CHF

Tags RLE

Congestive Heart Failure (CHF)

: A syndrome characterized by myocardial dysfunction that leads to impaired pump performance (diminished cardiac output) or to frank heart failure
and abnormal circulatory congestion.
: Pump failure usually occurs in a damaged left ventricle ( left heart failure ) but may happen in the right ventricle ( right heart failure )
primarily, or secondary to left heart failure.

Causes
: May result from a primary abnormality of the heart muscle - such as
an infarction -inadequate myocardial perfusion due to coronary disease
or cardiomyopathy. Other causes include:
Mechanical disturbances in ventricular filling during diastole there
is too little blood for the ventricles to pump.
Systolic hemodynamic disturbances, such as excessive cardiac
workload due to volume overloading or pressure overload, that
limit the heart's pumping ability.
Diagnosis
EKG
Reflects heart strain or enlargement, or ischemia.
May also reveal arterial enlargement, tachycardia, and
extrasystoles suggesting CHF.
Chest X-ray
Shows increased pulmonary vascular markings, interstitial
edema, or pleural effusion and cardiomegaly.

Pulmonary artery monitoring

Pathophysiology
Demonstrates elevated pulmonary artery and capillary wedge
: Reduced cardiac output triggers 3 compensatory mechanisms,
pressuures, which reflect left ventricular end-diastolic pressure
Ventricular dilation in left heart failure.
Ventricular hypertrophy Elevated right arterial pressure or central venous pressure in
Increased sympathetic activity right heart failure.

Ventricular Dilation Ventricular Hypertrophy Increased sympathetic activity

: An increase in end-diastolic ventricular
volume (preload) causes increased stroke work
and stroke volume during contraction,
stretching cardiac muscle fibers beyond
optimum limits and producing pulmonary
complications and pulmonary hypertension →
right ventricular failure.
: An increased in muscle mass or diameter
of the left ventricle allows the heart to pump
against increased resistance (impedence) to
the outflow of blood.
: An increased in ventricular diastolic
pressure necessary to fill the enlarged
ventricle may compromise diastolic
coronary blood flow → limiting oxygen
supply to the ventricle → ischemia and
impaired muscle contractility.
: A response to decreased cardiac output and
blood pressure by enhancing peripheral
vascular resistance, contractility, heart rate, and
venous return.
: Signs of increased sympathetic activity,
Cool extremities and clamminess
May indicate impending heart
failure.
Reduced Glomerular Filtration Rate
(GFR) and increasing tubular
reabsorption of salt and water

Restricted blood flow to the

kidneys → if unchecked, can
aggrevate.

📢 The mechanisms improve cardiac output at the expense of increased ventricular work

Managing Pulmonary Edema

Initial Stage Acute Stage Advance Stage
Symptoms Symptoms Symptoms

Persistent cough Acute shortness of breath Decreased level of consciousness

Slight dyspnea/orthopnea Respirations -rapid, noisy (audible Ventricular arrhythmmias; shock

wheeze, rales)
Exercise intolerance Diminished breath sounds
Cough - more intense and productive of
Restlessness and anxiety Nursing Responsibilities
frothy, blood-tinged sputum
Crepitant rales at lung bases Be prepared for cardioversion.
Cyanosis - cold, clammy skin

CHF 1
 Diastolic gallop Tachycardia - arrhythmias Assist with intubation and mechanical
ventilation, and resuscitate if necessary.
Nursing Responsibilities Hypotension

Check for color and amount of Nursing Responsibilities

expectoration.
Give oxygen (preferably by high
Position the patient for comfort. concentration mask or IPPB).

Auscultate chest for rales and S3. Insert I.V. if not already done.

Medicate, as ordered. Aspirate nasopharynx, as needed.

Monitor apical and radial pulse. Give digitalis, morphine, and potent
diuretic (e.g. furosemide), as ordered.
Assist patients with all needs, to conserve
strength. Insert foley catheter.

Provide emotional support (through all Calculate intake and output accurately.
stages) for patient and family.
Draw blood to measure arterial blood
gases.

Attach cardiac monitor leads, and

observe EKG.

Keep resusitation equipment available.

Signs and Symptoms of CHF

Right-sided Heart Failure Left-sided Heart failure
Congestion in the peripheral tissues and viscera Pulmonary congestion
: The right ventricle cannot eject the blood effectively and cannot : Pulmonary venous blood volume and pressure increase in the
accomedate all of the blood that normally returns to the blood from lungs, forcing fluid from the pulmonary capilliaries into the
the circulation. pulmonary tissues and alveoli → Pulmonary interstitial edema and
impaired gas exchange.
Dependent Edema
: Increased capillary hydrostatic pressure Dyspnea

Affects the feet and ankles Dyspnea on exertion (DOE) and/or othropnea

Paroxysmal nocturnal dyspnea (PND) - sudden attacks of

Worsens when the patient sits or stands.
dyspnea at night
Gradually progresses up to the legs, thighs, and eventually
: Fluid accumulated during the day may be reabsorbed into
into the external genitalia and lower trunk.
the circulating blood volume when the patient lies down.
Ascites The impaired left ventricle cannot eject the increased
Evidenced by increased abdominal girth blood volume → increased pressure in the pulmonary
circulation → fluid shift into the alveoli → impaired gas
Can increase pressure in the abdoment → gastrointestinal
exhange → dyspnea and difficulty sleeping at night
distress
Cough
Sacral edema
Initially dry and non-productive
Common in patients who are on bed rest
Become moist over time → pink or tan sputum (blood
Pitting edema
tinged)
Generally obvious after retention of at least 4.5 kg ( 10
Pulmonary crackles
Ibs ) of fluid ( 4.5 L )
Early phase - bibasilar crackles that do not clear with
Jugular Vein Distention (JVD)
coughing
: Increased venous pressure
Later phase - crackles through out the lungs
Hepatomegaly
Low oxygen saturation levels
: Caused by venous engorgement of the liver
Extra heart sound (S3) or ventricular gallop may detected
Secondary liver dysfunction upon auscultation
Increased pressure within the portal vessels → forces fluid Decreased stroke volume
into the cavity → Ascites
→ Stimulates the sympathetic nervous system (SNS) to release
Increase pressure on the diaphragm → respiratory distress cathecholamines ( e.g. dopamine, epinephrine [adrenaline], and
norepinephrine )
Anorexia

: May result from the venous engorgement and venous stasis within SNS stimulation
the abdominal organs. Vasoconstriction
Generalized weakness Pale or ashen skin; cool and clammy skin

CHF 2
 Tachycardia

Oliguria with recumbent nocturia

: Decreased blood flow to the kidneys due to decreased cardiac
output and increased catecholamines → decreased renal perfusion
→ oliguria

: When the patient is sleeping → decreased cardiac workload →

improved renal perfusion → nocturia

Decreased gastrointestinal perfusion

Altered digestion

Decreased brain perfusion

Diziness

Lightheadedness

Confusion

Restlessness

Anxiety

Fatigue

Decrease activity tolerance

: The body cannot respond to increased energy demands:

Expended in breathing

Insomia

Coughing

Nocturia

Treatment Nursing Interventions

: The aim of the therapy is to improve pump function by reversing the During the acute phase
compensatory mechanisms producing the clinical effects.
Weight the patient daily (best index of fluid retention).
Lifestyle changes
Check for peripheral edema.
D - Diet
Carefully monitor IV intake and urinary output (especially
Low sodium and fluid intake (2L + 2g or less per day) when receiving diuretics).

No fried food Monitor vital signs (for increased respiratory rate, heart rate,
No canned foods and narrowed pulse pressure) and mental status.

Auscultate the heart for abnormal sounds (S3 gallop) and the
No OTC
lungs for rales and rhonchi.
C - Cold & flu meds
Report changes immediately.
A - Acetaminophen
Frequently monitor BUN, creatinine, and serum potassium,
A - Antacids chloride, and magnesium levels.
N - NSAIDs Assist with range of motion exercises to prevent deep-vein
R - Risk for falls thrombosis due to vascular congestion.

Change position slowly Enforce bed rest and apply antiembolism stockings.

B - BP and BNP Watch for calf pain and tenderness

Should NOT be increasing To prepare the patient for discharge

Notify the HCP immediately Advise/educate the patient to avoid foods high in sodium, such
as canned or commercially prepared foods and dairy products to
E - Elevate legs
curb fluid overload.
With pillows and high fowlers
Tell the patient that potassium loss through diuretics must be
D - Daily weights replaced by taking a prescribed potassium supplement and eating
high-potassium rich foods such as bananas, apricots, and
S - Sex
orange juice.
Only after 2 flights of stairs with NO SOB
Stress the need for regular check-up
S - Stockings
Emphasize the importance of taking digitalis exactly as prescribed
TED hose

Decrease blood pooling

CHF 3
 Remove daily
Do not massage the calves
Pharmacological Treatment
A - ACEs and ARBs ( Lowers
ACE Inhibitors
-pril ending drugs ( Lisinopril,
1st choice of drug
Instruct the patient to watch for signs of toxicity (anorexia,
nausea and vomiting, yellow vision, cardiac arrhythmias).
Tell the patient to notify the doctor if pulse is unsually irregular or
less than 60 beats per minute; or if the patient experiences
BP ) dizziness, a persistent dry cough, palpitations, increased fatigue,
paroxysmal nocturnal dyspnea, swollen ankles, or decreased
urinary output; or if the patient gains 5 Ibs ( 2.25 kg ) in a week
enalapril, captopril )
OR 2 to 3 Ibs ( 1 to 2.25 kg ) in a day.

Angiotensin II Receptor Blockers

-sartan ending drugs ( Losartan )

2nd choice drug

Precautions

A - Avoid pregnancy

A - Angioedema

Airway risk ( only in ACE )

C - Cough ( only in ACE )

E - Elevated potassium

Avoid potassium rich foods

Green leafy vegetables

Avocados

Orange juice

Melon

Liver

Salt substitutes

Early signs of elevated potassium

Muscle spasms

Peaked T-waves and ST elevation

Potassium imbalances → Cardiac monitoring

B - Beta Blockers ( Lowers HR & BP )

-lol ending drugs ( Metoprolol, bisoprolol )

Check HR anf BP before administering

Hold the drug or question the order if the patient has

ASTHMA or COPD

Precautions

Bradycardia

Breathing problems

Bad for worsening heart failure patients

Blood sugar masking

Masks signs of low blood sugar

Monitor glucose levels closely

C - Calcium CB ( Lowers HR & BP )

-dipine, -zem, -amil ending drugs ( Nifedipine, diatilizem,

vamil )

Nursing Considerations

C - Count HR & BP

Not for low BP and HR

Except for Nifedipine (declines the BP)

C - Change positions slowly

B - Bad headaches is normal

CHF 4
 D - Digoxin ( Lowers HR )

Deep contractions

Very toxic

Precautions

A -Apical pulse checking

Do not give when lower than 60

T - Toxicity

Notify HCP

P - Potassuim level checking

Does NOT cause low potassium but low levels

of potassium can increase risk of digoxin toxicity

D - Dilators ( Vasodilator )

Nitroglycerin, Nitroprusside, Hydralazine, Isosobride,

Minoxidil

Lowers preload and afterload

Precautions

No viagra or "-afil" ending drugs

Stop drug if low BP is too low

Early signs of low BP

Confusion

Irritability

Sweating

Pallor

Normal side effects

Headache

Hypotension

Hot flushing "facial redness"

D - Diuretics ( Lowers BP )

Potassium wasting ( caution: hypokalemia - 3.5 or less

than 3.5 )

-ide ending drugs ( furosemide, hydrochlorothiazide

[HCTZ] )

1st choice - Loop diuretics

Furosemide

Administered too fast → Ear pain/Tinitus

(ringing in the ears) and hypotension

Administered too much → Nephrotoxic

and hypokalemia

2nd choice for - Thiazide

No licorice

Flat T-waves, ST depression, U-waves

DO NOT IV PUSH POTASSIUM - IV bag for more

than 1 hour

Potassium sparing ( caution: avoid potassium )

-actone ending drug ( spironolactone )

Nursing considerations

Check BP

Check BUN & Creatinine

Monitor potassium levels

CHF 5
 Administer in the morning

Slow postition changes

Daily weights

Risk for sunburns

Low sodium diet

: All drugs except Digoxin lowers BP, so change positions slowly

CHF 6