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- 2. GENERAL OBJECTIVE • Atthe end of the lecture/discussion students should be able to acquire knowledge on congestive cardiac failure and its management.
- 3. SPECIFIC OBJECTIVES At theend 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 compensatorymechanisms 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 themanagement of congestive cardiac failure. 9. State the complications of congestive cardiac failure. 10. Explain the health education given on discharge.
- 6. INTRODUCTION • Heart failureis 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 resultsof 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.
- 8. ANATOMY OF THEHEART
- 9. DEFINITION • Congestive cardiacfailure 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 CARDIACFAILURE • 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 heartdisease 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 likeanaemia, 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 cardiovasculardisease- 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 diseasefor example chronic tuberculosis causes damage to the arteries of the lungs.
- 15. TYPES OF CONGESTIVE CARDIACFAILURE • Right sided heart failure. • Left sided heart failure.
- 16. COMPENSATORY MECHANISM • Asheart 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 tothe 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 decreasein 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 IIalso 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.
- 20. CONT… 3. Ventricular dilatation. •As the heart’s workload increases, the contractility of the myocardial muscle fibers decreases.
- 21. CONT… • Decreased contractilityresults 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 ofthe 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 thishappens 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 theleft 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 thishappens, 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 increasedpressure 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 eventuallyfails, 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 Leftsided 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 nocturnaldyspnoea- 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 Effusionand 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 renalfunction, • 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 andnausea- these develop secondary to venous congestion in the gastro intestinal tract which delay digestion.
- 36. CONT… • Dependent oedema. •Coolness of the extremities. • Abdominal ascites. • Distended jugular veins.
- 37. INVESTIGATION • Health historymay reveal the following information; Activity intolerance. Nocturnal paroxysmal dyspnoea. Tachycardia. Orthopnoea. Family history.
- 38. CONT… • Physical Assessment. Oninspection 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 cardiovascularsystem may reveal abnormal heart sounds. On inspection, oedema is seen in dependent areas such as sacrum and ankles .
- 40. CONT… • Chest X-raywill show an enlarged heart, pulmonary and venous congestion and interstitial oedema. • Electrocardiogram may show evidence of a myocardial infarction and arrhythmias.
- 41. CONT… • Echocardiography withDoppler 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 failuremanifests 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.
- 43. CONT… Full Blood Countmight show low haemoglobin and red blood cell count.
- 44. MEDICAL TREATMENT • Digoxin(cardiacglycoside) 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: Itincreases 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: Forexample 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- 50mg 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 • Toreduce myocardial workload • To improve ventricular pump performance. • To promote lifestyle conducive to cardiac health.
- 54. ENVIRONMENT • The patientwill 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 awarm 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 thepatient 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 thepatient 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 increaseactivities 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 • Reassurethe 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 thereason 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 diversionaltherapy 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 strictintake 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 fordependent 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 temperature4 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 forsigns 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 saltintake 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 orrestrict fluid intake to reduce fluid retention • Provide oral toilet to the patient to stimulate appetite especially if patient is on oxygen.
- 68. HYGIENE • In acutephase 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 thepatients 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 outpressure area care to prevent skin break down as the patient is almost always oedematus.
- 71. ELIMINATION • Offer thepatient a commode or bed pan for bowel movement to prevent constipation. • Ensure strict intake and output to monitor urinary function.
- 72. CONT… • Give adiet rich in roughage for example cabbage, to increase the bulky of stool thereby easing bowel movement.
- 73. EXERCISES • While patientis 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 thepatient 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 pulmonaryoedema: 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 SoreFormation: 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 • Advisethe 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 chestpain radiating to the arm, severe breathlessness and racing heart beat.
- 80. CONT… Diet Restrictions • Informthe 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 Cardiacfailure 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 aretwo 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 signsand 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.
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