Congestive heart failure

1. Presented by: Dave Jay S. Manriquez RN.
CONGESTIVE HEART FAILURE
 A state of circulatory congestion produced by myocardial dysfunction
 MI compromises myocardial function by reducing contractility and
producing abnormal wall motion.
 The ability of the ventricle to empty lessens, the stroke volume falls,
residual volume increases.
 Heart failure is the inability of the heart to pump the amount of
oxygenated blood necessary to affect venous return and to meet the
metabolic requirements of the body.
GENERAL INCIDENCE RATE
- CHF is present in 2 percent of persons age 40 to 59, more than 5
percent of persons age 60 to 69, and 10 percent of persons age 70 and
older.
- Prevalence is at least 25 percent greater among the black population
than among the white population.
- Prevalence at each age increased substantially between two periods
surveyed nationally: 1976-80 and 1988-91
WORLD HEALTH ORGANIZATION
- More than 22 million people worldwide suffer from congestive heart
failure.
INCIDENCE IN THE PHILIPPINES
- Out of the 86,241,697 people in the Philippines, 1,521,912 have
Congestive Heart Failure
- CHF is the 6th
leading cause of mortality in the Philippines, affecting
males more often than females.
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.

2.  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.
 If pulmonary edema is not treated, death will occur from
suffocation because the client literally drowns in his or her own
fluids
 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.
 Low Output, High Output
 In low-output failure, not enough cardiac output is available to
meet the demands of the body.
 High-output failure occurs when a condition causes the heart to
work harder to meet the demands of the body.
 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.
CAUSES OF CONGESTIVE HEART FAILURE
 Intrinsic
 Myocardial Infarction
 Cardiomyopathy/myocarditis
 Congenital heart disease
 Valvular heart defects
 Percarditis/cardiac tamponade
 Extrinsic
 Systemic hypertension
 Chronic obstructive pulmonary disease
 Pulmonary embolism
 Anemia
 Thyrotoxicosis

3.  Metabolic/respiratory acidosis
 Blood volume excess/polycythemia
 Drug toxicity
 Cardiac dysrhythmias
 Metabolic diseases
PATHOPHYSIOLOGY (see separate page for pathophysiology)
 Congestive Heart Failure
 Left-sided CHF
 Right-sided CHF
SIGNS AND SYMPTOMS OF CONGESTIVE HEART FAILURE
Comparison of Left and Right CHF
Left-sided Congestive Heart Failure Right-sided Congestive Heart Failure
 Signs of
pulmonary congestion
 Dyspnea
 Tachypnea
 Crackles in
the lungs
 Dry, hacking
cough
 Paroxysmal
nocturnal dyspnea
 Increased BP
(from fluid volume excess)
 Dependent edema (legs and
sacrum)
 Jugular vein distention
 Abdominal distention
 Hepatomegaly
 Splenomegaly
 Anorexia and nausea
 Nocturnal diuresis
 Swelling of the fingers and
hands
 Increased BP (from fluid volume
excess)
*** Assessment Findings of Acute Pulmonary Edema
• Severe dyspnea and orthopnea
• Pallor
• Tachycardia
• Expectoration of large amounts of blood-tinged, frothy sputum
• Wheezing and crackles on auscultation
• Bubbling respirations
• Acute anxiety, apprehension, restlessness
• Profuse sweating
• Cold, clammy skin
• Cyanosis
• Nasal flaring
• Use of accessory breathing muscles

4. • Tachypnea
• Hypocapnia, evidenced by muscle cramps, weakness, dizziness and
paresthesias
COLLABORATIVE MANAGEMENT
 Medications
 Digitalis Therapy
 Major therapy for CHF
 Has positive inotropic (strengthens force of cardiac
contractility) and negative chronotropic effects (decreases
heart rate)
 DOC: Lanoxin (Digoxin)
 Antidote for Toxicity: Digibind
 Nursing Responsibilities
• Assess heart rate before administration; if below 60
bpm or above 120 bpm, withhold the drug.
• Monitor serum potassium
• Assess for signs of Digitalis toxicity
- Bradycardia
- GI manifestations (anorexia, nausea, vomiting and
diarrhea)
- Dysrhythmias
- Altered visual perceptions
- In males: gynecomastia, decreased libido and
impotence
 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)
 Nursing Responsibilities
• Assess for signs of hypokalemia when administering
loop and thiazide diuretics.
• Give potassium supplement and potassium-rich foods.
• Administer early in the morning or early in the
afternoon to prevent sleep pattern disturbance related
to nocturia.

5.  Vasodilators
 To decrease afterload by decreasing resistance to ventricular
emptying
 Commonly used vasodilators:
• Nitroprusside (Nipride)
• Hydralazine (Apresoline)
• Nifedipine
• Captopril (Capoten)
 Other Drugs
 Sympathomimetics
• Dopamine
• Dobutamine
TREATMENT
 Diet: sodium-restricted diet to prevent fluid excess
 Activity: balanced program of activity and rest
 Oxygen Therapy: to increase oxygen supply
NURSING MANAGEMENT
 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
 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
 Use pillows for added support when in High-Fowler’s position
 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 dangling, sitting up on a chair
and then walking in increased distances under close supervision
 Assess for signs of activity intolerance (dyspnea, fatigue and
increased pulse rate that does not stabilize readily)

6.  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.
 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)
 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
 Promoting Nutrition
 Provide bland, low-calorie, low-residue with vitamin supplement
during acute phase
 Frequent small feedings minimize exertion and reduce
gastroistestinal 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
 Facilitating Learning
 Teach the client and his family about the disorder and self-care
 Monitor signs and symptoms of recurring CHF (weight gain, loss of
appetite, dyspnea, orthopnea, edema of the legs, persistent cough
and report these to the physician)

7.  Avoid fatigue, balance rest with activity
 Observe prescribed sodium restrictions
 SFF rather than 3 large meals a day
 Take prescribed medications at regular basis
 Observe regular follow-up care as directed
*** If acute pulmonary edema occurs in the client with CHF, the following are
the appropriate management:
 High-fowler’s position
 Morphine Sulfate 10-15mg/IV as ordered to allay anxiety, reduce
preload and afterlaod
 Oxygen 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.
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.

8. PATHOPHYSIOLOGY
OF
CONGESTIVE HEART FAILURE
CAUSES
• Heart Damage
• Ventricular Overload
• Decreased Ventricular Contraction
Tachycardia
Ventricular Dilatation
Myocardial Hypertrophy
Decreased Cardiac Output
Decreased Renal Perfusion
Increased Sodium Restriction Increased Osmotic Pressure
Increased ADH
Increased Water
Reabsorption
Fluid Overload Edema

9. PATHOPHYSIOLOGY OF
LEFT-SIDED CONGESTIVE HEART FAILURE
CAUSES:
• MI
• HPN
• Aortic Stenosis/ Insufficiency
• Mitral Stenosis/ Insufficiency
Reduced Myocardial Contractility
Increased Cardiac Workload
Decreased Diastolic Filling
Obstruction of Left Atrial Emptying
Increased Left Atrial Pressure
Left-Sided Congestive Heart Failure
Blood damns back into the
pulmonary capillary bed
Pressure of blood into the pulmonary
capillary bed increasesFluid shifts into the intra- and
interalveolar spacesPulmonary Edema
Decreased stroke volume
Decreased tissue perfusion
Increased cellular
hypoxiaSigns and symptoms of LSCHF
Decreased blood
flow to the kidneys

10. Signs and Symptoms of LSCHF:
 Dyspnea
 Paroxysmal Nocturnal Dyspnea
 Orthopnea
 Rales/Crackles
 Moist Cough
 Blood Tinged Frothy Sputum
 Wheezing/ Cardiac Asthma
 Dizziness
 Syncope
 Fatigue
 Weakness
 Anorexia
 Hypokalemia
 Clubbing of Fingers
 Polycythemia
 S3S4 Heart Sounds or Pulsus
Alternans
Decreased blood flow to the
kidneys
RAAS Stimulation
Vasoconstriction and Reabsorption of
Sodium and Water
Increased ECF Volume
Increased Total Blood Volume
Increased Systemic BP

11. PATHOPHYSIOLOGY
OF
RIGHT-SIDED CONGESTIVE HEART FAILURE
CAUSES:
• LSCHF
• Pulmonary Embolism
• Right Ventricular Infarction
• Congenital Septal Defects
Reduced Myocardial Contractility
Increased Cardiac Workload
Decreased Diastolic Filling
Obstruction of Right Atrial Emptying
Increased Right Atrial
Pressure
Right-Sided Congestive Heart
Failure
Blood drums back from the
RV to RA
Increased Pressure in the Venous
Circuit (Venous Back-up)
Signs and Symptoms of
RSCHF

12. ***The RSCHF which results from pulmonary disorders is called COR
PULMONALE.
Signs and Symptoms of RSCHF:
 Neck Vein Engorgement (Jugular Vein
Distention)
 Hepatomegaly
 Portal Hypertension leading to
Cardiac Cirrhosis
 Ascites
 Peripheral Edema (Pitting/
Dependent)
 Splenomegaly
 Jaundice
 Hemolytic Anemia
 Internal Hemorrhoids
 Leg Varicosities
 Weight Gain
 S3S4 Heart Sounds
 Elevated CVP Reading