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Congestive Heart Failure – Right

a) Definition

Congestive Heart Failure

- a constellation of sign and symptoms that results from the heart’s inability
to pump enough blood to meet the body’s metabolic demands
- a physiologic state in which the heart can not pump enough blood to meet
the metabolic needs of the body (determined as oxygen consumption)
- may occur when any one of the processes of the circulatory or vascular
systems fails and is unable to maintain circulation of blood adequate to
meet the metabolic or volumetric needs of the body

Functional Classification of Heart Failure

The Stages of Heart Failure – NYHA Classification

In order to determine the best course of of therapy, physicians often assess the stage of
heart failure according to the New York Heart Association (NYHA) functional
classification system. This system relates symptoms to everyday activities and the
patient's quality of life.

Class Patient Symptoms


Class I (Mild) No limitation of physical activity. Ordinary physical activity does not
cause undue fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but
ordinary physical activity results in fatigue, palpitation, or dyspnea.
Class III Marked limitation of physical activity. Comfortable at rest, but less
(Moderate) than ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (Severe) Unable to carry out any physical activity without discomfort.
Symptoms of cardiac insufficiency at rest. If any physical activity is
undertaken, discomfort is increased.

In its 2001 guidelines, the American College of Cardiology/American Heart Association


working group introduced four stages of heart failure:

• Stage A: Patients at high risk for developing HF in the future but no functional or
structural heart disorder;
• Stage B: a structural heart disorder but no symptoms at any stage;
• Stage C: previous or current symptoms of heart failure in the context of an
underlying structural heart problem, but managed with medical treatment;
• Stage D: advanced disease requiring hospital-based support, a heart transplant or
palliative care.

The ACC staging system is useful in that Stage A encompasses "pre-heart failure" - a
stage where intervention with treatment can presumably prevent progression to overt
symptoms. ACC stage A does not have a corresponding NYHA class. ACC Stage B
would correspond to NYHA Class I. ACC Stage C corresponds to NYHA Class II and
III, while ACC Stage D overlaps with NYHA Class IV.

Right – sided heart failure

- the right ventricle loses its ability to pump efficiently causing blood that would
normally be pumped through the heart into the lungs back up into the systemic
circulation
- impairs the ability to move deoxygenated blood from the systemic circulation
into the pulmonary circulation
- can occur as a result of chronic lung diseases, congestive heart disease, primary
pulmonary hypertension, heart valve disease, and left-sided heart failure

b) Etiology

• Persistent left-sided heart failure


• Stenosis / regurgitation of tricuspid or pulmonic valves
• Right ventricular infarction
• Acute / chronic pulmonary disease: COPD, severe pneumonia, pulmonary
embolus
• Pulmonary hypertension (cor pulmonale) – increases afterload which
increases the workload of the heart and in turn leads to hypertrophy of
myocardial muscle fibers; hypertrophy may decrease the heart’s ability to fill
properly during diastole.

c) Incidence

d) Pathophysiology

e) Signs and Symptoms

• Peripheral edema –major manifestation


- venous congestion in the peripheral vascular beds causes increased
hydrostatic capillary pressure. Capillary hydrostatic pressure overwhelms the
opposing pressure of plasma proteins, and fluid shifts out of the capillary beds
and into the interstitial spaces, with resulting pitting edema.
• Weight gain – due to accumulation of fluid, congestion of viscera
• Hepatomegaly – occurs as the liver becomes congested with venous blood. If
this occurs rapidly, stretrching of the capsule surrounding the liver causes
severe discomfort
• Sharp pain in the right upper quadrant may be felt
• Ascites – presence of congestion of the portal circulation in the
gastrointestinal tract and liver affected which interferes digestion and
absorption of nutrients
• Anorexia and abdominal discomfort – develop secondary to venous
congestion of the gastrointestinal tract
• Jugular Vein Distention- very specific sign of right ventricular failure
resulting form increased venous pressure
• Pitting edema

f) Diagnostic exam

• Chest x-ray
• Echocardiography – to assess anatomical and functional abnormalities in the
heart
- An ECG is a simple, painless test that detects and records the heart’s electrical
activity. The test shows how fast the heart is beating and its rhythm (steady or
irregular). An EKG also records the strength and timing of electrical signals as
they pass through each part of the heart.
- may show whether the walls in a heart's pumping chambers are thicker than
normal. Thicker walls can make it harder for the heart to pump blood.

• Elevated SGPT
• B-type natriuretic peptide (BNP) - a protein secreted from the ventricles in
response to overload, such as heart failure. As the degree of heart failure
worsesn, the level of BNP secreted into the blood increases.
• Doppler Ultrasound - uses sound waves to measure the speed and direction of
blood flow. This test often is done with echo to give a more complete picture
of blood flow to the heart and lungs.
• Holter monitor - records your heart’s electrical activity for a full 24- or 48-
hour period, while you go about your normal routine. You wear small patches
called electrodes on your chest that are connected by wires to a small, portable
recorder. The recorder can be clipped to a belt, kept in a pocket, or hung
around your neck.
• Tracer studies / radioactive imaging – a means of assessing the heart though
introducing low-dose radioactive tracers that are injected into the blood stream
and visualized going to the heart. It gives information on perfusion defects
and metabolic abnormalities of the myocardium.

g) Medical Management
The basic objectives in treating patients with CHF are the following:
⇒ Reducing the workload on the heart
⇒ Increasing the force and efficiency of myocardial contraction
⇒ Eliminating the excessive accumulation of body water by avoiding excess
fluid intake, controlling the diet, and monitoring diuretic and ACE inhibitor
therapy

 Medications
 ACE inhibitors
 Promote vasodilation and diuresis by decreasing afterload and
preload
 Vasodilation reduces resistance to left ventricular ejection of blood
and improves ventricular emptying
 Decrease the secretion of aldosterone, a substance that causes the
kidneys to retain sodium
 Excretes sodium and fluid while retaining potassium thereby
reducing left ventricular filling pressure and decreasing pulmonary
congestion
 Nursing Responsibilities
• Monitor blood pressure, urine output, and electrolyte levels.
• Monitor serum creatinine and creatinine clearance.
• Teach patient to change positions gradually and to report
signs of dizziness or lethargy.
• Weigh patient daily and report raid weight gain and
significant feet and hand swelling.
 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
• 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
- In males: gynecomastia, decreased libido and
impotence
 Diuretic Therapy
 To decrease cardiac workload by reducing circulating volume and
thereby reduce preload which therefore lessens systemic and
pulmonary congestion.

 Commonly used diuretics:


• Thiazides: Chlorthiazide (Diuril)
• Loop diuretics: Furosemide (Lasix)
*inhibits sodium chloride reabsorption in the ascending
loop of Henle
• Potassium-Sparing: Spironolactone (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 preload and afterload by decreasing resistance to
ventricular emptying
 Commonly used vasodilators:
• Nitroglycerin
*reduces myocardial oxygen demand by lowering preload
and afterload.
• Hydralazine (Apresoline)
• Nifedipine
• Captopril (Capoten)

 Other Drugs
 Sympathomimetics
• Dopamine
*opens the kidney’s vascular beds leadting to improved
GFR, urine output, and excretion of sodium
• Dobutamine
*produces strong beta-stimulatory effects within the
myocardium; increases heart rate, AV conduction, and
myocardial contractility.
*capable of increasing cardiac output without increasing
myocardial oxygen demands or reducing coronary blood
flow.

TREATMENT
 Diet: sodium-restricted diet to prevent fluid excess
 Activity: balanced program of activity and rest
 Oxygen Therapy: to increase oxygen supply

h) Surgical Management

• Heart valve surgery is a procedure to


treat heart valve disease. In heart valve disease,
one or more of the four heart valves that keep
blood flowing in the correct direction through
your heart doesn't function properly. In heart
valve surgery, your surgeon repairs or replaces
your heart valve.

• Coronary bypass surgery is a treatment


for coronary artery disease (CAD), a hardening and
narrowing of your arteries (atherosclerosis) that supply
oxygen and nutrients to your heart.In coronary bypass
surgery, a surgeon creates a detour around a blocked
artery using arteries or veins from other parts of your
body (grafts). When connected to other arteries in your
heart, the graft brings oxygen and nutrients to your
heart.

• Surgical Anterior Ventricular Endocardial Restoration (SAVER). A


related operation called surgical anterior ventricular endocardial restoration
(SAVER), or the Dor procedure (after its inventor), combines elements of
ventricular remodeling and coronary bypass surgery. It may be beneficial for
those whose heart muscle has been scarred by a heart attack. An early study
found that 85% of patients who had the surgery did not need to return to the
hospital during an 18-month follow-up period. Additional trials are under way.

• Dynamic cardiomyoplasty is an investigative treatment that has been


useful in carefully selected patients with congestive heart failure, though long-
term and larger studies are still needed: a) The procedure detaches one end of a
muscle from the back and wraps it around the ventricles of the heart, and b)
After a few weeks, these relocated muscles are conditioned with a pacemaker to
behave and beat as if they were heart muscles.
• Heart transplantation is surgery to remove a damaged or diseased heart
and replace it with a healthy donor heart.

i) Nursing Management

 Providing Oxygenation
 Administer oxygen therapy per nasal cannula at 2-6 LPM as ordered
 Evaluate ABG analysis results
 Semi-Fowler’s or High-Fowler’s 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-Fowler’s 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)

 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-fowler’s 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.