Sarah Michelle A. Nidua IV-B Grp.

Congestive Heart Failure

Heart failure, also called congestive heart failure, is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. It is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion.

Causes
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y y y

Weakened heart muscle Damaged heart valves Blocked blood vessels supplying the heart muscle (coronary arteries), leading to a heart attack Toxic exposures, like alcohol or cocaine Infections High blood pressure that results in thickening of the heart muscle (left ventricular hypertrophy) Pericardial disease, such as pericardial effusion (a large collection of fluid around the heart in the space between the heart muscle and the thick layer of pericardium surrounding the heart) and/or a thickened pericardium, which does not allow the heart to fill properly Congenital heart diseases Prolonged, serious arrhythmias Idiopathic cardiomyopathy or heart muscle disease of unknown cause

Symptoms
 Left-sided heart failure Signs of pulmonary congestion -Dyspnea -Dry, hacking Cough -Pulmonary Crackles -Low oxygen saturation levels Extra heart sound S3 (Ventricular Gallop) Paroxysmal nocturnal dyspnea Orthopnea Blood tinged / frothy sputum Oliguria        Right-sided heart failure Dependent edema Hepatomegaly Splenomegaly Ascites Jugular Vein Distention Weight gain Anorexia and nausea

    

Systolic and Diastolic Failure

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Systolic. Systolic heart failure is a pumping problem. In systolic failure, the heart muscles weaken and cannot pump enough blood throughout the body. The left ventricle is usually stretched (dilated). Fluid backs up and accumulates in the lungs (pulmonary edema). Systolic heart failure typically occurs in men between the ages of 50 - 70 years who have had a heart attack. Diastolic. Diastolic heart failure is a filling problem. When the left ventricle muscle becomes stiff and cannot relax properly between heartbeats, the heart cannot fill fully with blood. When this happens, fluid entering the heart backs up. This causes the veins in the body and tissues surrounding the heart to swell and become congested. Patients with diastolic failure are typically women, overweight, and elderly, and have high blood pressure and diabetes.

Exams and Tests

The following tests may be used to diagnose or monitor heart failure:
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Chest x-ray ECG Echocardiogram Cardiac stress tests Heart CT scan Heart catheterization MRI of the heart Nuclear heart scans Exercise Stress Test

Treatment
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 y Assess heart rate before administration; if below 60 bpm or above 120 bpm, withhold the drug. y Monitor serum potassium y 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: y Thiazides: Chlorthiazide (Diuril) y Loop diuretics: Furosemide (Lasix) y Potassium-Sparing: Spironolactone (Aldactone)  Nursing Responsibilities y Assess for signs of hypokalemia when administering loop and thiazide diuretics. y Give potassium supplement and potassium-rich foods. y 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: y Nitroprusside (Nipride) y Hydralazine (Apresoline) y Nifedipine y Captopril (Capoten)  Other Drugs  Sympathomimetics y Dopamine y Dobutamine  Diet: sodium-restricted, restricted fluid 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-Fowlers or High-Fowlers 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-Fowlers 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)

 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)  Maintain strict fluid restriction as prescribed.  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)  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-fowlers 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.