Congestive Heart Failure

(relates to Chapter 34, Nursing Management: Heart Failure and Cardiomyopathy, in the textbook)

Congestive Heart Failure

Definition
An abnormal condition involving impaired cardiac pumping CHF is not a disease but a syndrome Associated with long-standing hypertension and coronary artery disease (CAD)

Congestive Heart Failure

Definition
Heart is unable to pump adequate amount of blood to meet metabolic needs Affects about 5 million people in the United States The most common reason for hospitalization in adults older than 65

Congestive Heart Failure

Etiology and Pathophysiology
Risk factors CAD Age Hypertension Obesity

Congestive Heart Failure

Etiology and Pathophysiology
Risk factors Cigarette smoking Diabetes mellitus High cholesterol African American descent

Congestive Heart Failure

Etiology and Pathophysiology
May be caused by any interference with normal mechanisms regulating cardiac output (CO)

Congestive Heart Failure

Etiology and Pathophysiology
CO depends on: Preload Afterload Myocardial contractility Heart rate Metabolic state

Congestive Heart Failure

Etiology and Pathophysiology
Pathology of ventricular failure Systolic failure Most common cause of CHF Left ventricle (LV) loses ability to generate enough pressure to eject blood forward

Congestive Heart Failure

Etiology and Pathophysiology
Pathology of ventricular failure Systolic failure Hallmark is a in LV ejection fraction

Congestive Heart Failure

Etiology and Pathophysiology
Pathology of ventricular failure Diastolic failure Impaired ability of the ventricles to fill during diastole Usually the result of LV hypertrophy

Congestive Heart Failure

Etiology and Pathophysiology
Pathology of ventricular failure Diastolic failure Pulmonary congestion Normal ejection fraction

Congestive Heart Failure

Etiology and Pathophysiology
Pathology of ventricular failure Mixed systolic and diastolic failure Seen in dilated cardiomyopathy Biventricular failure Patient has extremely poor ejection fractions

Congestive Heart Failure

Etiology and Pathophysiology
Compensatory mechanisms Ventricular dilation Ventricular hypertrophy Increased SNS stimulation Neurohormonal responses

Congestive Heart Failure

Types of Congestive Heart Failure
One-sided failure eventually leads to biventricular failure

Congestive Heart Failure

Types of Congestive Heart Failure
Left-sided failure Most common form Blood backs up through the left atrium into the pulmonary veins Pulmonary congestion and edema

Congestive Heart Failure

Types of Congestive Heart Failure
Left-sided failure Most common cause: HTN Cardiomyopathy Rheumatic heart disease CAD

Left-Sided Heart Failure

Fig. 34-1

Congestive Heart Failure

Types of Congestive Heart Failure
Right-sided failure Backward flow to the right atrium and venous circulation Results from diseased right ventricle

Congestive Heart Failure

Types of Congestive Heart Failure
Right-sided failure Venous congestion Peripheral edema Hepatomegaly Splenomegaly Jugular venous distension

Congestive Heart Failure

Types of Congestive Heart Failure
Right-sided failure Primary cause is left-sided failure Cor pulmonale RV dilation and hypertrophy caused by pulmonary pathology

Acute Congestive Heart Failure

Clinical Manifestations
Pulmonary edema Agitation Pale or cyanotic Cold, clammy skin Severe dyspnea Tachypnea

Pulmonary Edema

Fig. 34-2

Chronic Congestive Heart Failure

Clinical Manifestations
Fatigue Dyspnea Paroxysmal nocturnal dyspnea (PND) Tachycardia Edema Nocturia

Chronic Congestive Heart Failure

Clinical Manifestations
Behavioral changes Restlessness, confusion, attention span Chest pain Weight changes Skin changes Dusky appearance

Congestive Heart Failure

Complications
Pleural effusion Arrhythmias Left ventricular thrombus Hepatomegaly

Congestive Heart Failure

Classification
Based on the persons tolerance to physical activity Class 1: No limitation of physical activity Class 2: Slight limitation

Congestive Heart Failure

Classification
Based on the persons tolerance to physical activity Class 3: Marked limitation Class 4: Inability to carry on any physical activity without discomfort

Congestive Heart Failure

Diagnostic Studies
Primary goal is to determine underlying cause Physical exam Chest x-ray ECG Hemodynamic assessment

Congestive Heart Failure

Diagnostic Studies
Primary goal is to determine underlying cause Echocardiogram Stress testing Cardiac catheterization Ejection fraction (EF)

Acute Congestive Heart Failure

Nursing and Collaborative Management
Primary goal is to improve LV function by: Decreasing intravascular volume Decreasing venous return Decreasing afterload

Acute Congestive Heart Failure

Nursing and Collaborative Management
Primary goal is to improve LV function by: Improving gas exchange and oxygenation Improving cardiac function Reducing anxiety

Acute Congestive Heart Failure

Nursing and Collaborative Management
Decreasing intravascular volume Improves LV function by reducing venous return Loop diuretic: drug of choice

Acute Congestive Heart Failure

Nursing and Collaborative Management
Decreasing venous return (preload) Reduces the amount of volume returned to the LV during diastole High Fowlers position

Acute Congestive Heart Failure

Nursing and Collaborative Management
Decreasing afterload Decreases pulmonary congestion IV nitroprusside (Nipride) nesiritide (Natrecor)

Acute Congestive Heart Failure

Nursing and Collaborative Management
Improving gas exchange and oxygenation Decreases pulmonary congestion IV nitroprusside (Nipride) nesiritide (Natrecor)

Acute Congestive Heart Failure

Nursing and Collaborative Management
Improving cardiac function Digitalis Newer inotropics Dobutamine Hemodynamic monitoring

Acute Congestive Heart Failure

Nursing and Collaborative Management
Reducing anxiety Morphine IV inotropic drugs Vasodilators ACE inhibitors

Chronic Congestive Heart Failure

Collaborative Care
Treat underlying cause Maximize CO Alleviate symptoms

Chronic Congestive Heart Failure

Collaborative Care
Oxygen treatment Rest Biventricular pacing Cardiac transplantation

Chronic Congestive Heart Failure

Drug Therapy
ACE inhibitors Diuretics Inotropic drugs Vasodilators -Adrenergic blockers

Chronic Congestive Heart Failure

Nutritional Therapy
Fluid restrictions not commonly prescribed Sodium restriction 2 g sodium diet Daily weights Same time each day Wearing same type of clothing

Chronic Congestive Heart Failure

Nursing Management Nursing Assessment
Past health history Medications Functional health problems Cold, diaphoretic skin

Chronic Congestive Heart Failure

Nursing Management Nursing Assessment
Tachypnea Tachycardia Crackles Abdominal distension Restlessness

Chronic Congestive Heart Failure

Nursing Management Nursing Diagnoses
Activity intolerance Excess fluid volume Disturbed sleep pattern Impaired gas exchange Anxiety

Chronic Congestive Heart Failure

Nursing Management Planning
Overall goals: Peripheral edema Shortness of breath Exercise tolerance Drug compliance No complications

Chronic Congestive Heart Failure

Nursing Management Nursing Implementation
Acute intervention Establishment of quality of life goals Symptom management Conservation of physical/emotional energy Support systems

Chronic Congestive Heart Failure

Nursing Management Nursing Implementation
Ambulatory and home care Teaching Psychologic changes Exercise-saving behaviors Medications

Chronic Congestive Heart Failure

Nursing Management Nursing Implementation
Evaluation Respiratory status Sleep Fluid balance

Chronic Congestive Heart Failure

Nursing Management Nursing Implementation
Evaluation Activity tolerance Anxiety control Knowledge: disease process