Brief Description

Congestive heart failure

Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by: 1. 2. diseases that weaken the heart muscle, diseases that cause stiffening of the heart muscles, or

3. diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood. The heart has two atria (right atrium and left atrium) that make up the upper chambers of the heart, and two ventricles (left ventricle and right ventricle) that make up the lower chambers of the heart. The ventricles are muscular chambers that pump blood when the muscles contract. The contraction of the ventricle muscles is called systole. Many diseases can impair the pumping action of the ventricles. For example, the muscles of the ventricles can be weakened by heart attacks, infections (myocarditis) or toxins (alcohol, some chemotherapy agents). The diminished pumping ability of the ventricles due to muscle weakening is called systolic dysfunction. After each ventricular contraction (systole) the ventricle muscles need to relax to allow blood from the atria to fill the ventricles. This relaxation of the ventricles is called diastole. Diseases such as hemochromatosis (iron overload) or amyloidosis can cause stiffening of the heart muscle and impair the ventricles' capacity to relax and fill; this is referred to as diastolic dysfunction. The most common cause of this is longstanding high blood pressure resulting in a thickened (hypertrophied) heart. Additionally, in some patients, although the pumping action and filling capacity of the heart may be normal, abnormally high oxygen demand by the body's tissues (for example, with hyperthyroidism oranemia) may make it difficult for the heart to supply an adequate blood flow (called high output heart failure). In some individuals one or more of these factors can be present to cause congestive heart failure. The remainder of this article will focus primarily on congestive heart failure that is due to heart muscle weakness, systolic dysfunction. Congestive heart failure can affect many organs of the body. For example: The weakened heart muscles may not be able to supply enough blood to the kidneys, which then begin to lose their normal ability to excrete salt (sodium) and water. This diminished kidney function can cause the body to retain more fluid. The lungs may become congested with fluid (pulmonary edema) and the person's ability to exercise is decreased.

 Fluid may likewise accumulate in the liver, thereby impairing its ability to rid the body of toxins and produce essential proteins. The intestines may become less efficient in absorbing nutrients and medicines.

Fluid also may accumulate in the extremities, resulting in edema (swelling) of the ankles and feet. Eventually, untreated, worsening congestive heart failure will affect virtually every organ in the body. Causes Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure. In the United States, the most common causes of congestive heart failure are: coronary artery disease high blood pressure (hypertension) longstanding alcohol abuse disorders of the heart valves

unknown (idiopathic) causes, such as after recovery from myocarditis Less common causes include viral infections of the stiffening of the heart muscle, thyroid disorders, disorders of the heart rhythm, and many others. It should also be noted that in patients with underlying heart disease, taking certain medications can lead to the development or worsening of congestive heart failure. This is especially true for those drugs that can cause sodium retention or affect the power of the heart muscle. Examples of such medications are the commonly used nonsteroidal anti-inflammatory drugs(NSAIDs), which include ibuprofen (Motrin and others) and naproxen (Aleve and others) as well as certain steroids, some medication for diabetes (such as rosiglitazone [Avandia] or pioglitazone [Actos]), and some calcium channel blockers.

Signs & Symptoms

The symptoms of congestive heart failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensated" for the heart muscle weakness. An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible underlying congestive heart failure, it is obviously a nonspecific symptom that may be caused by many other conditions. The person's ability to exercise may also diminish. Patients may not even sense this decrease and they may subconsciously reduce their activities to accommodate this limitation.

 As the body becomes overloaded with fluid from congestive heart failure, swelling (edema) of the ankles and legs or abdomen may be noticed. This can be referred to as "right sided heart failure" as failure of the right sided heart chambers to pump venous blood to the lungs to acquire oxygen results in buildup of this fluid in gravity-dependent areas such as in the legs. The most common cause of this is longstanding failure of the left heart, which may lead to secondary failure of the right heart. Right-sided heart failure can also be caused by severe lung disease (referred to as "cor pulmonale"), or by intrinsic disease of the right heart muscle (less common) In addition, fluid may accumulate in the lungs, thereby causingshortness of breath, particularly during exercise and when lying flat. In some instances, patients are awakened at night, gasping for air. Some may be unable to sleep unless sitting upright. The extra fluid in the body may cause increased urination, particularly at night.

Accumulation of fluid in the liver and intestines may cause nausea,abdominal pain, and decreased appetite.

y Congested lungs. Fluid back up in the lungs can cause shortness of breath with exercise

or difficulty breathing at rest or when lying flat in bed. Lung congestion can also cause a dry, hacking cough or wheezing. y Fluid and water retention. Less blood to your kidneys causes fluid and water retention, resulting in swollen ankles, legs, abdomen (called edema), and weight gain. Symptoms may cause an increased need to urinate during the night. Bloating in your stomach may cause a loss of appetite or nausea. y Dizziness, fatigue, and weakness. Less blood to your major organs and muscles makes you feel tired and weak. Less blood to the brain can cause dizziness or confusion. y Rapid or irregular heartbeats. The heart beats faster to pump enough blood to the body. This can cause a fast or irregular heartbeat.

Diagnosis
Blood tests. Blood tests are used to evaluate kidney and thyroid function as well as to check cholesterol levels and the presence of anemia. Anemia is a blood condition that occurs when there is not enough hemoglobin (the substance in red blood cells that enables the blood to transport oxygen through the body) in a person's blood. B-type Natriuretic Peptide (BNP) blood test. BNP is a substance secreted from the heart in response to changes in blood pressure that occur when heart failure develops or worsens. BNP blood levels increase when heart failure symptoms worsen, and decrease when the heart failure condition is stable. The BNP level in a person with heart failure -- even someone whose condition is stable -- is higher than in a person with normal heart function. BNP levels do not necessarily correlate with the severity of heart failure.

 Chest X-ray. A chest X-ray shows the size of your heart and whether there is fluid buildup around the heart and lungs. Echocardiogram. This test shows the heart's movement. Ejection fraction (EF). A test called the ejection fraction (EF) is used to measure how well your heart pumps with each beat to determine if systolic dysfunction or heart failure with preserved left ventricular function are present. Your doctor can discuss which condition is present in your heart. Electrocardiogram (EKG or ECG) . An EKG records the electrical impulses traveling through the heart. Cardiac catheterization. Stress Test. Treatment Lifestyle modifications -exercise -healthy life style -healthy diet Parmacologic Angiotensin Converting Enzyme (ACE) Inhibitors captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril, Prinivil), benazepril (Lotensin), and ramipril (Altace). angiotensin receptor blockers (ARBs), losartan (Cozaar), candesartan (Atacand), telmisartan (Micardis), valsartan (Diovan), irbesartan (Avapro), and

olmesartan (Benicar). Beta-blockers Digoxin

Diuretics

Nursing Intervention
Keep blood pressure low. In heart failure, the release of hormones causes the blood vessels to constrict or tighten. The heart must work hard to pump blood through the constricted vessels. It is important to keep your blood pressure as low as possible, so that your heart can pump effectively without extra stress. Monitor symptoms. Check for changes in your fluid status by weighing yourself daily and checking for swelling. Call your doctor if you have unexplained weight gain (3 pounds in one day or 5 pounds in one week) or if you have increased swelling. Maintain fluid balance. Your doctor may ask you to keep a record of the amount of fluids you drink or eat and how often you go to the bathroom. Remember, the more fluid you carry in your blood vessels, the harder your heart must work to pump excess fluid through your body. Limiting your fluid intake to less than 2 liters per day will help decrease the workload of your heart and prevent symptoms from recurring. Limit salt (sodium) eaten. Sodium is found naturally in many foods we eat. It is also added for flavoring or to make food last longer. If you follow a low-sodium diet, you should have less fluid retention, less swelling, and breathe easier. Monitor weight and lose weight if needed. Learn what your "dry" or "ideal" weight is. Dry weight is your weight without extra water (fluid). Your goal is to keep your weight within 4 pounds of your dry weight. Weigh yourself at the same time each day, preferably in the morning, in similar clothing, after urinating but before eating, and on the same scale. Record your weight in a diary or calendar. If you gain two pounds in one day or five pounds in one week, call your doctor. Your doctor may want to adjust your medications. Monitor symptoms. Call your doctor if new symptoms occur or if your symptoms worsen. Do not wait for your symptoms to become so severe that you need to seek emergency treatment. Take medications as prescribed. Medications are used to improve your heart's ability to pump blood, decrease stress on your heart, decrease the progression of heart failure, and prevent fluid retention. Many heart failure drugs are used to decrease the release of harmful hormones. These drugs will cause your blood vessels to dilate or relax (thereby lowering your blood pressure). Schedule regular doctor appointments. During follow-up visits, your doctors will make sure you are staying healthy and that your heart failure is not getting worse. Your doctor will ask to review your weight record and list of medications. If you have questions, write them down and bring them to your appointment. Call your doctor if you have urgent questions. Notify all your doctors about your heart failure, medications, and any restrictions. Also, check with your heart doctor about any new medications prescribed by another doctor. Keep good records and bring them with you to each doctor visit.

Risk factors
Medical Condition The following medical conditions put you at increased risk for developing CHF:
y :: Hypertension (high blood pressure)

y y y y y y y

:: Coronary artery disease :: Diabetes Obesity :: Hyperthyroidism Severe :: emphysema Previous history of heart disease Valvular heart disease

Specific Lifestyle Factor These lifestyle factors can increase your risk of developing CHF:
y Excessive alcohol consumption y Smoking y Long-term use of anabolic steroids

Age CHF is most common in people who are older; most people who have CHF are age 65 or older. CHF is the leading cause of hospital admission in patients older than 65. Gender Both men and women can develop CHF. However, men are at a slightly higher risk of developing CHF.

Rheumatic Heart Disease

Rheumatic (roo-MAT-ik) heart disease was formerly one of the most serious forms of heart disease of childhood and adolescence. Rheumatic heart disease involves damage to the entire heart and its membranes. Rheumatic heart disease is a complication of rheumatic fever and usually occurs after attacks of rheumatic fever. The incidence of rheumatic heart disease has been greatly reduced by widespread use of antibiotics effective against the streptococcal bacterium that causes rheumatic fever.

Cause
Rheumatic fever causes rheumatic heart disease. Rheumatic fever results from an untreated strep throat. Rheumatic fever can damage the heartvalves. If the heart valves are damaged, they will fail to open and close properly. When this damage is permanent, the condition is called rheumatic heart disease.

Risk Factor
Rheumatic fever is uncommon in the United States. However, rheumatic fever can occur in children who have had strep infections that were untreated or inadequately treated.

Signs and Symptoms

Some of the most common symptoms of rheumatic heart disease are: breathlessness, fatigue, palpitations, chest pain, and fainting attacks.

Treatment
Treatment of rheumatic heart disease may includemedication and surgery. Medication will aim to avoid overexertion. Surgery may be needed to replace the damaged valve(s). Aspirin Patients with rheumatic heart disease may be given aspirin as part of the treatment for their disease, reports the UCSF Benioff Children's Hospital. Patients with rheumatic heart disease often develop inflammation. Aspirin is used to treat the inflammation that occurs within the heart and joints. Aspirin is a non-steroidal anti-inflammatory drug, or NSAID, that drastically reduces the inflammation caused by the disease. Reduced inflammation usually correlates with less damage to the heart tissue and valves. Erythromycin Erythromycin is an antibiotic that is used to treat rheumatic heart disease in patients who are allergic to penicillin, reports the Merck Manuals. Erythromycin is a member of the macrolide antibiotic family and is able to eradicate the bacterial infection without causing an allergic response in patients allergic to penicillin. Erythromycin is given in 250 mg pills twice per day for at least one week. Patients may also take this drug as prophylaxis against further Streptococcus infections. Diuretics The inflammation caused by rheumatic heart disease can be treated with medicines classified as diuretics, states the Texas Heart Institute. Diuretics lessen the amounts of water and sodium in the body. In turn, this reduces the swelling and other signs of inflammation in the heart. The duration of diuretic treatment depends on the severity of the disease and the overall health of the patient. Prednisone Inflammation seen in patients with rheumatic heart disease can be treated with prednisone. Prednisone is a type of corticosteroid that is routinely used to treat bouts of cardiac inflammation in rheumatic heart disease patients. Prednisone should be used in patients that have persistent inflammation even after aspirin has been administered. Penicillin Penicillin is one of the drugs commonly used to treat rheumatic heart disease and rheumatic fever. Penicillin is an antibiotic that prevents the bacteria from forming a stable cell wall. Without this cell wall the bacteria are unable to reproduce and the patient's immune system can

destroy the infection. Penicillin G and Penicillin V are the more common kinds of penicillin used in rheumatic heart disease. These antibiotics are used to fight off the infection and prevent further infection from occurring. In children recovering from rheumatic fever, penicillin therapy may be used for years afterward to protect the patient from rheumatic heart disease.

Diagnostic Test
Antinuclear antibody (ANA)This test checks blood levels of antibodies that are often present in people who have connective tissue diseases or other autoimmune disorders, such as lupus. Since the antibodies react with material in the cells nucleus (control center), they are referred to as antinuclear antibodies. There are also tests for individual types of ANAs that may be more specific to people with certain autoimmune disorders. ANAs are also sometimes found in healthy people. Therefore, having ANAs in the blood does not necessarily mean that a person has a disease. ArthrocentesisArthrocentesis or joint aspiration is done to obtain a sample of synovial fluid. The doctor injects a local anesthetic, inserts a thin, hollow needle into the joint, and removes the synovial fluid into a syringe. The test provides important diagnostic information. For example, the test allows the doctor to see whether crystals (found in patients with gout or other types of crystal-induced arthritis) or bacteria or viruses (found in patients with infectious arthritis) are present in the joint. ComplementThis test measures the level of complement, a group of proteins in the blood. Complement helps destroy foreign substances, such as germs, that enter the body. A low blood level of complement is common in people who have active lupus. Complete blood count (CBC)This test determines the number of white blood cells, red blood cells, and platelets present in a sample of blood. Some rheumatic conditions or drugs used to treat arthritis are associated with a low white blood count (leukopenia), low red blood count (anemia), or low platelet count (thrombocytopenia). When doctors prescribe medications that affect the CBC, they periodically test the patients blood. CreatinineThis blood test is commonly ordered in patients who have rheumatic diseases to monitor for underlying kidney disease. Erythrocyte sedimentation rate (sed rate)This blood test is used to detect inflammation in the body. Higher sed rates indicate the presence of inflammation and are typical of many forms of arthritis, such as rheumatoid arthritis and ankylosing spondylitis, and many of the connective tissue diseases.

 Hematocrit (PCV, packed cell volume)This test and the test for hemoglobin (a substance in the red blood cells that carries oxygen through the body) measure the number of red blood cells present in a sample of blood. A decrease in the number of red blood cells (anemia) is common in people with inflammatory arthritis and rheumatic diseases. Rheumatoid factorThis test determines whether rheumatoid factor is present in the blood. Rheumatoid factor is an antibody found in the blood of most (but not all) people who have rheumatoid arthritis. Rheumatoid factor may be found in many other diseases besides rheumatoid arthritis, and sometimes in normal, healthy people. UrinalysisIn this test, a urine sample is studied for protein, red blood cells, white blood cells, or casts. These abnormalities indicate kidney disease, which may be seen in several rheumatic diseases such as lupus or vasculitis. Some medications used to treat arthritis can also cause abnormal findings on urinalysis. White blood cell count (WBC)This test determines the number of white blood cells present in a sample of blood. The number may increase as a result of infection or decrease in response to certain medications, or with certain diseases, such as lupus. Low numbers of white blood cells increase a persons risk of infections.

Community-acquired pneumonia
is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen(alveoli) from the atmosphere become filled with fluid and cannot work effectively. CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination. Signs and symptoms

Signs and Symptoms

problems breathing coughing that produces greenish or yellow sputum

 a high fever that may be accompanied with sweating, chills, and uncontrollable shaking sharp or stabbing chest pain rapid, shallow breathing that is often painful Less common symptoms include: the coughing up of blood (hemoptysis) headaches (including migraine headaches) loss of appetite excessive fatigue blueness of the skin (cyanosis) nausea vomiting diarrhea joint pain (arthralgia) muscle aches (myalgia) The manifestations of pneumonia, like those for many conditions, might not be typical in older people. They might instead experience: new or worsening confusion hypothermia falls* Additional symptoms for infants could include: being overly sleepy yellowing of the skin (jaundice) difficulties feeding

Cause
There are over a hundred microorganisms which can cause CAP. The most common types of microorganisms are different among different groups of people. Newborn infants, children, and adults are at risk for different spectrums of disease causing microorganisms. In addition, adults with chronic illnesses, who live in certain parts of the world, who reside in nursing homes, who have recently been treated withantibiotics, or who are alcoholics are at risk for unique infections. Even when aggressive measures are taken, a definite cause for pneumonia is only identified in half the cases.

Risk factors

Some people have an underlying problem which increases their risk of getting an infection. Some important situations are covered below: Obstruction When part of the airway (bronchi) leading to the alveoli is obstructed, the lung is not able to clear fluid when it accumulates. This can lead to infection of the fluid resulting in CAP. One cause of obstruction, especially in young children, is inhalation of a foreign object such as a marble or toy. The object is lodged in the small airways and pneumonia can form in the trapped areas of lung. Another cause of obstruction islung cancer, which can grow into the airways block the flow of air. Lung disease People with underlying lung disease are more likely to develop CAP. Diseases such as emphysema or habits such as smoking result in more frequent and more severe bouts of CAP. In children, recurrent episodes of CAP may be the first clue to diseases such as cystic fibrosisor pulmonary sequestration. Immune problems People who have immune system problems are more likely to get CAP. People who have AIDS are much more likely to develop CAP. Other immune problems range from severe immune deficiencies of childhood such as Wiskott-Aldrich syndrome to less severe deficiencies such ascommon variable immunodeficiency

Diagnosis
Individuals with symptoms of CAP require further evaluation. Physical examination by a health provider may reveal fever, an increasedrespiratory rate (tachypnea), low blood pressure (hypotension), a fast heart rate (tachycardia), and/or changes in the amount of oxygen in theblood. Feeling the way the chest expands (palpation) and tapping the chest wall (percussion) to identify dull areas which do not resonate can identify areas of the lung which are stiff and full of fluid (consolidated). Examination of the lungs with the aid of a stethoscope can reveal several things. A lack of normal breath sounds or the presence of crackling sounds (rales) when the lungs are listened to (auscultated) can also indicate consolidation. Increased vibration of the chest when speaking (tactile fremitus) and increased volume of whispered speech during auscultation of the chest can also reveal consolidation. X-rays of the chest, examination of the blood and sputum for infectious microorganisms, and blood tests are commonly used to diagnose individuals with suspected CAP based upon symptoms and physical examination. The use of each test depends on the severity of illness, local practices, and the concern for any complications resulting from the infection. All patients

with CAP should have the amount of oxygen in their blood monitored with a machine called a pulse oximeter. This helps determine how well the lungs are able to work despite infection. In some cases, analysis of arterial blood gas may be required to accurately determine the amount of oxygen in the blood. Complete blood count (CBC), a blood test, may reveal extra white blood cells, indicating an infection. Chest x-rays and chest computed tomography (CT) can reveal areas of opacity (seen as white) which represent consolidation. A normal chest x-ray makes CAP less likely; however, CAP is sometimes not seen on x-rays because the disease is either in its initial stages or involves a part of the lung not easily seen by x-ray. In some cases, chest CT can reveal a CAP which is not present on chest x-ray. X-rays can often be misleading, as many other diseases can mimic CAP such as heart problems or other types of lung damage.[11] Several tests can be performed to identify the cause of an individual's CAP. Blood cultures can be drawn to isolate any bacteria or fungi in the blood stream. Sputum Gram's stain and culture can also reveal the causative microorganism. In more severe cases, a procedure wherein a flexible scope is passed through the mouth into the lungs (bronchoscopy) can be used to collect fluid for culture. Special tests can be performed if an uncommon microorganism is suspected (such as testing the urine for Legionella antigen when Legionnaires' disease is a concern).

Treatment
Fluoroquinolones (Quinolones) Fluoroquinolones (also simply called quinolones) interfere with the bacteria's genetic material so they cannot reproduce. Quinolones are not only effective against many common bacteria, but they can also be used to treat tuberculosis. Macrolides, Azalides, and Ketolides Macrolides and azalides antibiotics also affect the genetics of bacteria. They include erythromycin, azithromycin (Zithromax, Zmax), clarithromycin (Biaxin), and roxithromycin (Rulid). These antibiotics are effective against the atypical bacteria, includingMycoplasma or Chlamydia. They are also used in some cases forS. pneumoniae and M. catarrhalis, but there is increasing bacterial resistance to these agents. Tetracyclines Tetracyclines inhibit bacterial growth. They include doxycycline, tetracycline, and minocycline. They can be effective against S. pneumoniae and M. catarrhalis, but bacteria that are resistant to penicillin are also often resistant to doxycycline. Tetracyclines' side effects include skin reactions to sunlight, possible burning in the throat, and tooth discoloration. Aminoglycosides Aminoglycosides (gentamicin, kanamycin, tobramycin, amikacin) are given by injection for very serious bacterial infections. They can be given only in combination with other antibiotics. Some are available in inhaled forms or by applying a solution directly to mucous membranes, skin, or

body cavity. They can have very serious side effects including hearing damage, balance problems, and kidney damage. Lincosamide Lincosamides prevent bacteria from reproducing. The most common lincosamide is clindamycin (Cleocin). This antibiotic is useful against S. pneumoniae and S. aureus, but not against H. influenzae. Glycopeptides Glycopeptides (vancomycin, teicoplanin) are used forStaphylococcus aureus infections that have become resistant to standard antibiotics. The drug can be taken by mouth or given intravenously. Trimethoprim-Sulfamethoxazole Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) is less expensive than amoxicillin. It is particularly useful for adults with mild bacterial upper respiratory infections who are allergic to penicillin. The drug is no longer effective against certain streptococcal strains. It should not be used in patients whose infections occurred after dental work or in people allergic to sulfa drugs. Allergic reactions can be very serious. Oxazolidinone Linezolid (Zyvox) is the first antibacterial drug in a new class of synthetic antibiotics called oxazolidinones. It has been shown to work against certain aerobic gram-positive bacteria.

Nursing Management
Nursing interventions and responsibilities in caring for the patient with pneumonia include administering oxygen and medications as prescribed and monitoring for their effects. Monitoring vital signs including oxygen level, monitoring lung sounds, watching for edema and patients feeling of shortness of breath. It may also include doing chest physiotherapy, educating on the use of incentive spirometry and flutter valve. If the patient is immobile it is imperative that the patient be turned every two hours and encouraged to cough and deep breathe. If the patient has a tracheostomy proper trach care and suctioning after hyperoxygenating is also a responsibility.