PRESENTED BY ASMAA ABDELHAMEED AHMED

outlines
-Definition of Heart Failure. -Definition Congestive Heart Failure. -CAUSES OF CONGESTIVE HEART FAILURE. -PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE. -SYMPTOMS OF HEART FAILURE. - TYPES OF CONGESTIVE HEART FAILURE. -Comparison of Left and Right CHF. -Diagnostic tests. - MANAGEMENT. -Nursing Diagnoses . -Treatment Options. -ASSESSMENT OF EDEMA. -Complications of Congestive Heart Failure.

Definition of Heart Failure

Loss of cardiac pump activity due to systolic or diastolic dysfunction, leading to insufficient cardiac output and mismatched tissue perfusion to meet the metabolic demand. The pathogenic process and the resulting syndrome are defined as heart failure.

Congestive Heart Failure (CHF)

CHF represents a late stage of chronic heart failure. Loss of cardiac output and venous return mismatch cause increased plasma sodium level, systemic water retention and increased blood volume, leading to peripheral tissue swelling and cardiac chamber dilation as its main symptoms.

CAUSES OF CONGESTIVE HEART FAILURE

Congenital heart disease Atherosclerosis Rheumatic fever Cardiomyopathy Valve disorders Ventricular failure Metabolic diseases Hypertension Prolonged alcohol or drug addiction Previous heart attack Diabetes Drug toxicity Cardiac dysrhythmias

PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE

CAUSES Heart Damage Ventricular Overload Decreased Ventricular Contraction

Tachycardia Ventricular Dilatation Myocardial Hypertrophy

Fluid Overload Edema Increased Water Reabsorption Increased ADH

Decreased Cardiac Output

Decreased Renal Perfusion

Increased Sodium Restriction

Increased Osmotic Pressure

SYMPTOMS OF HEART FAILURE

Edema of the bronchial mucosa Pulmonary edema Cardiomegaly Edema in other body parts Tachycardia Coughing Dyspnea Fatigue

TYPES OF CONGESTIVE HEART FAILURE 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.

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. Most heart failure begins with left ventricular failure and progresses to failure of both ventricles 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.

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)

Left Ventricular Failure

Left Ventricle can no longer pump enough blood to the systemic circulation Pressure rises in the LV, LA & pulmonary vasculature Hydrostatic forces can cause intracellular fluid to accumulate in the pulmonary capillary bed, leading to pulmonary congestion

Left ventricular failure

Paroxysmal Nocturnal Dyspnea

Restless, Confused
Dysponea on Exertion

Rales, Wheezes, Cough

Orthopnea, Tachycardia, Cyanosis

Blood Tinged sputum

Right Ventricular Failure

Pressure increases on right side of the heart
Hydrostatic forces can cause intracellular fluid to accumulate in systemic venous circulation

Right Ventricular failure

Distended jugular veins

Fatigue

Anorexia

Ascites enlarged liver & Spleen

Dependent edema

Diagnostic tests
X-ray ECG Echocardiography Blood tests ABG analysis Pulse oximetr Coronary Angiography Exercise Stress Test Nuclear Scanning

Medications

MANAGEMENT

Digitalis Therapy

Major therapy for CHF Has positive inotropic (strengthens force of cardiac contractility) and negative chronotropic effects (decreases heart rate)

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.

Diuretic Therapy To decrease cardiac workload by reducing circulating volume and thereby reduce preload Commonly used diuretics: (Diuril)(Lasix) (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. Vasodilators To decrease afterload by decreasing resistance to ventricular emptying. Commonly used vasodilators:Captopril (Capoten) Other Drugs (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 Diagnoses
Problem List Inadequate oxygenation Excess fluid Low cardiac output Anxiety Activity intolerance Knowledge deficit

Inadequate Oxygenation
Goal: Maintain oxygenation saturation >93% Absence of respiratory distress Interventions Nasal oxygen Oxygen mask Consider bipap Prepare for intubation

Excess fluid
Goal: Optimize fluid and electrolyte balance
Absence of pulmonary congestion: clear lung sounds, clear chest x-ray Absence of peripheral edema Electrolytes within normal limits Stable vital signs Adequate urine output

Interventions
Strict I&O, calculate fluid balance, monitor electrolytes Monitor lung sounds Administer diuretics as ordered and assess effect

Low Cardiac Output

Goal
Skin warm and dry. Alert and oriented Vital signs within normal limits Urine output >30 mLs/hour Absence of edema Lungs clear

Interventions:
Continuous cardiac monitor; assess and treat dysrhythmias Monitor VS, Capillary re-fill, edema, mental status ; lab values Administer medications that increase cardiac output when ordered by physician (dopamine)

Activity Intolerance
Goal
Promote activity Reduce fatigue

Intervention
Bed-rest during acute phase only Space activities to allow for rest Monitor heart rate, respiratory rate, and oxygen saturation with initial activity. Avoid large meals - encourage frequent small meals As patient recovers, initiate exercise regimen as tolerated.

Treatment Options
Surgery and other Medical Procedures Not often used in heart failure unless there is a correctable problem Coronary artery bypass Angioplasty Valve replacement Heart transplantation Left ventricular assist device(LVAD)
2/21/2014 24

Edema
Edema: is the accumulation of excessive body fluid in interstitial space or serous body cavity, which is a pathologic process caused by disease
classification According to the range that edema fluid spreads to: (generalized edema) Local edema According to the cause of edema: Renal edema Hepatic edema Cardiac edema Malnutritional edema lymphedema

Scale of edema
Edema is evaluated on it's ability to pit. The examiner's fingers are pressed into a dependent area of the patient's skin for 5 seconds. Areas used to check for pitting are the sacrum if the patient is bedridden, or the lower leg. If pitting edema is present, the fingers will sink into the tissue and leave an impression of the fingers when they are removed.

This pitting is graded on a scale of +1 to +4 as follows: +1 (Trace) Slight indentation, rapid return to normal +2 (Mild) 4mm indentation, rebounds in a few seconds +3 (Mod) 6mm indentation, 10-20 seconds to return to normal +4 (Severe) 8mm indentation, > 30 seconds to return to normal

Treatment of edema:

The simple act of elevating the legs sometimes will reduce edema. :

-limiting the salt in the diet

-taking diuretics, medications that stimulate the kidneys to excrete the excess salt and water -taking angiotensin-converting enzyme inhibitors (ACE --inhibitors) and vasodilator drugs, which cause blood vessels to expand and allow blood to flow easier, decreasing the work required of the heart -taking beta blockers, which improve the functioning of the left ventricle of the heart -taking digitalis, a drug that expands the ability of the heart to pump blood through the body

Complications of Congestive Heart Failure

Pleural effusion
Increased pressure in pleural capillaries Leakage of fluid from capillaries into pleural space.

Arrhythmias Left ventricular thrombus Hepatomegaly

Liver becomes congested with venous blood Leads to impaired liver function