Chapter 34CongestiveHeartFailure

7/28/2019 Chapter 34CongestiveHeartFailure

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Congestive Heart Failure

(relates to Chapter 34, Nursing Management:

Heart Failure and Cardiomyopathy, in the

textbook)


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Definition

An abnormal condition involvingimpaired cardiac pumping

CHF is not a disease but a syndrome

Associated with long-standinghypertension and coronary artery disease

(CAD)


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Definition

Heart is unable to pump adequateamount of blood to meet metabolic needs

Affects about 5 million people in the

United States The most common reason for

hospitalization in adults older than 65


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Etiology and Pathophysiology

Risk factors CAD

Age

Hypertension Obesity


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Risk factors Cigarette smoking

Diabetes mellitus

High cholesterol African American descent


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May be caused by any interference withnormal mechanisms regulating cardiac

output (CO)


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CO depends on:

Preload

Afterload

Myocardial contractility

Heart rate

Metabolic state


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Pathology of ventricular failure

Systolic failure

Most common cause of CHF

Left ventricle (LV) loses ability to

generate enough pressure to ejectblood forward


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Systolic failure

Hallmark is a in LV ejectionfraction


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Diastolic failure Impaired ability of the ventricles to

fill during diastole

Usually the result of LV hypertrophy


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Diastolic failure Pulmonary congestion

Normal ejection fraction


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Mixed systolic and diastolic failure Seen in dilated cardiomyopathy

Biventricular fai lure

Patient has extremely poor ejection

fractions


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Compensatory mechanisms

Ventricular dilation

Ventricular hypertrophy

Increased SNS stimulation

Neurohormonal responses


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Types of Congestive Heart Failure

One-sided failure eventually leads tobiventricular failure


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Left-sided failure

Most common form

Blood backs up through the left atrium

into the pulmonary veins

Pulmonary congestion and edema


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Left-sided failure

Most common cause: HTN

Cardiomyopathy

Rheumatic heart disease

CAD


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Left-Sided Heart Failure

Fig. 34-1


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Right-sided failure

Backward flow to the right atrium andvenous circulation

Results from diseased right ventricle


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Right-sided failure

Venous congestion Peripheral edema

Hepatomegaly

Splenomegaly

Jugular venous distension


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Right-sided failure

Primary cause is left-sided failureCor pulmonale

RV dilation and hypertrophy caused

by pulmonary pathology


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AcuteCongestive Heart Failure

Clinical Manifestations Pulmonary edema

Agitation

Pale or cyanotic

Cold, clammy skin

Severe dyspnea Tachypnea


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Pulmonary Edema

Fig. 34-2


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ChronicCongestive Heart Failure

Clinical Manifestations Fatigue

Dyspnea

Paroxysmal nocturnal dyspnea (PND)

Tachycardia

Edema

Nocturia


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ChronicCongestive Heart Failure

Clinical Manifestations Behavioral changes

Restlessness, confusion, attention span Chest pain

Weight changes

Skin changes Dusky appearance


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Complications

Pleural effusion

Arrhythmias Left ventricular thrombus

Hepatomegaly


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Classification

Based on the persons tolerance to physical

activity Class 1: No limitation of physical activity

Class 2: Slight limitation


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Classification

Based on the persons tolerance to physical

activity Class 3: Marked limitation

Class 4: Inability to carry on any physical

activity without discomfort


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Diagnostic Studies

Primary goal is to determine underlying

cause Physical exam

Chest x-ray

ECG

Hemodynamic assessment


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Congestive Heart FailureDiagnostic Studies

Primary goal is to determine underlying

cause Echocardiogram

Stress testing

Cardiac catheterization

Ejection fraction (EF)


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Acute Congestive Heart FailureNursing and Collaborative

Management

Primary goal is to improve LV function by:

Decreasing intravascular volume Decreasing venous return

Decreasing afterload


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Management

Primary goal is to improve LV function by:

Improving gas exchange and oxygenation Improving cardiac function

Reducing anxiety


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Management

Decreasing intravascular volume

Improves LV function by reducingvenous return

Loop diuretic: drug of choice


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Management

Decreasing venous return (preload)

Reduces the amount of volume returnedto the LV during diastole

High Fowlers position


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Management

Decreasing afterload

Decreases pulmonary congestion IV nitroprusside (Nipride)

nesiritide (Natrecor)


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Management

Improving gas exchange and oxygenation

Decreases pulmonary congestion IV nitroprusside (Nipride)

nesiritide (Natrecor)


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Management

Improving cardiac function

Digitalis Newer inotropics

Dobutamine

Hemodynamic monitoring


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Management

Reducing anxiety

Morphine IV inotropic drugs

Vasodilators

ACE inhibitors


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Chronic Congestive Heart Failure

Collaborative Care

Treat underlying cause

Maximize CO

Alleviate symptoms


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Collaborative Care

Oxygen treatment

Rest

Biventricular pacing

Cardiac transplantation


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Drug Therapy

ACE inhibitors

Diuretics Inotropic drugs

Vasodilators

-Adrenergic blockers


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Nutritional Therapy Fluid restrictions not commonly prescribed

Sodium restriction

2 g sodium diet

Daily weights

Same time each day Wearing same type of clothing


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Chronic Congestive Heart FailureNursing Management

Nursing Assessment

Past health history

Medications

Functional health problems

Cold, diaphoretic skin


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Nursing Assessment

Tachypnea

Tachycardia Crackles

Abdominal distension

Restlessness


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Nursing Diagnoses

Activity intolerance

Excess fluid volume

Disturbed sleep pattern

Impaired gas exchange

Anxiety


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Planning

Overall goals:

Peripheral edema Shortness of breath Exercise tolerance Drug compliance

No complications


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Nursing Implementation

Acute intervention

Establishment of quality of life goals

Symptom management

Conservation of physical/emotional energy

Support systems


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Ambulatory and home care

Teaching

Psychologic changes

Exercise-saving behaviors

Medications


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Evaluation

Respiratory status

Sleep

Fluid balance

C i C i i


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Evaluation

Activity tolerance

Anxiety control

Knowledge: disease process

Chapter 34CongestiveHeartFailure

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