MEDICAL SURGICAL NUERSING NOTES

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CONGESTIVE HEART FAILURE
Presented by,
MR.RAMESH MORADI.
Assistant Professor,
VM. Patil College of
Nursing Akluj.

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OUTLINE
 Anatomy and physiology
 Definition
 Etiology
 Clinical classification of cardiac failure
 Pathophysiology
 Stages of cardiac failure
 Clinical manifestations
 Diagnostic evaluations
 Management
 Pharmacological management
 Nursing management
 References

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ANATOMY AND PHYSIOLOGY OF HEARTT

4. Heart failure is a physiological state in
which the heart cannot pump enough blood to
meet the metobolic needs of thebody.
•Heart failure occurs when the cardiac out put is
inadequate to provide the oxygen needed by the
body.
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DEFINITION OF HEART FAILURE EART

5. The incidence: 1 in 1000 population per year;
increasing by about 10% every year. In >85y
incidence is 10 cases per 1000 [ 2017].
The prevalence ranges from 3-20 cases per 1000
population, increasing to at least 80 cases per 1000 in
people aged 75 years and over [ 2017].
INCIDENCE AND PREVALENCE

6. ETIOLOGY
•The most common cause of Heart failure is in Ejection fraction.

7. Causes of heart failure classified in three
categories:-
 Underling cause:-comprising the structural
abnormalities
 Fundamental cause:- comprising the
biochemical and physiological mechanism.
 Precipitating cause:-comprising the specific
causes or incidents that precipitating heart
failure.

8. Precipitants based on:-
[H-E-A-R-T F-A-I-L-E-D]
H-Hypertension
E- Endocarditis.
A-Anemia.
R-Rheumatic heart disease.
T-Thyrotoxicosis.
F-Failure to take meds.
A-Arrhythmia.
I-Infection/Ischemia/Infarction.
L-Lung problems.
E-Endocrine(pheochromacytoma)
D-Dietary abnormalities.

9.  Dysfunction of myocardium
Myocardial damage
 Myocardial infraction
 Cardiomyopthay
 Myocarditis
 Metabolic disturbance
Ischemia and Hypoxia
Beriberi

10. • Overload of myocardium
• Infection like lung infection
• Arrhythmia
• Tachycardia
• Bradycardia
• Excessive physical activity
• Pregnancy and delivery
• Anemia
• Alcohol consumption, obesity
• Dyslipidemia / Hypercholesterolemia

11. CLINICAL CLASSIFICATION OF CARDIAC FAILURE:
According to theposition
• Backward failure
• Forward failure
According to the location of heartfailure
• Left ventricularfailure
• right ventricularfailure
• Biventricular failure(Total Heartfailure)
According to the cardiac output
• High outputfailure
• low outputfailure
According to the functionimpaired
• Systolic failure
• Diastolicfailure

12. Backward failure : It is the condition of venous
congestion arising from the damming of blood
behind the failing chamber.
Forward Failure : it is the condition of inadequate
perfusion. It results when reduced contractility
produces stroke volume and cardiac output.

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14. Left ventricular failure(Left sided Heartfailure)
 The failureofthe leftventricle to maintainadequate
cardiac output.
 In LVF basic fault lies in the heart muscles itself .
Practicallyalwaysresult from damage to theventricular
myocardium.
 Precipitating factors:
• MI
• Hypertension
• Dysrhythmias
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15. RIGHT VENTRICULAR FAILURE
• Occurs when the right pump fails.
• It develop as a result of the stress placed upon the right
ventricle it attempts to pumps blood against resistance
into the patient’s congested lungs.
• Causes of right ventricular failure
Pulmonary diseases
Constrictive pericarditis
Tricuspid and pulmonic valve disorders
Infarction of the right ventricle(rare)
Biventricular failure: LV Failure + RVfailure

16. High out put failure: It occurs whenthe body need
excess oxygen. The heart increases out put but is still unable
to meet body’s needs.
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Low out put failure: It is the condition when theheart
is unable to pump an adequate supply of blood to the body.
• Low output failure results in Hypoperfused tissue cells.
• It occurs when the myocardium is so damaged that it cannot
maintain adequate cardiac output.
• Right and left sided cardiac failure are sometimes referred to
as low output failure.

17. SYSTOLIC FAILURE:
Systolicdysfunctionorejection failure is the inabilityof
theventricles topumpand emptyadequately.
Theventriclesaredilated and therefore need todevelop
higher tension in its walls toeject the blood efficiently.
Diastolic failure:
Stiffening and lossof
adequaterelaxation
of the myocardium
during diastole.
Cardiac out put is reduced
but ejection fraction may be
normal.
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18. Systolic
Dysfunction
Diastolic
Dysfunction
Ventriclescannot pump
effectively
ventricles cannot relax
and fill duringdiastole
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19. SYSTOLIC AND DIASTOLIC HEART COMPARE WITHNORMAL HEART
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20. Cardiac performance is depends on
four essentialcomponents:
 Preload
 After load
 Contractilityof the muscle
 Heartrate

21. PRELOAD:
Volumeof blood in ventriclesat the end of diastole
Due to CO Blood volume remains after systole
Stretch of myocardial fibers.
But in failed heart Did not response
As heart failure worsens
Preload contributes to
symptoms
Dyspnoea
Hepatic enlargement
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22. The pressure against which the left ventricle ejects.
Systemic resistance CO
•Afterload is the tension or stress
developed in the wall of the left
Ventricle during ejection.
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AFTERLOAD:

23. CONTRACTILITY OF THEMUSCLE:
It is the force of contraction generated by the
myocardium under loadingconditions.
Heart Rate:
it is the majordeterminantof the cardiac failure
As the function of the heart in failure, an in heart
rate is the first compensatorymechanism.
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24. Pathophysiology of cardiacfailure:
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• Neurohumoral or extrinsic compensation involves
two major mechanisms:
 The sympathetic nervoussystem
 Renin-angiotensin aldosterone
The most important intrinsiccompensatory
mechanism is Myocardial Hypertrophy or
Ventricular Remodeling.

25. Cardiac failure
Reduced CO Ses
cardiac filling
Renin pressure
Sympathetic
NS activation
Angiotension I
vasoconstriction
Angiotension II
Na & Water
retention
Aldosterone
Cardiacremodeling
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26. Salt and waterretention
Due to CO & RBF RAA activation(renin
angiotensin aldosteroneactivation)
Sympatheticactivation
Causes salt and waterretention
Angiotensin
Aldosterone
via renal tubules
Both tries to compensate the low CO & lowBP
But itcan worsen thevenous pressure(preload)
More fluid accumulation in theinterstitium
Worsens the signs of heartfailure
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27. VENTRICULAR REMODELING:
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It is the most important intrinsiccompensatory
mechanism referred as cardiacremodeling
It is the processof progressiveof ventricularsize,
shape and function owing to the influence of
Mechanical, Neurohumoral and possibly genetic
factors in clinical conditionsincluding
• Myocardial infraction
• Cardiomyopathy
• Hypertension
• Valvular heartdisease
Hall marks are: Hypertrophy, loss of myocytesand
interstitial fibrosis.

28. VENTRICULAR REMODELING IN DIASTOLE&SYSTOLE
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29. STAGES OF CARDIAC FAILURE:
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Stage A: A symptomaticwith no heartdamage but haverisk
factors for heartfailure.
Thesecould include persons with hypertension diabetes,
alcohol abuse, family history ofcardiomayopathy.
Stage B: Asymptomatic but have signs of structural heart
damage
Patients in this category may have leftventricular
hypertrophy, valvular heartdisease.
Stage C: Have symptoms and heartdamage.
Patients exhibit fatigueand dyspnoeaas a resultof
ventriculardysfunction
Stage D: End stage cardiacfailure

30. CLINICAL MANIFESTATIONS
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Respiratory system
 Dyspnea onexertion
 Shortness of breath
 Tachypnea
 Orthopnea
 Drycough
Gastro intestinal
Anorexia , nausea
Abdominal distention
Liverenlargement
Right upper quadrantpain

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Musculoskeletal
 Fatigue
 Weakness
Neurologic
 Confusion
 Impaired memory
 Anxiety , restlessness
 Insomnia
Cardiovascularsystem
 Tachycardia
 Palpitations
 Hepatojugularreflux

32. DIAGNOSTIC TESTS FOR HEART FAILURE

33.  MEDICAL MANEGEMENT
MANAGEMENT
 PHARMACOLOGICAL MANEGEMENT
 NURSING MANEGEMENT
 SURGICAL MANEGEMENT

34.  MEDICAL MANEGEMENT
 Long Term Management Of Heart Failure.
 Short term goals of therapy are to relive symptoms and
improve the quality of life.
 Long term goal is to prolong life by slowing, halting, or
reversing the progressive LV dysfunction.
 Treat the cause /aggravating factors.
 Oxygen, bed rest, elevation of head of bed.

35.  Cardiac Glycosides Digoxin
Digitaliscontrols theexcessiveventricularrate.
 Other positive inotropic drugs:-
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 PHARMACOLOGICAL MANEGEMENT
 They increase the heart’s ability to pump more effectively
by improving thecontractile force of the
muscle.
• It includeselective betaagonistsand Bipyridines
• Dobutamine
 Mechanismof action: selectiveagoniston cardiac activity
 Pharmacological action: Increase Cardiacoutput(CO)

36. Dopamine
Mechanism of action : Dose related action D1,β1,α1
Therapeuticuse : used in acutedecompensated
cardiac failure.
Bipyridines(Milrinone)
Mechanismof action
• Inhibits phosphodiesterase type 3enzyme.

37. Angiotensin Converting Enzyme Inhibitors (ACEI)
Plays a vital role in the management of heart failure due to
systolicdysfunction . ACEI given in combinewith diuretics.
ACE inhibitors promotes vasodilation and diuresisby
decreasing afterload and preload
Diuretics
• Eliminate excess body waterand decreaseventricular
pressure.
• Some diuretics may have slight venodilator
properties.
• Diuretics are used in chronic heart failure usually in
combination withothers.

38. Angiotensin II receptor blockers(ARB)
Blocks the effects of Angiotension II at the Ang IIreceptor
ACE inhibitors and ARBs havesimilar
Hemodynamiceffects: BP , systemic vascularresistance,
improved cardiacoutput
ARBs are Used in patients who cannot tolerateACEI
due tocough.

39. Beta blockers:
 Hence β blockers reducesympatheticof the heart
and blood vessels.
 Therefore ,beta blockers heart rate,contractility
and reduce bloodpressure.
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40. Vasodilators
 Ses the workload of the heart bydilating peripheral
vessels.
By relaxing capacitance vessels(veins ,venules),
vasodilators decrease preload and volumes.
Hydralazine predominantly affects arterioles ;reduces
arteriolartone.
Sodium nitroprusside predominantly affectsarterioles.
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41. Nitrates
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 Nitrates such as NTG , Isosorbate , NTGointment
predominantly dilate systemicveins.
 Nitratesare useful forpatientswith pulmonary
congestion ,dyspneasymptoms.

42. SURGICAL MANEGEMENT
 Heart pumps.
 Pacemaker and ICDS.
 Coronary bypass grafting surgery.
 Coronary stenting.
 Heart valve replacement.
 Heart transplantation.

43. • Keeping an intake and output chart to identify a negative balance.
• Weighing the patient daily.
• Auscultation of lung at least daily to detect an increase or decrease in pulmonary
crackles.
• Monitoring pulse and blood pressure.
• Examination of skin turgor and mucous membranes for sign of dehydration.
• Assessing the symptoms of fluid overload.
• Monitor electrolyte levels.
• Administering diuretic to reducing intravascular volume.
NURSING MANEGEMENT

44. • Placing the patient high semi fowlers position with feet
horizontal in bed.
• Administer I.V nitropruside to reduce preload.
• Administer oxygen based on patient saturation level.
• Monitor digitalis toxicity.
• Monitor patients vital signs.

45. CONCLUSION
The primary function of heart is to pump the
blood to all parts of the body, bringing nutrients and
oxygen to the tissues and removing waste products. A
heart failure is a inability of heart to maintain adequate
cardiac output to meet the demands of whole body
metabolism. There are different types of heart failure
includes, right side and left side heart failure, forward
and backward failure etc.

46. REFRENCES
 Text book of Medical Surgical Nursing, B. Venkantesan, Emmess
Medical Publishers, page-229,230,231.
 Text book of Medical Surgical Nursing, Brunner and siddarths’s, 12th
edition, wolters publication. Page-620,621.
 Future nurses, success in a nutshell+ second part of success in
nutshell, zodiac publication,page-4,6,9.

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