Weight is
a guide to diuretic treatment and the
degree of oedema.
63. CONT…
• Check for dependent oedema on the
sacrum and lower limbs.
• Check pulse 4 hourly to rule out
bradycardia a sign of cardiac shock.
• Check respirations 4 hourly to rule
out dyspnoea secondary to
pulmonary congestion.
64. CONT…
• Check temperature 4 hourly , if high it
could be due to secondary infection as
temperature is usually low or even
subnormal in heart failure.
• Blood pressure to rule out cardiac shock.
• Observe the pressure points for pressure
sores.
65. CONT…
• Observe for signs of dehydration by
checking the skin tugor and eyes
sunkenness as dehydration is a side
effect of diuretic therapy.
• Observe the patient for ascites by
taking an abdominal circumference
daily.
66. NUTRITION
• Reduce salt intake in the diet to reduce
sodium retention.
• Offer small frequent easily digestible
meals as heavy meals put strain on the
heart, small meals also helps to avoid
overloading the already congested gastro
intestinal tract.
67. CONT…
• Reduce or restrict fluid intake to
reduce fluid retention
• Provide oral toilet to the patient to
stimulate appetite especially if
patient is on oxygen.
68. HYGIENE
• In acute phase provide bed baths for
the patients comfort while ensuring
that the patient is having adequate
rest.
• Oral toilet to moisten the oral mucosa
and prevent halitosis especially if
patient is on oxygen and on fluid
restriction.
69. CONT…
• Change the patients bed linen whenever
wet as moisture can bring about skin
break down.
• Ensure that the bedding are straightened
and that there are no craps as these
predisposes to skin break down or
pressure sore formation.
70. CONT…
• Carry out pressure area care to
prevent skin break down as the
patient is almost always oedematus.
71. ELIMINATION
• Offer the patient a commode or bed
pan for bowel movement to prevent
constipation.
• Ensure strict intake and output to
monitor urinary function.
72. CONT…
• Give a diet rich in roughage for
example cabbage, to increase the
bulky of stool thereby easing bowel
movement.
73. EXERCISES
• While patient is in the acute phase they
should not do any exercises but be
allowed strict bed rest.
• As patient becomes less dyspnoeic carry
out passive exercises to prevent the
complications of prolonged bed rest
such as Deep Vein Thrombosis and
pressure sore formation.
74. CONT…
• Once the patient is no longer
dyspnoeic and can tolerate some
activities he/she should be allowed to
sit out of bed then walk to the toilet
as necessary.
75. COMPLICATIONS
• Acute pulmonary oedema:
characterized by severe dyspnoea,
Orthopnoea, pallor, tachycardia and
expectoration of large amounts of
frothy blood stinged sputum.
• Deep Vein Thrombosis:due to
prolonged bed rest
76. CONT…
• Pressure Sore Formation: Due to
prolonged bed rest.
• Renal Failure: Due to inadequate
kidney perfusion.
• Portal Hypertension: Due to
congestion in the hepatic veins and this
results in oesophageal varices and
haemorrhoids.
77. HEALTH EDUCATION
Medication
• Advise the patient to take the
medication as per doctor’s
prescription to improve cardiac
function.
Activity
• Inform the patient to avoid strenuous
physical activity
78. CONT…
Follow up Care
• Advise the patient to regularly
attend the cardiac clinic.
• Monitoring of Disease Progress.
• Patient should be vigilant and
seek medical care immediately for
symptoms such as;
79. CONT…
• sudden chest pain radiating to the
arm, severe breathlessness and racing
heart beat.
80. CONT…
Diet Restrictions
• Inform the patient to adhere to a low
sodium diet in order to reduce fluid
retention.
• The patient should also consume
potassium rich food to prevent
hypokaleamia.
81. SUMMARY
• Congestive Cardiac failure is the
inability of the heart to pump
sufficient blood to meet the needs of
the tissues for oxygen and nutrients.
• Among the causes is myocardial
infarction, arteriosclerotic diseases
and rheumatic heart disease.
82. CONT…
• There are two forms of congestive
cardiac failure left sided and right sided
failure.
• The cardinal signs and symptoms of left
sided failure is dyspnoea, Orthopnoea,
paroxysmal nocturnal dyspnoea, cough,
pleural effusion and pulmonary oedema.
83. CONT…
• The signs and symptoms of right
sided failure are oedema, ascites,
nausea and anorexia.
84. REFERENCES
• Dirksen, H. L., (2004). Medical Surgical
Nursing.6th ed. Elsevier Mosby: Mousori.
• Long, B., (1993). Medical Surgical Nursing, A
Nursing Care Approach.3rd ed. Mosby: Mousori.
• Smeltzer et al, (2010).Brunner and Suddarth’s
Textbook of Medical- Surgical Nursing.20th
edition, London: Lippincott William and Wilkins.
• Kumar. P., and Clark.M. eds., (2005). Clinical
medicine 6th ed. St Louis: Elsevier Saunders.
