CONGESTIVE HEART FAILURE A state of circulatory congestion produced by myocardial dysfunction MI compromises myocardial function by reducing contractility and

nd producing abnormal wall motion. The ability of the ventricle to empty lessens, the stroke volume falls, residual volume increases. Heart failure is the inability of the heart to pump the amount of oxygenated blood necessary to affect venous return and to meet the metabolic requirements of the body. 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. If pulmonary edema is not treated, death will occur from suffocation because the client literally drowns in his or her own fluids 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. CAUSES OF CONGESTIVE HEART FAILURE Intrinsic Myocardial Infarction Cardiomyopathy/myocarditis Congenital heart disease Valvular heart defects Percarditis/cardiac tamponade Extrinsic Systemic hypertension Chronic obstructive pulmonary disease

Pulmonary embolism Anemia Thyrotoxicosis Metabolic/respiratory acidosis Blood volume excess/polycythemia Drug toxicity Cardiac dysrhythmias Metabolic diseases

PATHOPHYSIOLOGY (see separate page for pathophysiology) Congestive Heart Failure Left-sided CHF Right-sided CHF SIGNS AND SYMPTOMS OF CONGESTIVE HEART FAILURE Comparison of Left and Right CHF Left-sided Congestive Heart Failure Right-sided Congestive Heart Failure Signs of pulmonary congestion Dyspnea Tachypnea Crackles in the lungs Dry, hacking cough Paroxysmal nocturnal dyspnea Increased BP (from fluid volume excess) Dependent edema (legs and sacrum) Jugular vein distention Abdominal distention Hepatomegaly Splenomegaly Anorexia and nausea Nocturnal diuresis Swelling of the fingers and hands Increased BP (from fluid volume excess)

*** Assessment Findings of Acute Pulmonary Edema Severe dyspnea and orthopnea Pallor Tachycardia Expectoration of large amounts of blood-tinged, frothy sputum Wheezing and crackles on auscultation Bubbling respirations Acute anxiety, apprehension, restlessness Profuse sweating

Cold, clammy skin Cyanosis Nasal flaring Use of accessory breathing muscles Tachypnea Hypocapnia, evidenced by muscle cramps, weakness, dizziness and paresthesias

COLLABORATIVE MANAGEMENT Medications 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 Commonly used diuretics: Thiazides: Chlorthiazide (Diuril) Loop diuretics: Furosemide (Lasix) 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 afterload by decreasing resistance to ventricular emptying Commonly used vasodilators: Nitroprusside (Nipride) Hydralazine (Apresoline) Nifedipine Captopril (Capoten) Other Drugs Sympathomimetics Dopamine Dobutamine TREATMENT Diet: sodium-restricted 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) 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. PROGNOSIS The prognosis depends on the patient's age, the severity of the heart failure, the severity of the underlying heart disease and other factors. When congestive heart failure develops suddenly and has a treatable underlying cause, patients can sometimes return to normal heart function after treatment. With appropriate treatment, even individuals who develop congestive heart failure as a result of long- standing heart disease can often enjoy many years of productive life.

PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE

CAUSES Heart Damage Ventricular Overload Decreased Ventricular Contraction

Tachycardia Ventricular Dilatation Myocardial Hypertrophy

Fluid Overload Edema

Increased Water Decreased Cardiac Output Reabsorption

Decreased Renal Perfusion

Increased ADH

Increased Sodium Restriction

Increased Osmotic Pressure

PATHOPHYSIOLOGY OF LEFT-SIDED CONGESTIVE HEART FAILURE CAUSES: MI HPN Aortic Stenosis/ Insufficiency Mitral Stenosis/ Insufficiency

Reduced Myocardial Contractility Increased Cardiac Workload Decreased Diastolic Filling Obstruction of Left Atrial Emptying

Increased Left Atrial Pressure

Left-Sided Congestive Heart Failure

Blood damns back into the pulmonary capillary bed Pressure of blood into the pulmonary capillary bed increases Fluid shifts into the intra- and interalveolar spaces Pulmonary Edema

Decreased stroke volume

Decreased tissue perfusion

Increased cellular hypoxia

Decreased blood flow to the kidneys

Signs and symptoms of LSCHF

Signs and Symptoms of LSCHF: Decreased blood flow to the Dyspnea kidneys Paroxysmal Nocturnal Dyspnea Orthopnea Rales/Crackles RAAS Stimulation Moist Cough Blood Tinged Frothy Sputum Wheezing/ Cardiac Asthma Dizziness PATHOPHYSIOLOGY Vasoconstriction and Reabsorption of Syncope OF Sodium and Water Fatigue RIGHT-SIDED CONGESTIVE HEART FAILURE Weakness Anorexia Hypokalemia CAUSES: Increased ECF Volume Clubbing of Fingers LSCHF Polycythemia Pulmonary Embolism S3S4 Heart Sounds or Pulsus Right Ventricular Infarction Alternans Congenital Septal Defects Increased Total Blood Volume Increased Systemic BP Reduced Myocardial Contractility Increased Cardiac Workload Decreased Diastolic Filling Obstruction of Right Atrial Emptying

Increased Right Atrial Pressure

Right-Sided Congestive Heart Failure

Blood drums back from the Signs Pressure in the Venous Increased and Symptoms of RV to RA RSCHF Circuit (Venous Back-up)

Signs and Symptoms of RSCHF: Neck Vein Engorgement (Jugular Vein Distention) Hepatomegaly Portal Hypertension leading to Cardiac Cirrhosis Ascites Peripheral Edema (Pitting/ Dependent) Splenomegaly Jaundice Hemolytic Anemia Internal Hemorrhoids Leg Varicosities Weight Gain S3S4 Heart Sounds Elevated CVP Reading

***The RSCHF which results from pulmonary disorders is called COR

PULMONALE.