INTRODUCTION:

 Congestive Cardiac Failure or Heart failure Often termed "congestive heart failure" or CHF, is a global term for
the physiological state which most commonly caused when cardiac output is low and the body becomes
congested with fluid due to an inability of heart output to properly match venous return.
 A state of circulatory congestion produced by myocardial dysfunction.
 It is the inability of the heart to pump an adequate amount of blood to the systemic circulation to meet the
metabolic demand of the body.
 It is not a disease itself but a group of manifestations related to inadequate heart performance due to any
reason either muscular or valvular.

EPIDEMIOLOGY:
 CCF is present in 2% of persons age 40 to 59, more than 5% of persons age 60 to 69, and 10% of persons age 70
and older.
 Prevalence is at least 25% greater among the black population than among the white population.
 More than 22 million people worldwide suffer from congestive cardiac failure. (WHO).
 CCF is the 6th leading cause of mortality in the Philippines, affecting males more often than females.
 In the context of Nepal about 15% of the population is suffering from heart diseases and the number is
increasing year after year. (Nepal Health Foundation, NHF).

CAUSES:
 Intrinsic Causes
 Myocardial Infarction (Blocked blood vessels supplying the heart muscle (coronary arteries), which may
lead to a heart attack).
 Cardiomyopathy (Weakened heart muscle)
 Myocarditis
 Congenital heart disease
 Valvular heart defects
 Percarditis/cardiac tamponade
 Diseases such as hemochromatosis (iron overload) or amyloidosis can cause stiffening of the heart muscle
and impair the ventricles capacity to relax and fill
 Extrinsic causes
 Systemic hypertension that results in thickening of the heart muscle (left ventricular hypertrophy)
 Chronic obstructive pulmonary disease
 Pulmonary embolism
 Severe Anemia
 Thyrotoxicosis
 Metabolic/respiratory acidosis
 Blood volume excess/polycythemia
 Drug toxicity
 Prolonged Cardiac dysrhythmias,
 Congenital heart diseases
 Metabolic disease
 Infections, commonly viruses
 There are over a hundred other less common causes of heart failure, which include-
 variety of infections,
 exposures (such as radiation or chemotherapy)
 endocrine disorders (including thyroid disorders),
 complications of other diseases,
 toxic effects,
 genetic predisposition.
 However, the cause of congestive heart failure is often idiopathic, or unknown. People who have diabetes are at
increased risk for both ischemic and non-ischemic heart failure.
RISK FACTORS:
 Age o Hypertension
 Physical inactivity o Diabetes
 Obesity o Smoking
 Metabolic syndrome o Coronary artery disease
 Family history of heart failure
 Enlargement of the left ventricle
 Some types of valvular heart disease, including infection
 High cholesterol and triglycerides
 Excessive alcohol consumption
 Prior heart attack
 Certain exposures, such as to radiation and some types of chemotherapy
 Infection of the heart muscle (usually viral)

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
 Acute pulmonary edema, a medical emergency, results from left ventricular failure.
 Right-side heart failure occurs if the heart cant pump enough blood to the lungs for gas exchange.
 Left-side heart failure occurs if the heart cant pump enough oxygen-rich blood to the rest of the body.
 If pulmonary edema is not treated, death will occur from suffocation because the client literally drowns in
his or her own fluids.
 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.
 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.

CLASSIFICATION:
Functional classification generally relies on the New York Heart Association Functional Classification The classes (I-IV)
are:
 Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
 Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
 Class III: marked limitation of any activity; the patient is comfortable only at rest.
 Class IV: any physical activity brings on discomfort and symptoms occur at rest

PATHOPHYSIOLOGY:
CLINICAL MANIFESTATIONS
Signs:
 Pulmonary rales
 Pulmonary edema
 Cool extremities
 Pleural effusion
 Tachycardia
 Narrow pulse pressure
 Cardiomegaly
 Peripheral edema
 Jugular venous distension
 Hepatojugular reflux
 Hepatomegaly

Symptoms:
 Dyspnea
 particularly on exertion
 Orthopnea
 Paroxysmal nocturnal dyspnea
 Exercise intolerance
 Tachypnea
 Cough
 Fatigue
 Nocturia
 Hemoptysis
 Abdominal pain
 Anorexia
 Nausea
 Bloating
 Poor appetite, early satiety
 Ascites
 Mental status changes

DIAGNOSTIC EVALUATION:
 A thorough patient history may disclose the presence of one or more of the symptoms of CCF described above.
 In addition, a history of significant coronary artery disease, prior heart attack, hypertension, diabetes, or
significant alcohol use can be clues.
 The physical examination is focused on detecting the presence of extra fluid in the body (breath sounds, leg
swelling, or neck veins) as well as carefully characterizing the condition of the heart (pulse, heart size, heart
sounds, and murmurs).
 CCF can be confused with other illnesses that cause breathing difficulties, such as bronchitis, pneumonia,
emphysema, and asthma. No single test can diagnose heart failure.
 Chest X-ray: is very helpful in identifying the buildup of fluid in the lungs. Also, the heart usually enlarges in CHF,
and this may be visible on the X-ray film.
 ECG: changes may be seen. However, the ECG result may be normal in heart failure.
 Blood tests: Low blood cell counts (anemia) may cause symptoms much like congestive heart failure or
contribute to the condition.
 Sodium, potassium, magnesium, and other electrolyte levels may be abnormal, especially if the person has been
treated with diuretics and/or has kidney disease.
 Tests for kidney function: B-type natriuretic peptide (BNP) can be measured. This is a hormone produced at
higher levels by the failing heart muscle. This is a good screening test; the levels of this hormone generally
increase as the severity of heart failure worsens.
 Echocardiography: (echo) uses sound waves to create a moving picture of heart. Echo also can identify size and
shape of the heart, areas of poor blood flow to the heart, areas of heart muscle that arent contracting normally,
and heart muscle damage caused by lack of blood flow.
 Heart catheterization allows the arteries to the heart to be visualized with angiography.
 Biopsy of the heart tissue
TREATMENT/MANAGEMENT:
MEDICAL MANAGEMENT
 Early diagnosis and treatment can help people live longer, more active lives. Treatment for heart failure will
depend on the type and stage of heart failure (the severity of the condition).
 The goals of treatment:
 Treating the conditions underlying cause, such as coronary heart disease(CHD), high blood pressure, or
diabetes
 Reducing symptoms
 Stopping the heart failure from getting worse
 Increasing lifespan and improving your quality of life.
 Treatments usually include lifestyle changes, medicines, and ongoing care.
 If severe heart failure, patient also may need medical procedures or surgery.
 Lifestyle Changes
 Simple changes can help feel better and control heart failure
 Heart Healthy Diet
 Following a heart healthy diet is an important part of managing heart failure. In fact, not having a
proper diet can make heart failure worse.
PHARMACOLOGICAL MANAGEMENT:
 Commonly used medicines:
 Diuretic Therapy: To decrease cardiac workload by reducing circulating volume and thereby reduce
preload.
 Commonly used diuretics:
 Thiazides: Chlorthiazide (Diuril)
 Loop diuretics: Furosemide (Lasix)
 Potassium-Sparing: Spironolactone (Aldactone)
 Vasodilators: To decrease afterload by decreasing resistance to ventricular emptying.
 Commonly used vasodilators:Nitroprusside (Nipride), Hydralazine (Apresoline), Nifedipine, Captopril
(Capoten)
 Beta blockers: slow heart rate and lower blood pressure to decrease hearts workload.• Digitalis
therapy(Digoxin): Has positive inotropic (strengthens force of cardiac contractility) and negative
chronotropic effects (decreases heart rate).
 Morphine – Because catecholamines are released in response to the anxiety and pain associated with
suffering an acute MI (increasing the workload of the heart). Morphine can be used to help reduce the
pain that can be associated with congestive heart failure
 Other Drugs: Sympathomimetics
 Dopamine
 Dobutamine
ONGOING CARE:
1. Watch for signs that heart failure is getting worse. For example, weight gain may mean that fluids are building
up in body. Weigh yourself & report weight changes .
2. Getting medical care for other related conditions is important. If the pt. has diabetes or high blood pressure,
work up to control these conditions. Check blood sugar level and blood pressure regularly.
3. Try to avoid respiratory infections like the flu and pneumonia. Get flu and pneumonia vaccines.
4. Oxygen therapy (oxygen given through nasal prongs or a mask). Oxygen therapy can be given in a hospital or at
home.
MEDICAL PROCEDURE OR SURGERY:
 As CHF worsens, lifestyle changes and medicines may no longer control the symptoms. May need a medical
procedure or surgery such as, cardiac resynchronization therapy (CRT) device or an implantable cardioverter
defibrillator (ICD).
 In heart failure, the right and left sides of the heart may no longer contract at the same time. This disrupts the
hearts pumping. To correct this problem, CRT device (a type of pacemaker) may be implanted.
 This device helps both sides of your heart contract at the same time, which can decrease heart failure
symptoms.
DIETARY MANAGEMENT:
 A healthy diet includes a variety of vegetables and fruits, whole grains, fat-free or low-fat dairy products, and
protein foods, such as lean meats, eggs, poultry without skin, seafood, nuts, seeds, beans, and peas.
 A healthy diet is low in sodium and solid fats (saturated fat and trans fatty acids). Too much salt can cause extra
 fluid to build up in the body, making heart failure worse. Saturated fat and trans fatty acids can cause unhealthy
blood cholesterol levels.
 A healthy diet is low in added sugars and refined grains (come from processing whole grains, which results in a
loss of nutrients, such as dietary fiber). Examples of refined grains include white rice and white bread.
 A balanced, nutrient-rich diet & getting enough potassium is important. Some heart failure medicines deplete
the potassium in the body. Lack of potassium can cause very rapid heart rhythms that can lead to sudden death.
 Potassium is found in foods like white potatoes and sweet potatoes, greens (such as spinach), bananas, many
dried fruits, and white beans and soybeans.
 Its important to drink the correct amounts and types of fluid. Drinking too much fluid can worsen heart failure.
 Patient should not drink alcohol.
 Other Life style modification:
 Taking steps to control risk factors for CHD, high blood pressure, and diabetes will help control heart
failure.
 For example:Lose weight if you are overweight or obese. Work with your health care team to lose weight
safely.
 Be physically active to become more fit and stay as active as possible.
 Quit smoking and avoid using illegal drugs. Also, try to avoid secondhand smoke.
 Get enough rest.
NURSING MANAGEMENT:

NURSING DIAGNOSIS
1. Decreased cardiac output r/t ventricular damage, ischemia and restriction secondary to fluid overload.
NURSING INTERVENTIONS
 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. Use pillows for added support.
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.

NURSING DIAGNOSIS
2. Impaired gas exchange r/t increased pulmonary interstitial fluid accumulation.
NURSING INTERVENTIONS
 Promoting Rest and Activity
 Gradual ambulation is encouraged to prevent risk of venous thrombosis and embolism due to prolonged
immobility
 Activities should progress through simple to complex.
 Assess for signs of activity intolerance (dyspnea, fatigue and increased pulse rate that does not stabilize readily).

NURSING DIAGNOSIS
3. Altered tissue perfusion r/t imbalance between oxygen demand and supply.
NURSING INTERVENTIONS
 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 soresFacilitating Fluid Balance
 Control of sodium intake
 Administer diuretics and digitalis as prescribed
 Monitor I and O, weight and V/S
 Dry phlebotomy (rotating tourniquets)

SUMMARIZATION:
Impaired cardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs
Not a disease but a “syndrome” associated with long-standing HTN and CAD. A state of circulatory congestion
produced by myocardial dysfunction.It is the inability of the heart to pump an adequate amount of blood to the
systemic circulation to meet the metabolic demand of the body. Heart failure describes the clinical syndrome that
develops when the heart cannot maintain an adequate cardiac output. • The heart pumps blood inadequately,
leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and other changes that may
further weaken the heart.

CONCLUSION:
Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of your heart
muscles. While often referred to simply as “heart failure,” CHF specifically refers to the stage in which fluid builds up
around the heart and causes it to pump inefficiently.You have four heart chambers. The upper half of your heart has
two atria, and the lower half of your heart has two ventricles. The ventricles pump blood to your body’s organs and
tissues, and the atria receive blood from your body as it circulates back from the rest of your body.

BIBLIOGRAPHY: