Introduction
- Heart failure, sometimes known as congestive heart failure is a condition in which the heart is unable to pump sufficient blood to meet the needs of the tissues.
- Heart failure is a significant cardiac functional disorder that can result in reduced oxygen delivery to the body’s organ and tissues.
- When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.
Causes of CCF
- Conditions that increases pre load: Hypervolemia, VSD, Aortic regurgitation
- Conditions that increases after load: Hypertension, Aortic or pulmonary stenosis
- Abnormal muscles functions: Myocardial infraction, Myocarditis, cardiomyopathy
- Conditions that increases demand for oxygen delivery
- Physical and emotional stress
- Infections
- Anemia
- Chronic pulmonary disease
General classification of CCF
- Right sided heart failure
- Left sided heart failure
Right-sided heart failure
- The failure of the right ventricle to pump the entire blood present in it during systole results in retention of some amount of blood after every systole
- Right-sided heart failure means the right ventricle is not squeezing effectively then the blood in the right ventricle is not going to get squeezed out into the pulmonary artery to the lungs then there will be decreased amount of blood into the lungs, and backup of blood into the right atrium
Pathophysiology of Right-Sided Heart Failure
- Right side of heart is unable to pump blood into pulmonary circulation
- Blood accumulate in right ventricles
- Blood back up into right atrium
- Blood goes back up to systemic circulation
- Increased JVP and increased pressure in hepatic circulation
- Hepatomegaly, splenomegaly, ascites, peripheral edema
Sign and symptoms
- Increased JVP (neck vein becomes engorged and elevated)
- Hepatomegaly, increase bilirubin and liver enzymes may result from hepatic dysfunction
- Ascites and anasarca in advanced failure
- Other GI symptoms: anorexia, fullness, nausea
- Peripheral edema: secondary to fluid accumulation
- Nocturia or diuresis at night may occur.
- Altered fluid and electrolytes
Mnemonic to recall S/S of Right-Sided Heart Failure (HEAD)
- H – Hepatomegaly
- E – Edema (Bipedal)
- A – Ascites
- D – Distended Neck Vein
Left Sided Heart Failure
- The failure of the left ventricle to pump the entire blood present in it during systole results in the retention of some amount of blood after every systole
- Thus blood accumulates in the left ventricle after a few systoles of the heart
- The left ventricle fails to accept the blood from the auricles and lungs thus the uncollected blood due to backup pressure remains in the lungs resulting in pulmonary edema
Pathophysiology
Left side of the heart is unable to pump blood
Blood backs up in left atrium and pulmonary veins
As volume of blood in lungs increases, pressure of pulmonary capillary bed goes to a critical point, therefore, fluid passes across the pulmonary capillary membrane into interstitial space around the alveoli and finally into the alveoli
Nocturnal dyspnea, wheezing cough (cardiac Asthma)
S/S of Left Sided Heart Failure
- Dyspnea on exertion
- Orthopnea
- Paroxysmal Dyspnea
- Non – productive cough: Secondary to pulmonary congestion
- Wheezing on auscultation
- Worried or anxious look
- Insomnia
- Excessive sweating
- Gallop rhythm of the heart
- Pulmonary hypertension
Mnemonic to recall S/S of Left – sided Heart Failure (CHOP)
- C = Cough
- H = Hemoptysis
- O = Orthopnea
- P = Pulmonary Congestion (Crackles / rales)
Diagnosis
- History taking
- Physical examination: examination for jugular venous distension
- Cardiac auscultation
- Pulmonary exam (wheezing)
- Peripheral edema
Laboratory Investigation
- ECG may show ventricular hypertrophy
- Altered fluid and electrolytes
- Concentrated urine with increased Sp. Gravity
- Liver function tests: Increased bilirubin, and liver enzymes (SGOT, SGPT) due to hepatic impairment
- BUN and creatinine (early sign of kidney failure)
- Chest X-ray
- Size and shape of heart
- Pleural effusion
- Echocardiogram
- Examine the function of both ventricles
- Valvar abnormality
- – Cardiac Catheterization: When CAD or valvar cause is suspected
Pharmacologic Management of Heart Failure
- Diuretics
– If there are symptoms of findings of volume overload, the patient should be immediately started diuretics
- In general loop diuretics are preferred. For patients with severe symptoms or significant findings the diuretics should be administered intravenously.
- Diuretics improve urinary output and sodium excretion leading to reduction in blood plasma volume, therefore, reduce preload
- ACE inhibitors
ACE inhibitors should be prescribed to all patients with heart failure who do not have contraindications, due to evidence that these medications reduce mortality and improve functional status
ACE inhibitors frequently need to be used at higher than average doses to have the desired effect on a patient with CHF
Mild or transient side effects are not an indication to discontinue ACE inhibitors for these patients
- Alternative agents for patients who cannot take ACE inhibitors include isosobride dinitrate and hydralazine
- Captopril, the first ACE inhibitors
- Others include: zofenopril, enalapril, perindopril
- Digoxin: Digoxin can be very effective in patients with CHF. Digoxin should be initiated along with ACE inhibitors in patients with severe CHF. For patients with milder CHF, ACE inhibitors alone may be sufficient to control symptoms.
- Symptoms include anorexia, nausea and vomiting, fatigue, dysrhythmias
- Digoxin increases the force of myocardial contraction, promote diuresis by increasing cardiac output
Digoxin toxicity
- A serious complication of digoxin therapy is toxicity. Diagnosis of digoxin toxicity is based on the patient’s clinical symptoms, which include the following:
- Fatigue, depression, malaise, anorexia, nausea and vomiting
Management of CCF
- U = Upright position
- N = Nitrates (in low dose)
- L = Lasix
- O = oxygen
- A = Aminophylline
- D = digoxin
- F = Fluids (decrease)
- A = after load (decrease)
- S = Sodium restriction
- T = test (dig level, ABGs, K level)
Diet Therapy
- Restricted sodium
- Restricted fluids
- Good general nutrition and weight reduction for the obese patient
- Others:
- Moderation or elimination of alcohol consumption
- Smoking cessation
- Regular moderate aerobic exercise within limits of symptoms
Nursing Management
- Assessment
– Assess for clinical features, activity intolerance, level of knowledge
Nursing Diagnosis
- Decreased cardiac output related to altered heart rate and rhythm
- Excess fluid volume related to sodium and water retention
- Ineffective tissue perfusion related to decreased cardiac output
- Activity intolerance related to imbalance in oxygen demand and supply
- Deficit knowledge related to unknown disease condition and its treatment regimen
Interventions
1. Decreased cardiac output related to altered heart rate and rhythm
- Monitor vital sign and oxygen saturation at rest and during activity and provide oxygen
- Fluid restriction
- Plan frequent rest periods
- Keep accurate record of intake and output
- Teach about relaxation techniques
2. Excess fluid volume related to sodium and water retention
- Teach fluid restriction
- Follow low sodium diet
- Monitor intake and output
- Weight patient daily and compare the the previous measurement
- Assess for need for indwelling urinary catheter
- Give diuretics
3. Ineffective tissue perfusion related to decreased cardiac output
- Establish a quiet environment
- Elevate the head of the bed as it improves chest expansion and oxygenation
- Provide oxygen and monitor oxygen saturation
- Administer vasodilators
4. Activity intolerance related to an imbalance in oxygen demand and supply
- Monitor and evaluate the patient’s response to activities
- Provide oxygen as needed
- Teach energy-saving techniques
- Encourage a patient to have adequate bed rest and sleep
- Adjust the client’s daily activities and reduce the intensity of the level
Nursing Diagnosis of Cardiovascular System
- Altered cardiac output related to impaired contractibility of the heart
- Acute pain/ chest pain related to an imbalance of oxygen demand and supply
- Excess fluid volume related to sodium and water retention
- Impaired gas exchange related to alveolar edema due to elevated ventricular pressure
- Activity intolerance related to oxygen supply and demand imbalance
- Anxiety and fear of death related to unknown disease condition
- Deficit knowledge related to unknown disease conditions and their treatment procedure