by m.sowmya narauyana college of nursing nellore

1. Lesson plan on congestive heart failure
GENERALOBJECTIVE:

2. student will be able to gain knowledge regarding CCF, acquire skills, develop desirable attitude and able to practice in
all health care settings globally.
SPECIFIC OBJECTIVE:
Student will be able to,
 define CCF
 enlist the causes ofCCF
 narrate the patho physiology
 discuss the types of CCF
 enlist the diagnostic procedures
 brief out the management of CCF

3. S.NO TIME SPECIFIC
OBJECTIVE
CONTENT
TEACHING
ACTIVITY
LEARNE
R
ACTIVIT
Y
AV
AIDS
1 1min introduce
the topic BRINGING BACK INTO LIFE
 The heart is a hollow, muscular organ located in the centre of the thorax,
where it occupies the space between the lungs (mediastinum) and rests on
the diaphragm. It weighs approximately 300g (10.6 oz); heart weight and
size are influenced by age, gender, body weight, extent of physical
exercise and conditioning, and heart disease. The heart pumps blood to
the tissues, supplying them with oxygen and other nutrients.
 Congestive heart failure occurs when the heart is not strong enough to
pump blood efficiently around the body, causing fluid to collect in the
lungs and body tissue, which leads to congestion. Heart failure becomes
increasingly common with age.
Congestive heart failure does not mean that the heart stops. It is a long-term
condition that can be kept under control for many years with medication and
lifestyle changes
Asking
questions
Listening White
board

4. 2 2min explain the
anatomy
and
physiology
Heart failure affects more than 750,000 people in the UK.The condition can
affect people of all ages, but it is more common in older people (more than half
of all people with heart failure are over 75 years of age).
Heart failure is associated with a number of other serious health conditions,
including coronaryheart disease,heartattack and high blood pressure
(hypertension).
ANATOMY AND PHYSIOLOGY OF THE HEART:
The heart is a hollow, muscular organ located in the centre of the thorax, where
it occupies the space between the lungs (mediastinum) and rests on the
diaphragm. It weighs approximately 300g (10.6 oz); heart weight and size are
influenced by age, gender, body weight, extent of physical exercise and
conditioning, and heart disease. The heart pumps blood to the tissues, supplying
them with oxygen and other nutrients.
The pumping action of the heart is accomplished by the rhythmic contraction
and relaxation of its muscular wall. During systole (contraction of the muscle),
the chambers of the heart become smaller as the blood is ejected. During
diastole (relaxation of the muscle), the heart chambers fill with blood in
preparation for subsequent ejection. A normal resting adult heart beats
Asking
questions
Listening Chart

5. approximately 60 to 80 times per minute. Each ventricle ejects approximately
70 mL of blood per beat and has an output of approximately 5 L per minute.
STRUCTURE OF THE HEART

6. Heart Chambers
 The four chambers of the heart constitute the right- and left-sided
pumping systems. The right side of the heart, made up of the right atrium
and right ventricle, distributes venous blood(Deoxygenated blood) to the
lungs via the pulmonary artery (pulmonary circulation) for oxygenation.
 The right atrium receives blood returning from the superior vena cava
(head, neck, and upper extremities), inferior vena cava (trunk and lower
extremities), and coronary sinus (coronary circulation).
 The left side of the heart, composed of the left atrium and left ventricle,
distributes oxygenated blood to the remainder of the body via the aorta
(systemic circulation).
 The left atrium receives oxygenated blood from the pulmonary
circulation via the pulmonary veins. The varying thicknesses of the atrial
and ventricular walls relate to the workload required by each chamber.
 The atria are thin-walled because blood returning to these chambers
generates low pressures. In contrast, the ventricular walls are thicker
because they generate greater pressures during systole.
 The right ventricle contracts against low pulmonary vascular pressure

7. and has thinner walls than the left ventricle. The left ventricle, with walls
two-and-a-half times more muscular than those of the right
PHYSIOLOGY OF HEART:
 The heart itself is made up of 4 chambers, 2 atria and 2 ventricles. De-
oxygenated blood returns to the right side of the heart via the venous
circulation.
 It is pumped into the right ventricle and then to the lungs where carbon
dioxide is released and oxygen is absorbed. The oxygenated blood then
travels back to the left side of the heart into the left atria, then into the left
ventricle from where it is pumped into the aorta and arterial circulation
 The pressure created in the arteries by the contraction of the left ventricle
is the systolic blood pressure. Once the left ventricle has fully contracted
it begins to relax and refill with blood from the left atria.
 The pressure in the arteries falls whilst the ventricle refills. This is the
diastolic blood pressure.
 The atrio-ventricular septum completely separates the 2 sides of the
heart. Unless there is a septal defect, the 2 sides of the heart never
directly communicate. Blood travels from right side to left side via the

8. lungs only. However the chambers themselves work together. The 2
atria contract simultaneously, and the 2 ventricles contract
simultaneously.
Cardiac Electrophysiology
 The cardiac conduction system generates and transmits electrical
impulses that stimulate contraction of the myocardium. Under normal
circumstances, the conduction system firstStimulates contraction of the
atria and then the ventricles.
 The synchronization of the atrial and ventricular events allows the
ventricles to fill completely before ventricular ejection, thereby
maximizing cardiac output. Three physiologic characteristics of two
specialized electrical cells, the nodal cells and the Purkinje cells,
provide this synchronization:
Automaticity: ability to initiate an electrical impulse
Excitability: ability to respond to an electrical impulse
Conductivity: ability to transmit an electrical impulse from one cell to another
Both the senatorial (SA) node and the atrioventricular (AV) node are
composed of nodal cells. The SA node, the primary pacemaker of the heart, is
located at the junction of the superior vena cava and the right atrium. The SA

9. 3 2 mts Student
will be able
to define
CCF?
node in a normal resting adult heart has an inherent firing rate of 60 to 100
impulses per minute, but the rate can change in response to the metabolic
demands of the body. The electrical impulses initiated by the SA node are
conducted along the myocardial cells of the atria via specialized tracts called
intermodal pathways. The impulses cause electrical stimulation and subsequent
contraction of the atria. The impulses are then conducted to the AV node, which
is located in the right atrial wall near the tricuspid valve. The AV node
Coordinates the incoming electrical impulses from the atria and after a slight
delay (allowing the atria time to contract and complete ventricular filling) relays
the impulse to the ventricles.
DEFINITION OF CONGESTIVE CARDIAC FAILURE
HF is the inability of the heart to pump sufficient blood to meet the needs of
the tissues for oxygen and nutrients. In the past, HF was often referred to as
congestive heartfailure (CHF),
A/ c to Brunner and Suddarths
Heart failure is an abnormal clinical condition involving impaired cardiac
pumping .It results in the characteristic pathophysiologic changes of
vasoconstriction and fluid retention.
teaching listening Can
you
define
ccf?

10. 4. 2MIN Student
will be able
to
enumerate
the causes
of ccf
A/c to Lewis
Heart failure, often called congestive heart failure or congestive cardiac failure,
occurs when the heart is unable to provide sufficient pump action to
maintain blood flow to meet the needs of the body. ...
A/c to
Wikipedia
Congestive heart failure is the inability of the heart to pump an adequate
amount of blood to the systemic circulation at normal filling pressures to meet
the metabolic demands of the body.
CAUSES OF CCF
Heart failure is often a long-term (chronic) condition, but it may come on
suddenly. It can be caused by many different heart problems.
The condition may affect only the right side or only the left side of the heart.
More often, both sides of the heart are involved.
Heart failure is present when:
 Your heart muscle cannot pump (eject) the blood out of the heart very
well. This is called systolic heart failure.
lecturing Note
taking
Any
body
can
tell
causes
of
ccf?

11.  Your heart muscles are stiff and do not fill up with blood easily. This
is called diastolic heart failure.
As the heart's pumping becomes less effective, blood may back up in other
areas of the body. Fluid may build up in the lungs, liver, gastrointestinal tract,
and the arms and legs. This is called congestive heart failure.
The most common causes ofheart failure are:
 Coronary artery disease (CAD), a narrowing of the small blood vessels
that supply blood and oxygen to the heart. This can weaken the heart
muscle over time or suddenly.
 High blood pressure that is not well controlled, leading to problems with
stiffness, or eventually leading to muscle weakening.
1. Cardiac
a) Congenital heart disease – coarctation of aorta, endocardial
fibroelastosis, transposition of great vessels, aortic atresia and severe
pulmonary stenosis
b) Large intra cardiac shunts – (the physical effects increase the load
of one or both ventricles) Large septal defects, transposition and
truncus arteriosus
c) Acquired heart diseases – Rheumatic fever producing mitral
stenosis, mitral incompetence

12. d) Cardiac tamponade – Eg., pericardial effusion
e) Myocarditis – Coxsackie B, exanthematous fever, diphtheria, other
virus infections, scorpionsting, etc.
f) Systemic hypertension – essential
g) Cardiac arrhythmias
2. Non-cardiac
a) Anemia – Due to oxygen lack
b) Deficiencydiseases – Eg., Beri-beri
c) Acute nephritis
d) Sepsis – Septicemia
e) Metabolic disorders – Hypoglycemia, hypo or hyperthyroidism,
acidosis, glycogen storage disease
f) Respiratory diseases – Acute bronchiolitis, cor pulmonale,
pulmonary hypertension, pneumothorax, bronchopneumonia.
Other heart problems that may cause heartfailure are:
 Congenital heart disease
 Heart attack
 Heart valves that are leaky or narrowed)
 Infection that weakens the heart muscle
 Some types of abnormal heart rhythms (arrhythmias)

13. Other diseases thatcan cause orcontribute to heart failure:
 Amyloidosis
 Emphysema
 Overactive thyroid
 Sarcoidosis
 Severe anemia
 Too much iron in the body
 Underactive thyroid
Common causes ofheart failure include:
 Coronary artery disease
 Previous heart attack
 High blood pressure
 Valve disease
 Congenital heart disease
 Endocardities
 Myocarditis
 Diabetes

14. 5 10
mts
Student
will be able
to discuss
the
pathophysi
ology of
ccf
PATH PHYSIOLOGY
Normally the heart is able to expel the volume of blood it receives from the
various parts of the body.
In congestive heart failure a clinical syndrome develops wherein the heart is
not able to maintain the output at the optimum level or adequately manage
with the venous return or combination of both.
Result in development of the CCF
Heart failure is often separatedinto three categories:
 Right sided failure,
 Left-sided failure, and
 Combination of right and left-sided failure.
In right sided failure the right ventricle is unable to pump blood effectively
into the pulmonary artery, resulting in increased pressure in the right atrium and
systematic venous circulation. Systemic venous hypertension causes
hepatosplenomegaly and occasionally edema.
explaining Note
taking
Any
body
can tell
patho
physiology

15. In left-sided failure the left ventricle is unable to pump blood into the systemic
circulation, resulting in increased pressure in the left atrium and pulmonary
veins. The lungs become congested with blood, causing elevated pulmonary
pressures and pulmonary edema.
Although each type of heart failure produces different signs and symptoms,
clinically it is unusual to observe solely (alone) right or left-sided failure in
children. Because both sides of the heart depend on adequate function of the
other side, failure of one chamber causes a reciprocal change in the opposite
chamber.
Compensatorymechanisms:
The heart initially tries to meet the body’s demand for increased cardiac output
through several compensatory mechanisms called the cardiac reserve. These
include hypertrophy and dilation of the cardiac muscle and stimulation of the
sympathetic nervous system.
Hypertrophy and dilation of the cardiac muscle
In response to the need to increase cardiac output, the cardiac muscle
hypertrophies, developing greater tension. It is able to generate increased
pressure within the ventricle, pumping blood out of the heart at a higher
pressure. Also the cardiac muscle can dilate and increase the stretch of its
fibers, which increases the force of contraction. However, both hypertrophy and
dilation have potentially negative effects. Hypertrophy may result in decreased
ventricular compliance over time. Decreased compliance requires a higher
pressure to produce the same stroke volume. The increased muscle mass
impairs oxygenation to the heart muscle. Beyond a certain amount of dilation,
the force of contraction decreases and the heart fails.

16. Stimulation of the sympathetic nervous system
 When the cardiac output begins to fall, stretch receptors and
baroreceptors in the blood vessels stimulate the sympathetic nervous
system, releasing catecholamines.
 Catecholamines increase the force and rate of myocardial contraction, as
manifested by tachycardia. They cause peripheral vasoconstriction,
resulting in increased systemic vascular resistance, increased venous
return, and reduced blood flow to the limbs, viscera, and kidneys.
Sympathetic cholinergic fibers cause sweating.
 Although initially successful in increasing cardiac output, prolonged
sympathetic stimulation also has negative effects. By shortening the
diastolic period, tachycardia increases oxygen consumption by the heart
muscle, eliminates the heart’s resting phase, and impairs coronary artery
perfusion. A continues increase in systemic vascular resistance increases
the afterload on the heart muscle, which requires extra work by the heart
muscle and reduces systemic blood flow.
 The renal system is particularly sensitive to reduction in blood flow and
renal perfusion, activating the rennin-angiotension-aldosterone
mechanism. Rennin-angiotension secretion causes vasoconstriction and
leads to an increase in aldosterone secretion, which causes retention of
salt and water.
 Retention of salt and water causes an increase in preload. Although at
first helpful to the failing heart, the sodium and water retention becomes
excessive, resulting in signs of systemic venous congestion and fluid
overload.

17. 6.
7.
7 mts
5 mts
Student
will be able
to narrate
the types of
ccf.
Student
will be able
to enlist the
clinical
manifestati
Types of congestive cardiacfailure:
There are two types of HF, which are identified by assessment of left
ventricular functioning, usually by echocardiogram. The more common type is
an alteration in ventricular contraction called systolic heart failure, which is
characterized by aweakened heart muscle. The less common alteration is
diastolic heart failure, which is characterized by a stiff and noncompliant heart
muscle, making it difficult for the ventricle to fill. An assessment of the
ejection fraction (EF) is performed to assist in determining the type of HF. EF,
an indication of the volume of blood ejected with each contraction, is calculated
by subtracting the amount of blood at the end of systole from the amount at the
end of diastole and calculating the percentage of blood that is ejected. A normal
EF is 55% to 65% of the ventricular volume; the ventricle does not completely
empty between contractions. The EF is normal in diastolic HF but severely
reduced in systolic HF.
CLINICAL MANIFESTATIONS:
The clinical manifestations produced by the different types of HF (systolic,
diastolic, or both) are similar and therefore do not assist in differentiating the
Lecture
Asking
questions
Listening
Answeri
ng
questions
What
are the
types
of ccf?
Can
you
state the
manife

18. ons of ccf types of HF. The signs and symptoms of HF are most often described in terms
of the effect on the ventricles. Left-sided heart failure (left ventricular failure)
causes different manifestations than right-sided heart failure (right ventricular
failure). In chronic HF, patients may have signs and symptoms of both left and
right ventricular failure. There are mostly two types of cardiac failure, they are
 Left side heart failure
 Right side heart failure
Left Side Heart Failure:
 Left-sided CHF damages your left ventricle (the chamber that pumps
blood to the body), and is the most common type of CHF. It can cause
fluid to build up in your lungs, which makes breathing difficult.
 Pulmonary congestion occurs when the left ventricle cannot effectively
pump blood out of the ventricle into the aorta and the systemic
circulation.
 The increased left ventricular end-diastolic blood volume increases the
left ventricular end-diastolic pressure, which decreases blood flow from
the left atrium into the left ventricle during diastole.
 The blood volume and pressure in the left atrium increases, which
decreases blood flow from the pulmonary vessels. Pulmonary venous
stations
of ccf

19. 8. 8min
Student
will be able
to briefout
the
assessment
Of heart
failure
blood volume and pressure increase, forcing fluid from the pulmonary
capillaries into the pulmonary tissues and alveoli, causing pulmonary
interstitial edema and impaired gas exchange.
 The clinical manifestations of pulmonary congestion include Dyspnoea,
cough, pulmonary crackles, and low oxygen saturation levels. An extra
heart sound, the S3, or ventricular “gallop,” may be detected on
auscultation. It is caused by a large volume of fluid entering the ventricle
at the beginning of diastole.
Assessing for Heart Failure
Be on the alert for the following signs and symptoms:
General
 Pale, cyanotic skin (with decreased perfusion to extremities)
 Dependent edema (with increased venous pressure)
 Decreased activity tolerance
 Unexplained confusion or altered mental status
Cardiovascular
 Apical impulse, enlarged and left lateral displacement (with cardiac
Explainin
g
listening PPT

20. enlargement)
 Third heart sound (S3)
 Murmurs (with valvular dysfunction)
 Tachycardia
 Increased jugular venous dissention (JVD)
Cerebrovascular
 Light headedness
 Dizziness
 Confusion
Gastrointestinal
 Nausea and anorexia
 Enlarged liver
 Ascites
 Hepatojugular test, increased
Renal
 Decreased urinary frequency during the day
 Nocturia
Respiratory
 Dyspnea on exertion

21.  Orthopnea
 Paroxysmal nocturnal Dyspnea
 Bilateral crackles that do not clear with cough
 Cough on exertion or when supine
Right Side Heart Failure:
 Right-sided CHF may accompany left-sided CHF, but does not always.
Right-sided CHF is when the right ventricle has difficulty pumping blood
to the lungs. Blood builds up in your blood vessels, which causes fluid
retention in your lower extremities, abdomen, and other vital
organs.When the right ventricle fails, congestion in the peripheral
tissues and the viscera predominates.
 This occurs because the right side of the heart cannot eject blood and
cannot accommodate all the blood that normally returns to it from the
venous circulation. Increased venous pressure leads to JVD and increased
hydrostatic pressure throughout the venous system.The systemic clinical
manifestations include edema of the lower extremities (dependent
edema), hepatomegaly (enlargement of the liver), ascites (accumulation
of fluid in the peritoneal cavity), anorexia and nausea, and weakness and
weight gain due to retention of fluid.

22.  Edema usually affects the feet and ankles and worsens when the patient
stands or dangles the legs. The edema decreases when the patient elevates
the legs. The edema can gradually progress up the legs and thighs and
eventually into the external genitalia and lower trunk. Edema in the
abdomen, as evidenced by increased abdominal girth, may be the only
edema present. Sacral edema is not uncommon in patients who are on
bed rest, because the sacral area is dependent. Pitting edema, in which
indentations in the skin remain after even slight compression with the
fingertips, is obvious only after retention of at least 4.5 kg (10 lb) of fluid
(4.5 L).Hepatomegaly and tenderness in the right upper quadrant of the
abdomen result from venous engorgement of the liver. The increased
pressure may interfere with the liver's ability to function (secondary liver
dysfunction).
 As hepatic dysfunction progresses, increased pressure within the portal
vessels may force fluid into the abdominal cavity, a condition known as
ascites. Ascites may increase pressure on the stomach and intestines and
cause gastrointestinal distress. Hepatomegaly may also increase pressure
on the diaphragm, causing respiratory distress. Anorexia (loss of
appetite) and nausea or abdominal pain results from the venous

23. engorgement and venous stasis within the abdominal organs. The
weakness that accompanies right-sided HF
Symptoms of Heart Failure:
In the early stages of CHF, you most likely will not notice any changes in your
health. But, as your condition gets worse, you will experience gradual changes
in your body. You may feel more tired than usual, or experience noticeable
weight gain even when your dietary habits have not changed.
Symptoms you may notice first:
 fatigue
 swelling in your ankles, feet, and legs
 weight gain
 increased need to urinate, especially at night
Symptoms that indicate your condition has worsened:
 irregular heartbeat
 a cough that develops from congested lungs
 wheezing

24. 9. 3min List out the
diagnostic
procedures
Symptoms that indicate a severe heartcondition that requires immediate
medical attention:
 chest pain that radiates through the upper body(this can also be a sign of a
heart attack)
 rapid breathing
 skin that appears blue (from lack of oxygen in your lungs)
 fainting
Diagnostic Findings:
It is mainly based on the
1. Presence of clinical symptoms (or) clinical history
2. Physical examination
3. Chest x-ray – to determine cardiomegaly and increased pulmonary
vascular marking due to increased pulmonary blood flow
4. Electrocardiography
5. Echocardiography
6. Laboratory studies includes arterial blood gas values, serum electrolytes
levels, complete blood count, sedimentation rate, serum glucose, and
calcium levels, urinalysis.
Discussio
n
Answeri
ng
Flash
cards

25. These tests may include:
magnetic resonance imaging (MRI), which takes pictures of your heart
 stress tests to see how well your heart performs under different levels of
stress
 blood tests to check for abnormal blood cells and infections
 An echocardiogram is usually performed to confirm the diagnosis of HF, help
identify the underlying cause, and determine the EF, which helps identify the
type and severity of HF. This information may also be obtained noninvasively
by radionuclideventriculography or invasively by ventriculography as part of
a cardiac catheterization procedure. A chest x-ray and an electrocardiogram
(ECG) are obtained to assist in the diagnosis and to determine the underlying
cause of HF. Laboratory studies usually completed in the initial workup
include serum electrolytes, blood urea nitrogen (BUN), creatinine, thyroid
stimulating hormone, complete blood cell count, B-type natriuretic peptide
(BNP), and routine urinalysis. The BNP level is a key diagnostic indicator of
HF.

26. 10.
10
mts
Student
will be
Discuss the
manageme
nt of CCF
Management:
Therapeutic Management:
The goals of the treatment are to
1. Improve cardiac function (increase contractility and decrease after load)
2. Remove accumulated fluid and sodium (decrease preload)
3. Decrease cardiac demands
4. Improve tissue oxygenation and decrease oxygen consumption
5. Medical management is based on the type, severity, and cause of HF.
Specific objectives of medical management include the following:
For most infants diagnosed with CHF, the cause is CHD. Infants are stabilized
on medical therapy and then for surgical repair. For children newly diagnosed
with CHF, the cause may be worsening ventricular function after a previous
cardiac repair, cardiomyopathy, arrhythmia, or other causes. In addition to
management of CHF, the underlying cause is treated if possible.
To improve cardiac function
Two groups of drugs are used to enhance myocardial performance in CHF.
1. Digitalis glycosides, which improve contractility. (Eg., Digoxin)
2. Angiotensin-converting enzyme (ACE) inhibitors, which reduce the
afterload on the heart, making it easier for the heart to pump. (Eg.,
Captopril, Enalapril, and lisinopri)
To remove accumulated fluid and sodium
Treatment consists of diuretics, possible fluid and sodium restriction.
Diuretics are mainstay of therapy to eliminate excess water and salt to prevent
teaching listening

27. reaccumulation.
The most common used agents are,
 Furosemide (Lasix)
 Chlorothiazide (Diuril)
 Spironolactone (Aldactone)
 Bumetanide (Bumex)
 Metolazone (Zaroxolyn)
 Decrease cardiac demands
To decrease cardiac demands
To lessen the workload on the heart, metabolic needs are minimized by
1. Providing a neutral thermal environment to prevent cold stress in infants
2. Treating any existing infections
3. Reducing the effort of breathing (semi-fowler position)
4. Using medication to sedate an irritable child
5. Providing rest and decreasing environmental stimuli.
To improve tissue oxygenation
Supplemental cool humidified oxygen may be administered to increase the
amount available oxygen during inspiration.
Oxygen administration is especially helpful in patients with pulmonary edema,
inter-current respiratory infections, and increased pulmonary vascular resistance
(oxygen is a vasodilator that decreases pulmonary vascular resistance).
An oxygen hood is preferred with young infants to provide increased
concentration of the gas. A nasal cannula or face tent may be useful with older
infants and children.

28. PharmacologicTherapy
Several medications are routinely prescribed for systolic HF, including ACE
inhibitors, beta-blockers, diuretics, and digitalis. Medications for diastolic
failure depend on the underlying condition, such as hypertension or valvular
dysfunction
Nutritional Therapy
A low-sodium (2 to 3 g/day) diet and avoidance of excessive amounts of fluid
are usually recommended. Dietary restriction of sodium reduces fluid retention
and the symptoms of peripheral and pulmonary congestion. The purpose of
sodium restriction is to decrease the amount of circulating blood volume, which
would decrease the need for the heart to pump that volume. A balance needs to
be achieved between the ability of the patient to comply with the diet and the
recommended dietary restriction. Any change in diet needs to be made with
consideration of good nutrition as well as the patient's likes, dislikes, and
cultural food patterns. Patient compliance is important because dietary
indiscretions may result in severe exacerbations of HF requiring hospitalization.
However, behavioral changes in this area are difficult for many patients (Sneed
& Paul, 2003).

29. Nursing Management
 Despite advances in medical and surgical approaches to HF, mortality
remains high. Nurses can make a major difference in promoting positive
outcomes. In both inpatient and outpatient settings, nursing interventions
for the patient with HF include the following:
 Administering medications and assessing the patient's response to the
pharmacologic regimen
 Assessing fluid balance, including intake and output, with a goal of
optimizing volume status
 Weighing the patient daily at the same time and on the same scale,
usually in the morning after urination; monitoring
 for a 2- to 3-lb gain in a day or 5-lb gain in a week
 Auscultation lung sounds to detect an increase or decrease in pulmonary
crackles
 Determining the degree of jugular venous distension (JVD)
 Identifying and evaluating the severity of dependent edema
 Monitoring pulse rate and blood pressure; checking for postural
hypotension due to dehydration

30.  Examining skin turgor and mucous membranes for signs of dehydration
 Assessing for symptoms of fluid overload (eg, orthopnea, PND, DOE)
Surgeries
If medications are not effective on their own, surgery may be required.
Angioplasty, a procedure to open up blocked arteries, is one option. Your
cardiologist may also consider heart valve repair surgery to help your valves
open and close properly.
NURSING DIAGNOSIS:
 Decreased cardiac output related to, myocardial dysfunction as evidence
by dyspnoea.
 Ineffective breathing pattern related to pulmonary congestion as evidence
by observation.
 Activity intolerance and fatigue related to imbalance between oxygen
supply and demand because of decreased CO
 Excess fluid volume related to excess fluid or sodium intake, and
retention of fluid related to the HF syndrome
 Anxiety related to breathlessness and restlessness from inadequate
oxygenation as evidenced by observation.
 Powerlessness related to inability to perform role responsibilities because
of chronic illness and hospitalizations.

31.  Imbalanced nutritional status less than body requirement related to
nausea as evidenced by verbalization.
 Sleep pattern disturbance related to fear and anxiety as evidenced by
verbalization.
 Knowledge deficit related to treatment regimen as evidenced by
verbalization.
Nursing Process
Assessment:
Subjective data: Patient complaints of dyspnoea, dry hacking cough
Objective data: breathlessness, sweating, discomfort
Diagnosis:
Decreased cardiac output related to, myocardial dysfunction as evidence by
dyspnoea.
Goal: To improve the cardiac output
Planning Rationale
 Monitor the patient condition
and vital signs of patient
 Place the patient in semi-fowlers
position.
Helps to know the patient condition
Helps to relive the dyspnoea.

32.  Maintain the hourly urine output
 Administer medications as
prescribed by the physician
 Assess the condition with lab
investigations.
 Provide psychological support
to the patient
To know the output of the patient
Helps to relive the condition
Helps to know the patient condition
To reduce the anxiety and tension of
the patient.
ExpectedOutcome:
Patients cardiac output may be improved.
Assessment:
Objective data: Patient is having dyspnea,chesttightness,anxiety,sweating
Diagnosis:
Ineffective breathing pattern related to pulmonary congestion as evidence by
observation.
Goal: To improve the breathing pattern
Planning Rationale
 Place the patient in a
comfortable position
 Monitor the vital signs
 To relive the dyspnoea
 To know the patient condition

33.  Administer oxygen to the
patient
 Administer medications as
prescribed by the physician
 Avoid tight clothing of the chest
 Avoid visitors
 Helps to improve the breathing
pattern
 Helps to improve the patient
condition
 To relive from chest discomfort
 To prevent infection
Expectedoutcome: Patients breathing pattern may be improved
Assessment
Subjective data: Patient complaints of chest pain, weakness, fatigue, anxiety
Objective data: Fear, weakness, unable to perform the activities
Diagnosis:
Activity intolerance and fatigue related to imbalance between oxygen supply
and demand because of decreased CO
Goal: To improve the patient’s activities
Planning Intervention

34.  Assess the patient condition
 Monitor the vital signs of the
patient
 Assess the patient in doing the
daily activities.
 Administer the medications as
prescribed by the physician.
 Monitor daily weight ,intake
and urine output of the patient
 Provide the Psychological
supportto the patient.
 Educate the patient and
relatives regarding the
condition.
 To know the baseline data of
the patient
 Helps to know about the
patient
 To help the patient in doing the
daily activities.
 Helps to improve the patient
condition
 To know about the patient
condition
 Helps to relive the anxiety
level of the patient
 Helps to know about the
condition and gains knowledge
Expectedoutcome: Patients activity may be improved.
4)Nursing diagnosis:Imbalanced nutrition more than bodyrequirements
may be related to Excessive intake in relation to metabolic need as

35. evidenced by nutritional assessment.
Goal:maintain normal nutritional pattern.
Nursing diagnosis Rationale
Assess patient understanding of
direct relationship between
hypertension and obesity.
Obesity is an added risk with high
blood pressure because of the
disproportionbetween fixed aortic
capacity and increased cardiac
output associated with increased
bodymass. Reduction in weight
may obviate the need for
drug therapy or decrease the
amount of medication needed
for control of BP.Faulty eating
habits contribute to atherosclerosis
and obesity, which predisposeto
hypertension and
subsequent complications, e.g.,
stroke, kidney disease, heart failure.
Discuss necessity for decreased
caloric intake and limited intake of
fats, salt, and sugar as indicated.
Excessive salt intake expands the
intravascular fluid volume and may
damage kidneys, which can further
aggravate hypertension. Note: One
study showed that sodium reduction
reduced the need for medication by
31%. Weight loss lowered the need
for medication by 36% and the
combination of the two by 53%.
Determine patient’s desire to lose Motivation for weight reduction is

36. weight. internal. The individual must want
to lose weight, or the program most
likely will not succeed.
Review usual daily caloric intake
and dietary choices.
Identifies current
strengths/weaknesses in dietary
program. Aids in determining
individual need for
adjustment/teaching.
5)Nursing diagnosis:Knowledge deficient regarding condition, treatment plan,
self-care and discharge needs.
Goal:patient will gain knowledge regarding the condition.
Nursing diagnosis Rationale
Assess readiness and blocks to
learning. Include significant other
(SO).
Misconceptions and denial of the
diagnosis because of long-standing
feelings of well-being may interfere
with patient/SO willingness to learn
about disease, progression, and
prognosis. If patient does not accept
the reality of a life-threatening
condition requiring continuing
treatment, lifestyle/behavioral changes
will not be initiated/sustained.
Define and state the limits of desired
BP. Explain hypertension and its
Provides basis for understanding
elevations of BP, and clarifies

37. effects on the heart, blood vessels,
kidneys, and brain.
frequently used medical terminology.
Understanding that high BP can exist
without symptoms is central to
enabling patient to continue treatment,
even when feeling well.
Avoid saying “normal” BP, and use
the term “well-controlled” to describe
patient’s BP within desired limits.
Because treatment for hypertension is
lifelong, conveying the idea of
“control” helps patient understand the
need for continued
treatment/medication.
BLOCK BASED LEARNING
 II Year BSc Nursing
 SUBJECT: medical and surgical nursing.
 UNIT:3
REFLECTIVE LEARNING:
5X1=5M
1. What is CCF
2. What are the types of CCF?
3. Write the clinical manifestations of CCF?

38. 4. Name some diagnostic procedures of CCF?
5. Write the medical management of CCF?
RESEARCHBASED LEARNING
Roberts SL (2017) PAE can occur as a consequence of heart failure.
Depending upon the extent of left ventricular failure, pulmonary edema can
vary widely in severity. To anticipate potential health care needs and,
ultimately, to treat PAE, the critical care nurse identifies common nursing
diagnoses. Once the nurse understands the physiologic or psychological
mechanisms for the particular nursing diagnoses, he or she can serve as a
reference point to identify expected nursing outcomes.
INTERACTIVE LEARNING
Students has been equally divides into two groups and conducted group
discussionon etiological factors and patho physiology of CCF.
INTERNET BASEDLEARNING
 https://en.wikipedia.org/wiki/pumonary edema
 https://www.emedicinehealth.com

39. CONTEXTUALLEARNING
ASSIGNMENT 10M
Write an assignment on the medical & surgical management of CCF
CAPSTONE PROJECT
Students has to write about CCF in 200 words in their own language
SUPERVISED LEARNING
 Divided the students in to 4 groups, 10 students in each group
And provided etiological factors, Pathophysiology, clinical manifestations and
medical management for discussionfor each group and.
SUMMARY
Today we have discussed about the brief review of anatomy and physiology of
lheart and the definition , incidence, etiology, pathophysiology, clinical
manifestations and collaborative management of CCF in detail.

40. CONCLUSION
Heart failure is an abnormal clinical condition involving impaired cardiac
pumping .It results in the characteristic pathophysiologic changes of
vasoconstriction and fluid retention.
BIBLIOGRAPHY
BOOK REFERENCES
 Brunner and Suddharth’s “textbook of medical surgical nursing”, 11th
edition, volume 1, 2006 by Lippincott William Wilkins publications.
 Donna D Ignatavicius “medical surgical nursing-a nursing process
approach”, 2nd edition, volume 2, 1995 by saunders company
 Lewis, Heitkemper’s “medical surgical nursing” , 6th edition,2006,by
mosby’s publications.
 Luckmann’s “core principles and practice of medical surgical nursing” ,
1996, by WB Saunders company.
 Mosby’s “clinical nursing“ 4th edition, 1997 by mosby publications,
Missouri.
 Phipps “medical surgical nursing” 8th edition, 2007 by mosby elesevier
publications.

41.  Prescilla Lemone’s “medical surgical nursing-critical thinking in client
care” 4th edition by Saunders publications.
 Tortora , Grabowski’s “Anatomy and physiology” , 10th edition 2003 by
wiley & sons,inc