SEMINAR

ON

CONGESTIVE CARDIAC
FAILURE
SUBMITTED

TO

Mrs. DEEPA SATARDEKAR

ASSOCIATE PROFESSOR

L.T. COLLEGE OF NURSING

SUBMITTED

BY

SONALI VASANT UMARE

1ST YEAR M.SC. NURSING

L.T. COLLEGE OF NURSING

SUBJECT : CLINICAL SPECIALITY I A

TOPIC : CONGESTIVE CARDIAC FAILURE

DATE AND TIME

OF SEMINAR : 17TH DECEMBER 2022

VENUE : VIRTUAL ( ZOOM )

METHOD OF TEACHING : LECTURE CUM DISCUSSION

A.V. AIDS : PPT

POSTER

FLASH CARDS

FLIP CHART

SUBMITTED ON : 19th DECEMBER 2022

 CONGESTIVE HEART FAILURE

AIMS : At the end of the seminar group will be able to understand CONGESTIVE
HEART FAILURE thoroughly & can provide comprehensive care to the CCF patients.

GENERAL OBJECTIVES :

At the end of the seminar, the student will be able to gain knowledge regarding
congestive cardiac failure, develop a positive attitude towards it and apply the
knowledge in teaching and clinical nursing practice.

SPECIFIC OBJECTIVES :
At the end of the seminar , the group will be able to
1. Review about anatomy & physiology of circulatory system.
2. Define the congestive heart failure.
3. Describe the four stages of congestive cardiac failure
4. Review the risk factors associated with congestive heart failure.
5. Enumerate the causes of congestive heart failure.
6. Describe the pathophysiology of congestive heart failure.
7. Distinguish the difference between classification of congestive heart failure.
8. Identify the clinical manifestation of congestive heart failure.
9. Understanding the diagnostic approach of congestive heart failure.
10. Identify physical examination of patient with congestive heart failure.
11. Identify & explain the assessment of severity of congestive heart failure.
12. Explain the medical management of congestive heart failure.
13. Explain the surgical management of congestive heart failure.
14. Discuss the nursing management of patients with congestive heart failure.
15. Design health education for congestive heart failure patients.
16. Design strategies for prevention of congestive heart failure.
17. Analyse the complications of congestive heart failure.
18. Discuss the prognosis of congestive heart failure.
 I. INTRODUCTION
“Congestive heart failure can be defined as a physiologic state in which the heart is unable to
pump enough blood to meet the metabolic needs of the body ( determined as oxygen
consumption ) at rest or during exercise , even through filling pressures are adequate”.
Heart failure is not a disease itself ; instead the term denotes the group of
manifestations related to inadequate pump performance. Whatever the cause, pump failure
results in hypoperfused tissue followed by pulmonary & systemic venous congestion.
Because heart failure causes vascular congestion , it is often called as congestive
heart failure.
Other terms used to denote heart failure include cardiac decompression, cardiac
insufficiency , & ventricular failure.

II. INCIDENCE
The incidence of those developing the condition is around 400,000. Annually 37,371 clients
die from CHF.

III. ANATOMY AND PHYSIOLOGY

 IV. STAGES OF CONGESTIVE HEART FAILURE

1. NEW YORK HEART ASSOCIATION ( NYHA )

It is a measure of how much the symptoms of heart failure limit the activities of patients. EF
is used to define left ventricular function, EF is poorly corelated with the patients functional
capacity or prognosis.

CLASS No limitation of physical activity. Ordinary physical activity

I does not cause undue fatigue or dyspnoea.

CLASS Slight limitation of physical activity. Comfortable at rest,

II but ordinary physical activity results in fatigue or dyspnoea.

CLASS Marked limitation of physical activity without symptoms.

III
Symptoms are present even at rest. If any physical activity is undertaken,
symptoms are increased.

CLASS unable to carry on any physical activity without symptoms.

IV
Symptoms are present even at rest. If any physical activity is undertaken,
symptoms are increased.

2. KILLIP CLASSIFICATION
 3. AMERICAN COLLEGE OF CARDIOLOGY (ACC) / AMERICAN HEART
ASSOCIATION (AHA) GUIDELINES

Stage Definition of Stage Usual Treatments

Stage • People at high • Exercise regularly, Quit smoking.

A risk of • Treat high blood pressure.
developing heart • Treat lipid disorders.
failure (pre-heart • Discontinue alcohol or illegal drug use.
failure), • An angiotensin converting enzyme inhibitor (ACE inhibitor) or
including people an angiotensin II receptor blocker (ARB) is prescribed if you
with:High blood have coronary artery disease, diabetes, high blood pressure, or
pressure other vascular or cardiac conditions.
• Diabetes • Beta blockers may be prescribed if you have high blood
• Coronary artery pressure or if you've had a previous heart attack.
disease
• Metabolic
syndrome
• History of
cardiotoxic drug
therapy
• History of
alcohol abuse
• History of
rheumatic fever
• Family history of
cardiomyopathy
Stage
People diagnosed with • Treatment methods above for Stage A apply
B
systolic left ventricular • All patients should take an angiotensin converting enzyme
dysfunction but who inhibitor (ACE inhibitors) or angiotensin II receptor blocker
have never had (ARB)
symptoms of heart • Beta-blockers should be prescribed for patients after a heart
failure (pre-heart attack
failure), including people • Surgery options for coronary artery repair and valve repair or
with: replacement (as appropriate) should be discussed
If appropriate, surgery options should be discussed for patients who
• Prior heart attack
have had a heart attack.
• Valve disease
• Cardiomyopathy
The diagnosis is usually
made when an ejection
fraction of less than 40%
is found during an
echocardiogram test.
Stage Patients with known • Treatment methods above for Stage A apply
systolic heart failure and
C • All patients should take an angiotensin converting enzyme
current or prior
inhibitor (ACE inhibitors) and beta-blockers
symptoms. Most
common symptoms • African-American patients may be prescribed a
include: hydralazine/nitrate combination if symptoms persist
• Shortness of • Diuretics (water pills) and digoxin may be prescribed if
breath symptoms persist
• Fatigue
• Reduced ability • An aldosterone inhibitor may be prescribed when symptoms
to exercise remain severe with other therapies
• Restrict dietary sodium (salt)
• Monitor weight
• Restrict fluids (as appropriate)
• Drugs that worsen the condition should be discontinued
• As appropriate, cardiac resynchronization therapy
(biventricular pacemaker) may be recommended
• An implantable cardiac defibrillator (ICD) may be
recommended

Stage Patients with systolic • Treatment methods for Stages A, B & C apply
D heart failure and • Patient should be evaluated to determine if the following
presence of advanced treatments are available options: heart transplant, ventricular
symptoms after assist devices, surgery options, research therapies, continuous
receiving optimum infusion of intravenous inotropic drugs and end-of-life
medical care. (palliative or hospice) care
 V. RISK FACTORS OF CONGESTIVE CARDIAC FAILURE

1. Physical or emotional stress

2. Dysrrhythmias
3. Infection
4. Anemia
5. Thyroid disorders
6. Pregnancy
7. PAGETS disease
8. Nutritional deficiency
9. Pulmonary disease
10. Hypovolemia
11. Myocardial infarction
12. Restrictive pericarditis and cardiac temponade

VI. CAUSES OF CONGESTIVE CARDIAC FAILURE

IMPAIRED CARDIAC FUNCTION EXCESSIVE WORK DEMANDS

MYOCARDIAL DISEASE INCREASED PRESSURE WORK

•
Cardiomyopathies ▪ Systemic hypertension
• Myocarditis ▪ Pulmonary hypertension
• Coronary insufficiency ▪ Coarctation of aorta
• Myocardial infarction

VALVULAR HEART DISEASE INCREASED VOLUME WORK

• Stenotic valvular disease ▪ Arteriovenous shunt
• Regurgitant valvular disease ▪ Excessive administration of IV
fluids
CONGENITAL HEART DEFECTS INCREASED PERFUSION WORK
▪ Thyrotoxicosis
▪ Anaemia

CONSTRICTIVE PERICARDITIS
 VII. PATHOPHYSIOLOGY OF CONGESTIVE CARDIAC FAILURE
A. COMPENSATION
B. DECOMPENSATION

1. Tachycardia
2. Ventricular dilation
3.Myocardial
hypertrophy
Increased
water Decreased
absorption cardiac output

Increased
Decreased
antidiuretic
renal perfusion
hormone

Increased Decreased
osmotic glomerular
pressure filtration
Increased
sodium
retention
 Decreased stroke volume

Reduced blood to kinney- Activation of

renin-angiotensin-aldosterone system
Na+ & water retention Increased sympathetic tone

Vasoconstriction Increased heart rate

Venous Arterial

Increased preload Increased afterload

Increased pulmonary congestion Increased cardiac workload

( cough, increased RR, dyspnoea,
frothy sputum ) Greatly decreased stroke volume

Peripheral edema Decreased tissue perfusion

( jugular venous distention, (confusion, angina,palpitations,
decreased urine output) fatigue, Hepatomegaly, edema )

VIII. CLASSIFICATION`
1. BACKWARD VERSUS FORWARD HEART FAILURE
Backward heart failure is said to be the result of damming up of blood in the vessels proximal
to the heart.
Forward heart failure , conversely is the result of the inability of the heart to maintain cardiac
output.
It should be emphasized that because the heart is part of a closed system, forward failure and
backward failure always are associated with each other
2. HIGH VERSUS LOW OUTPUT FAILURE :
High output failure occurs when the heart despite normal to high cardiac output levels, is
simply not able to meet the accelerated needs of the body.
Causes of high output failure include sepsis, Pagets disease, beriberi, anaemia, thyrotoxicosis,
arteriovenous fistula, pregnancy.
low output failure occurs in most forms of heart disease, including congenital, valvular,
rheumatic, coronary cardiomyopathic heart diseases.
Because the heart is unable to pump an adequate supply of blood to the body, low output failure
results in hypo-perfused tissue cells.
3. SYSTOLIC VERSUS DIASTOLIC HEART FAILURE :
Systolic heart failure refers to a decrease in the ability of the ventricle to contract forcefully &
maintain an adequate forward cardiac output. Situations in which the inotropic state is impaired
include MI, coronary atherosclerosis, dilated cardiomyopathy& massive pulmonary embolus.
Diastolic heart failure occurs when ventricular relaxation is incomplete & the chamber is
unable to accept sufficient blood.
Examples of heart diseases in which diastolic dysfunction may occur include coronary
atherosclerosis, amyloidosis, restrictive cardiomyopathy, or subendocardial fibrosis.

IX. CLINICAL MANIFESTATION

LEFT RIGHT
VENTRICULAR FAILURE VENTRICULAR FAILURE

❑ Weakness ❑ Weight gain

❑ Fatigue ❑ Jugular vein distention
❑ Mental confusion ❑ Neck vein pulsations
❑ Insomnia ❑ Increased central venous pressure
❑ Anorexia ❑ Parasternal life
❑ Anxiety ❑ Subcostal pain
❑ Diaphoresis ❑ Abdominal distention
❑ Breathlessness ❑ Anorexia, nausea, gastric distress
❑ Cough ❑ Ascites
❑ Pulmonary crackles ❑ Hepatomegaly
❑ Orthopnoea or paroxysmal ❑ Pitting edema ( in dependent areas
nocturnal dyspnoea ; sacral, ankle, pretibial )
❑ Ankle or pretibial swelling and
❑ Tachycardia, premature atrial
pigmentation
contractions
❑ Gallop heart sounds ( S3, S4 )
❑ Diminished S3
❑ Pulse alternans
❑ Elevated pulmonary artery wedge
pressure
❑ Enlarged point of maximal impulse
 X. DIAGNOSIS
1. COMPLETE To identify anaemia or infection.
BLOOD COUNT
Anaemia workup , To rule out hematochromatosis
2. IRON STUDIES

3. THYROID
FUNCTION TEST Hypothyroidism or hyperthyroidism

4. ELECTROLYTES Effects of diuresis , To rule Hyponatremia

5. BLOOD UREA
NITROGEN & Assess renal function
CREATININE Bilirubin ( low albumin makes peripheral edema )
6. LIVER
FUNCTION
TESTS
7. HIV
8. LIPID
To assess coronary artery disease & nutritional status.
9. BNP
❑ ECG Identification of atrial fibrillation & ventricular dysrhythmias,
ischemia, MI.
Provide information about both structure & function of heart &
❑ Echocardiography
used to measure EF.
❑ Radionuclide
A radionuclide ventriculogram or multigated acquisition
ventriculography
(MUGA) scan is a precise means of calculating EF using
radioactive isotope. It describes abnormal wall motion, dilation,
& wall thickness.
To identify pulmonary oedema , chronic congestion, infection,
❑ Chest
pneumonia, COPD or mass
radiography
The patient is exercised on a treadmill or exercise bicycle while a
❑ Exercise testing
12 lead ECG is obtained & BP is measured in response to
graded exercise.
❑ Pulse oximetry A low pulse oximetry reading in patients with heart failure & no
pulmonary oedema suggests pulmonary disease is complicating
heart failure.
❑ Cardiac
This invasive procedure helps determine whether coronary
catheterization
artery disease is a cause of heart failure.
❑ Stress test
Provide information about CAD.
 XI. MEDICAL MANAGEMENT

AGENT ACTION

ACE inhibitors : Block renin-angiotensin-aldosterone system,

decrease symptoms & mortality.
Lisinopril
Block conversion of angiotensin I to angiotensin II
Enalpril
for afterload reduction.
Captopril

HYDRALAZINE Pre vasodialator

Used to decrease afterload

NITRATES : Decrease preload

Isosorbide dinitrate Relieve angina
Isosorbide mononitrate Decrease orthopnoea

CARDIAC Oral inotrope

GLYCOSIDES :
Blocks neurohormonal bombardment of heart.
DIGOXIN

DIURETICS : Control fluid volume

Frusemide
Metolazone

SPIRONOLACTONE Blocks effects of aldosterone & protects potassium.

B – BLOCKERS: Improve symptoms

Metoprolol Increase exercise tolerance
Carvedilol Decrease hospitalization & mortality.
Bisoprolol
 XII. CUTE EXACERBATION OF CONGESTIVE CARDIAC
FAILURE

INODILATORS: Increase contractility

Dobutamine Decrease afterload & therefore increases cardiac
output
milinone
Increased forward flow
Decreases left ventricular end-diastolic pressure

DOPAMINE Increases renal perfusion & improves diuresis.

NITROPRUSSIDE Used for afterload reduction & BP control

CALCIUM CHANNEL Used as vasodilators & with minimal inotropic effects

BLOCKERS
2nd line generation : amlodepine

NESINITIDE Used for afterload reduction.

HYDRALAZINE Used for afterload reduction & BP control

XIII. SURGICAL MANAGEMENT

1. Implantable left ventricular assist device (LVAD):

The LVAD is known as the "bridge to transplantation" for patients who haven't
responded to other treatments and are hospitalized with severe systolic heart failure.
This device helps your heart pump blood throughout your body. It allows you to be
mobile, sometimes returning home to await a heart transplant. It may also be used as
destination therapy for long-term support in patients who are not eligible for
transplant.

2. Coronary artery bypass grafting surgery :

The most common surgery for heart failure caused by coronary artery disease
is bypass surgery. Although surgery is more risky for people with heart failure, new
strategies before, during, and after surgery have reduced the risks and improved
outcomes.
 3. Heart valve surgery:
Diseased heart valves can be treated both surgically (traditional heart valve surgery)
and non-surgically (balloon valvuloplasty).

4. Heart transplant :
A heart transplant is considered when heart failure is so severe that it doesn't respond
to all other therapies, but the person's health is otherwise good.

XIV. NURSING MANAGEMENT

CASE STUDY
Mrs. K , a 68 year old woman , has been admitted to the ICU with shortness of breath
at rest.
Vital signs are as follows:
BP – 218/100 mmHg , HR – 110/min. , RR – 38/min.
She has run out of her antihypertensive medication for the 4th time this yr & only came
to the hospital because of her breathing difficulties.
On examination, Mrs. K is pale , clammy sitting upright in a chair. She has bibasilar
crackles to her scapulae, and her heart rhythm is irregularly irregular. She has pitting
edema bilaterally to her thighs, jugular venous pulsation to the earlobe & hapatojugular
reflux. A chest radiograph shoes bilateral infiltrates. An echocardiogram shows a left
ventricular ejection fraction of 78% with estimated pulmonary artery pressures of 50 to
55 mmHg.

XV. PATIENT ASSESSMENT

i. HISTORY : History does not confirm diagnosis but helps to determine what follow-
up examination & diagnostic tests may be appropriate.
ii. ONSET : “ when did the symptoms start ?” answer will categorize into acute or
chronic.
iii. DURATION : symptoms to be checked for persistency & independent of activity or
come & go with activity.
iv. SEVERITY : The evaluation of severity requires that patients be asked certain
questions about their symptoms.
v. COMORBID DISEASES : comorbid conditions like CAD, HTN, DM, COPD
contributes in heart failure.
vi. MEDICATIONS : List should have both prescribed & non-prescription medications.
vii. PSYCHOSOCIAL FACTORS : Non cardiac factors may also affect patients with
heart failure. Financial hardships may force them to choose between medication &
buying food.
viii. SUBSTANCE ABUSE : alcohol contribute in development & progression of heart
failure.
 XVI. PHYSICAL EXAMINATION

Patients appears ill; often breathing rapidly looks anxious, & either sitting up straight
or leaning forward & resting their arms on a table or their knees.
Patients with stable, chronic heart failure may be quite , comfortable, but may have
evidence of cachexia, muscle wasting & thin skin.

❑ Vital signs
Systolic dysfunction – BP 218 /100 mmHg, HR – 110/min.

❑ Neck
Jugular venous pressure is an estimate of right heart filling pressures. When either the
total body fluid volume or right atrial pressure increases, the jugular venous pressure
increases & vein dilates.

❑ Lungs
Bibasilar crackles and wheezing

❑ Heart
Appearance of s3 sound ; all heart sounds may heard – called as summation gallop.
Heart murmur , mitral regurgitation murmur, holosystolic murmur at left sternal border
or in patients with very large hearts at , apex.

❑ Abdomen
Liver becomes reservoir for increased venous volume & results in hepatomegaly.
Ascitis

❑ Extremities
Bilateral, dependent & pitting oedema.
Leathery skin, discoloured
 NURSING CARE PLAN I
DATE DATABASE PROBLEM OBJECTIVE NURSING PRESCRIPTIONS

• Organize care to provide scheduled

Subjective Decreased Short – term
periods for rest & to minimize
data : cardiac output goal :
unnecessary disturbances.
related to
In history Maintain pulse
reduced stroke
patient said, she & respirations • Assess vital signs & heart rhythm
volume
had a history of within normal every 15 min. to 1 hr.
resulting in a
hospitalization limits.
compromised
due to • Monitor for dysrhythmia hourly.
state.
progressive
dyspnoea, • Monitor lung & heart sounds 2 to 4
triggered by hourly.
less than
ordinary Long – term • Monitor urine output hourly, noting
activities, lower goal : changes in colour and volume.
extremity
oedema & Identifies • Assess for changes in mental status 4
abdominal factors that hrly.
enlargement. increase
cardiac • Feed the client small meals & provide
workload rest periods after meals.

• Client may exhibit changes in problem

Objective data solving as an early indicator of
: cerebral hypoxia.
BP – 218/100
mmHg • Explain & encourage increases in
activity & ambulation to prevent a
HR – 110/min. sudden increase in cardiac workload.
RR – 38/min.
• Monitor respirations 4 hourly for
Cardiomegaly increased efforts, pulse for
& pulmonary tachycardia.
edema seen in
ECG • Monitor heart sounds 4 hourly for
presence of gallop rhythm.

• Teach patient to avoid Valsulva’s

maneouver.
 NURSING CARE PLAN II
DATE DATABASE PROBLEM OBJECTIVE NURSING PRESCRIPTIONS

• Assess vital signs every 2 – 4 hourly.

Subjective Impaired gas Short – term
data : exchange goal : • Monitor skin & mucous membrane color.
related to
Patient says , The client will
fluid • Auscultate breath sounds every 2 to 4
“ I am feeling have improved
accumulation hours, noting adventitious sounds, which
breathing gas exchange,
in alveoli. indicate congestion.
difficulty” as evidenced
by vital signs • Palpate for fremitus.
within normal
limits for • Encourage the client to turn, cough &
clients age & deep breath to clear the airway & to
Objective
condition. facilitate oxygen delivery.
data :
• Wheez • Fowlers position is maintained to
es Long – term facilitate diaphragmatic expansion &
upon goal : ventilation.
auscul
Skin & • Administer oxygen as ordered to improve
tation.
mucous tissue oxygenation & monitors arterial
• BP – blood gas results.
membranes
218/1
without
00 • ABG results may reveal severe hypoxia
cyanosis or
mmH or acidosis.
pallor,
g
decreased
• HR – • Pace activity & provide the rest periods to
dyspnoea &
110/m prevent fatigue.
ABG within
in.
normal limits. • If client develops respiratory failure, , he
• RR –
38/mi may require intubation & continuous
mechanical ventilation.
n.
• Pallor
 NURSING CARE PLAN III

DATE DATABASE PROBLEM OBJECTIVE NURSING PRESCRIPTIONS

• Monitor intake & output every

Subjective data : Fluid volume Short – term hourly.
excess goal :
Patient reports related to
weight gain , Client will • Monitor weight regularly using same
reduced
oedema in her feet, have normal scale at same time.
glomerular
lower legs. filtration , blood pressure.
• Monitor sodium & potassium levels .
Increased decreased
weakness & cardiac
• Weigh the client daily.
insomnia. output ,
increased Long – term • Monitor for the signs of increasing
antidiuretic
goal : peripheral oedema.
production &
sodium water Client will
Objective data : • Assess jugular neck vein distention ,
retention as demonstrate
peripheral oedema in the legs or
• BP – evidenced by absence of
sacrum, & hepatic engorgement.
218/100 increased oedema, stable
blood vital signs,
mmHg • Provide low sodium and high
pressure & decreasing
• HR – potassium diet.
110/min. oedema. weight, and
• – balanced input
RR • Fluid restrictions as per physicians
38/min. & output .
orders.
• Decreased
urine • Monitor infusion rate or parenteral
output fluids closely; administer via control
100ml. device or infusion pump.
• lethargic
• 2+oedema • Educate client & family members on
on legs. diet modification.

• Instruct client to elevate feet when

sitting down.
 NURSING CARE PLAN IV

DATE DATABASE PROBLEM OBJECTIVE NURSING PRESCRIPTIONS

• Assess vital signs regularly

Subjective Altered tissue Short – term
data : perfusion goal : • Establish rapport
related to
Patient said, decreased Improved tissue
perfusion . • Encourage movement & activity as
“ I am having blood flow to tolerated.
lower tissues and
extremities oedema.
• Assess neck vein distention, oedema
oedema. of extremities & coolness of skin 4
Long – term hourly.
goal :
Objective • Eliminate or reduce pressure points by
Exhibit Normal
data : changing position frequently, use of
vital signs.
pressure mattress.
BP – 218/100
Normal intake
mmHg
& output ratio • Give diuretics as prescribed.
HR – 110/min.
• Advise for sodium restricted diet.
RR – 38/min.
Pallor • Encourage for quite & restful
atmosphere.
Pale
conjunctiva • Discourage sitting/ standing for long
Lower periods.
extremities
oedema • Check for calf tenderness.

Low urine • Instruct to avoid sternous activities.

output
• Administer oxygen if ordered.
 NURSING CARE PLAN V

DATE DATABASE PROBLEM OBJECTIVE NURSING PRESCRIPTIONS

• Elevate head of bed as tolerated.

Subjective Activity Short – term
data : intolerance goal : • Encourage rest periods according to
related to
The patient imbalance Progresses to daily schedule & during the first hour
verbalized highest level of after meals.
between
reports of oxygen mobility
chest possible with • Assess patients response to activity
supply and
heaviness & demand. less fatigue & ( pulse, BP, repirations )
easy dyspnoea.
fatiguability. • Assess ability & tolerance to engage in
activities.

• Increase patients tolerance for activity

Long – term by having her perform activity more
Objective goal : slowly of for a shorter period of time
data : with more rest periods.
Identifies
Coughing factors that
• Explain the effects of increased oxygen
reduces his
Crackles demand with decreased oxygen supply.
activity
BP – 218/100 intolerance.
mmHg • Provide adequate rest & sleep periods
especially between activities.
HR – 110/min.
RR – 38/min. • Teach patient about cessation of
activities when feeling dizziness, chest
pain, palpitations occur.

OTHER NURSING DIAGNOSIS :

1. Risk for decreased peripheral tissue perfusion related to decreased cardiac output &
vasoconstriction.
2. Impaired skin integrity related to decreased tissue perfusion & immobility.
3. Risk for digitalis toxicity related to impaired drug excretion from hepatic & renal
involvement.
4. Risk for anxiety related to decreased cardiac output , hypoxia, fear of death or
consequences.
 HEALTH EDUCATION
1. Providing oxygenation :
O2 administration via nasal cannula at 2 to 6 lit/min.
Fowlers position

2. Promoting rest and activity:

High fowlers position during rest
Pillow placement at shoulder and back

3. Ambulation
Sitting up in a chair, & then walking increased distances under close supervision.

4. Decreasing anxiety :
Identify feelings & the content related to those feelings.

5. Facilitating fluid balance :

Intake and output records
Daily weighs on same scale

6. Providing skin care :

Inflatable mattress

7. Promoting nutrition :
Low-calorie, low-residue , vitamin rich bland diet

8. Diet :
Sodium restricted diet

9. Promoting elimination :
Avoid strain or constipation
High-fibre diet

10. Yoga :
Meditation
Regular yoga

11. Facilitating learning :

Prevention can be done by teaching patient & their family members

12. Providing sleep & rest :

13. Regular medication :
14. Regular follow up :
 PREVENTION
1. Treat your high blood pressure :
In heart failure, the release of hormones causes the blood vessels to constrict or tighten.
The heart must work hard to pump blood through the constricted vessels. It's important
to keep your blood pressure controlled so that your heart can pump more effectively
without extra stress.

2. Monitor your own symptoms :

Check for changes in your fluid status by weighing yourself daily and checking for
swelling. Call your doctor if you have unexplained weight gain (3 pounds in one day
or 5 pounds in one week) or if you have increased swelling.

3. Maintain fluid balance :

Your doctor may ask you to keep a record of the amount of fluids you drink or eat and
how often you go to the bathroom. Remember, the more fluid you carry in your blood
vessels, the harder your heart must work to pump excess fluid through your body.
Limiting your fluid intake to less than 2 liters per day will help decrease the workload
of your heart and prevent symptoms from coming back.

4. Limit how much salt you eat :

Sodium is found naturally in many foods we eat. It's also added for flavoring or to make
food last longer. If you follow a low-sodium diet, you should have less fluid retention,
less swelling, and breathe easier.
5. Monitor your weight and lose weight if needed : Learn what your "dry" or "ideal"
weight is. Dry weight is your weight without extra water (fluid). Your goal is to keep
your weight within 4 pounds of your dry weight. Weigh yourself at the same time each
day, preferably in the morning, in similar clothing, after urinating but before eating, and
on the same scale. Record your weight in a diary or calendar. If you gain three pounds
in one day or five pounds in one week, call your doctor. Your doctor may want to adjust
your medications.
6. Monitor your symptoms : Call your doctor if new symptoms appear or if your
symptoms get worse. Do not wait for your symptoms to become so severe that you
need emergency treatment.
7. Take your medications as prescribed : Medications are used to improve your
heart's ability to pump blood, decrease stress on your heart, decrease the progression
of heart failure, and prevent fluid retention. Many heart failure drugs are used to
decrease the release of harmful hormones. These drugs will cause your blood vessels
to dilate or relax (thereby lowering your blood pressure).
8. Schedule regular doctor appointments : During follow-up visits, your doctors
will make sure you are staying healthy and that your heart failure is not getting worse.
Your doctor will ask to review your weight record and list of medications. If you have
questions, write them down and bring them to your appointment. Call your doctor if
you have urgent questions. Notify all your doctors about your heart failure,
 medications, and any restrictions. Also, check with your heart doctor about any new
medications prescribed by another doctor. Keep good records and bring them with
you to each doctor visit.

What Medications Should I Avoid if I Have Heart Failure?

There are several different types of medications that are best avoided in those with
heart failure including:
• Nonsteroidal anti-inflammatory medications such as Motrin or Aleve. For relief of
aches, pains, or fever take Tylenol instead.
• Some antiarrhythmic agents
• Most calcium channel blockers (if you have systolic heart failure)
• Some nutritional supplements, such as salt substitutes, and
growth hormone therapies
• Antacids that contain sodium (salt)
• Decongestants such as Sudafed

COMPLICATIONS
1. Left ventricular failure : pulmonary congestion
pulmonary oedema
2. Right ventricular failure : abdominal organ & peripheral oedema

PROGNOSIS
It depends on :
1. The degree of cardiac hypertrophy
2. The amount of cardiac reserve
3. The presence of other heart or associated disorders

The prognosis can generally be predicted by the clients response to therapeutic

measures. A very slow or inadequate response to prescribed medications, special
diets, activity, limitations, & so forth signals a poor prognosis.
Nevertheless, thorough ongoing assessment, early interventions, therapeutic
compliance, and prevention of complications can control this disorder.
 RECAPITULATION

1. Which of the following statements best describes heart failure ?

a. It is episodic.
b. It is present even when symptoms are controlled
c. It is the result of poor eating habits & obesity
d. It is not preventable
ANS : b
2. Which of the following classes of drugs should be avoided in patients
with heart failure ?
a. B - blockers
b. diuretics
c. NSAID
d. Nitrates
ANS : c
3. Standard medications used in the treatment of heart failure may cause
dangerous increases in what electrolyte?
a. Potassium
b. Sodium
c. Chloride
d. Magnesium
ANS : b
4. Elevation in which biomarker is associated with heart failure
exacerbation in the patient who presents to the emg. Dept. with shortness
of breath?
a. Troponin I
b. Norepinephrine
c. BNP
d. Creatinine kinase
ANS : c
 ASSIGNMENT
I. Classify the stages of congestive cardiac failure
II. Plan the health education for a patient diagnosed with congestive cardiac
failure on discharge

BIBILOGRAPHY
❑ Luckmann’s core principles and practice of medical-surgical nursing , ARELENE L.
POLASKI, SUZANNE E. TATRO, Page NO. ( 696- 706 ).
❑ CRITICAL CARE NURSING, 4 Holistic Approach, 9th edition , Lippincott Williams
& Wilkins, Patricia Gonce Morton, Dorrie K. FONTAINE, Page NO. ( 438 – 465 ).
❑ Medical-surgical Nursing Across The Health Care Continuum, 3rd edition, Volume I,
DONNA D. IGNATAVICIOUS, M. LINDA WORKMAN, MARY A. MISHLER,
Page NO. ( 807 – 821 ).
❑ MEDICAL – SURGICAL NURSING , concepts & clinical practice, 5th edition,
NILMA J. PHILLIPS, VIRGINIA CASSMEYER, MARY KEH LEHMAN, Page
NO. ( 870 – 882 ).

RESEARCH
1. The effect on patient outcomes of a nursing care and follow-up program for
patients with heart failure: A randomized controlled trial
Background: Heart failure is associated with exacerbated symptoms such as dyspnea
and edema and results in frequent hospitalization and a poor quality of life. With the
adoption of a comprehensive nursing care and follow-up program, patients with heart
failure may exhibit improvements in their self-care capabilities and their
hospitalizations may be reduced.
Objective: The purpose of this study was to examine the effect of a nursing care and
follow-up program for patients with heart failure on self-care, quality of life, and
rehospitalization.
Design and setting: This research was conducted as a single-center, single-blind,
randomized controlled study at the heart failure outpatient clinic of a university
hospital in Turkey.
Participants: A total of 90 patients with heart failure were randomly assigned into
either the specialized nursing care group (n=45) or the control group (n=45).
Methods: The nursing care and follow-up program applied in the intervention group
was based on the Theory of Heart Failure Self-care. Data were collected at the
beginning of the trial, and at three and six months after the study commenced. Self-
care of the patients was assessed by the Self-Care of Heart Failure Index. Quality of
life was assessed with the "Left Ventricular Dysfunction Scale". Rehospitalization
was evaluated based on information provided by the patients or by hospital records.
Results: A statistically significant difference was found between the intervention and
control group with respect to the self-care and quality of life scores at both three and
six months. While the intervention group experienced fewer rehospitalizations at three
months, no significant differences were found at six months.
Conclusion: The results obtained in this study show that the nursing care and follow-
up program implemented for patients with heart failure improved self-care and quality
of life. Although there were no significant differences between the groups at six
months, fewer rehospitalizations in the intervention group was considered to be an
important result.
2. CONGESTIVE HEART FAILURE : IN ELDERLY
Objectives: The purpose of this study was to determine if fasting glucose levels are an
independent risk factor for congestive heart failure (CHF) in elderly individuals with
diabetes mellitus (DM) with or without coronary heart disease (CHD).
Background: Diabetes mellitus and CHF frequently coexist in the elderly. It is not
clear whether fasting glucose levels in the setting of DM are a risk factor for incident
CHF in the elderly.
Methods: A cohort of 829 diabetic participants, age > or =65 years, without prevalent
CHF, was followed for five to eight years. The Cox proportional hazards modeling was
used to determine the risk of CHF by fasting glucose levels. The cohort was categorized
by the presence or absence of prevalent CHD.
Results: For a 1 standard deviation (60.6 mg/dl) increase in fasting glucose, the
adjusted hazard ratios for incident CHF among participants without CHD at baseline,
with or without an incident myocardial infarction (MI) or CHD event on follow-up, was
1.41 (95% confidence interval 1.24 to 1.61; p < 0.0001). Among those with prevalent
CHD at baseline, with or without another incident MI or CHD event on follow-up, the
corresponding adjusted hazard ratio was 1.27 (95% confidence interval 1.02 to 1.58; p
< 0.05).
Conclusions: Among older adults with DM, elevated fasting glucose levels are a risk
factor for incident CHF. The relationship of fasting glucose to CHF differs somewhat
by the presence or absence of prevalent CHD.

3. Outcome of congestive heart failure in elderly persons : influence of left

ventricular systolic function
Background: Most persons with congestive heart failure are elderly, and many elderly
persons with congestive heart failure have normal left ventricular systolic function.
Objective: To evaluate the relationship between left ventricular systolic function and
outcome of congestive heart failure in elderly persons.
Design: Population-based longitudinal study of coronary heart disease and stroke.
Setting: Four U.S. sites: Forsyth County, North Carolina; Sacramento County,
California; Allegheny County, Pennsylvania; and Washington County, Maryland.
Participants: 5888 persons who were at least 65 years of age and were recruited from
the community.
Measurements: Total mortality and cardiovascular morbidity and mortality.
Results: Of 5532 participants, 269 (4.9%) had congestive heart failure. Among these,
left ventricular function was normal in 63%, borderline decreased in 15%, and overtly
impaired in 22%. The mortality rate was 25 deaths per 1000 person-years in the
reference group (no congestive heart failure and normal left ventricular function at
baseline); 154 deaths per 1000 person-years in participants with congestive heart failure
and impaired left ventricular systolic function; 87 and 115 deaths per 1000 person-years
in participants with congestive heart failure and normal or borderline systolic function,
respectively; and 89 deaths per 1000 person-years in persons with impaired left
ventricular function but no congestive heart failure. Although the risk for death from
congestive heart failure was lower in persons with normal systolic function than in those
with impaired function, more deaths were associated with normal systolic function
because more persons with heart failure fall into this category.
Conclusions: Community-dwelling elderly persons, especially those with impaired left
ventricular function, have a substantial risk for death from congestive heart failure.
However, more deaths occur from heart failure in persons with normal systolic function
because left ventricular function is more often normal than impaired in elderly persons
with heart failure.

RESEARCH 4
Objectives: To review the epidemiology, pathophysiology, and etiology of congestive
heart failure (CHF) in older adults
Methods: Published reports relevant to the epidemiology, pathophysiology, and
etiology of CHF were systematically reviewed. Studies involving older adults and more
recent studies were emphasized.
Results: More than 75% of patients with CHF in the United States are older than 65
years of age, and CHF is the leading cause of hospitalization in older adults. CHF is
also a major cause of chronic disability, and annual expenditures for CHF currently
exceed $10 billion. In addition, both the incidence and prevalence of CHF are
increasing, largely as a result of the aging of the population. Older adults are
predisposed to developing CHF as a result of age-related changes in the cardiovascular
system and the high prevalence of hypertension, coronary artery disease, and valvular
heart disease in this age group. Although the fundamental pathophysiology of CHF is
similar in younger and older patients, older individuals are more prone to develop CHF
in the setting of preserved left ventricular systolic function. This syndrome, referred to
as diastolic heart failure, accounts for up to 50% of all cases of CHF in adults more than
65 years of age. Coronary heart disease and hypertension are the most common
etiologies of CHF in older adults, and they often coexist. Valvular heart disease,
 especially aortic stenosis and mitral regurgitation, are also common in older adults,
whereas nonischemic dilated cardiomyopathy, hypertrophic cardiomyopathy, and
restrictive cardiomyopathy occur less frequently.
Conclusions: Congestive heart failure is a major public health problem in the
United States today as a result of its high and increasing prevalence in the older
population as well as its substantial impact on healthcare costs and quality of life.
There is an urgent need to develop more effective strategies for the prevention and
treatment of CHF in older individuals.

THEORY APPLICATION

Theory-guided interventions for adaptation to heart failure

Aim: This paper is a report of a study to examine the effects of a Roy Adaptation Model-
based experimental education, exercise and social support programme on adaptation in persons
with heart failure.
Background: In the past 20 years, a large number of studies have evaluated heart failure.
Several studies of other chronic diseases have been based on the Roy Adaptation Model and
show that this approach is useful in promoting adaptation for patients.
Method: A randomized, parallel, controlled clinical trial was conducted in 2005 with 43
patients (21 intervention and 22 control patients). A booklet for patient training was given to
those in the intervention group. Participants received a patient identification form, assessment
form for physiological data, the Minnesota Living with Heart Failure Questionnaire,
Interpersonal Support Evaluation List and the 6-Minute Walk Test.
Results: Patients in the intervention group adapted well to their condition and the four adaptive
modes of Roy Adaptation Model were interrelated. Patients' quality of life was enhanced, their
functional capacities increased and social support within the interdependence dimension
improved in patients in the intervention group.
Conclusion: This is the first study to use the Roy Adaptation Model in a study of patients
with heart failure. Roy's model is an effective guide for nursing practice when caring for
patients with heart failure.
 LATEST TRENDS

The Impella heart pump is the world’s smallest heart pump used to help maintain blood flow
during high-risk protected percutaneous coronary interventions (PCI).
What are PCIs?
PCIs are a variety of procedures used to open blocked coronary arteries through the use of
balloons and/or stents, caused by coronary artery disease. PCIs restore blood flow to your heart
muscle without open-heart surgery.
The doctor makes a small incision in your upper thigh and inserts a fine tube called a catheter
into your femoral artery.
The Impella device is then guided by the catheter and a wire into the left ventricle - the main
pumping chamber - of your heart.
The Impella pulls blood from the ventricle and pushes it out into the aorta, delivering oxygen-
rich blood to the rest of your body. This allows your heart to rest while the doctor performs the
PCI.
Once the PCI procedure is complete, the Impella is turned off and guided out. If your heart
requires support after the procedure, the heart pump is kept in the ventricle until your condition
is stable.