Contrary to its name, congestive heart failure does not mean that the heart has actually "failed.

" It means that the heart is no longer able to meet the body's need for blood because it is pumping inefficiently. This inefficient pumping causes a backup of blood in the veins leading to the heart. Backup of blood in the veins, together with retention of fluid by the kidneys, causes the body's tissues to swell. The swelling (edema) most commonly affects the legs, but it can also occur in the lungs (causing breathing difficulty) and in other tissues and organs. Congestive heart failure is often the end stage of another form of heart disease. Its many causes include coronary heart disease; hypertension; heart valve disorders (including rheumatic heart disease); congenital heart disorders; cardiomyopathy (disease of the heart muscle); myocardial infarction (heart attack); cardiac arrhythmias (problems with the heart rate and/or rhythm), and toxic exposures, including excessive intake of alcohol. Hyperthyroidism, diabetes, and chronic lung disease are also risk factors for congestive heart failure. All of these disorders may lead to congestive heart failure by weakening the heart muscle and/or increasing the heart's workload.

Symptoms
The first symptom of congestive heart failure may simply be fatigue. As the condition progresses, there may be breathing difficulties during exertion, and eventually shortness of breath and wheezing at rest. As fluid accumulates in the lungs, patients with heart failure may begin to sleep propped up with pillows to make breathing easier. Fluid may also collect in the legs and ankles, causing edema. In patients who are less active, collected fluid may accumulate at mid-body level, eventually causing swelling of the lower back, together with an intestinal swelling that produces abdominal discomfort. In some patients, there may be a need to urinate several times during the night, as the kidneys drain off some of the excess fluids that accumulate in the lower body during the daytime. As the body accumulates more and more fluid, the patient may notice significant weight gain. There may also be a chronic cough due to fluid accumulation in the lungs. Although congestive heart failure usually affects both sides of the heart, in some patients it may affect only the left or right side. In these cases, symptoms vary according to the side affected. For example, when heart failure affects mainly the left side of the heart, the symptoms are more likely to involve breathing difficulties. When the right side is primarily affected, leg swelling and abdominal discomfort may be the most prominent symptoms.

Prevention
To avoid congestive heart failure you must prevent the various forms of heart disease that lead to it. For coronary heart disease, this means eating a low-fat diet, controlling hypertension, maintaining a normal body weight and a low cholesterol level, adopting a program of regular exercise and not smoking. Congestive heart failure due to hyperthyroidism can be prevented with medications or surgery. Unfortunately, some causes of congestive heart failure cannot be prevented.

Treatment
Initial treatment of congestive heart failure focuses on controlling acute symptoms. Bed rest is prescribed to elevate the legs and discourage fluid accumulation in the feet and ankles. Diuretics ("water pills") are administered to remove excess body fluid by increasing urine

output. Next, medications are prescribed to help the heart beat more efficiently. These medications may include one or more of the following: Digoxin to strengthen the heart's contractions > Angiotensin-converting enzyme (ACE) inhibitors to expand blood vessels, decrease the resistance to blood flow and help prevent water retention > Beta-blockers to improve blood flow
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Sometimes anticoagulants (blood thinners) are also administered to prevent blood clots, particularly if the patient requires a long period of bed rest. Also, a large study suggests that another medication known as Aldactone (spironolactone) may have significant benefits in selected patients with chronic congestive heart failure. Once acute symptoms have been treated, the underlying cause of congestive heart failure is addressed. Treatment ranges from lifestyle changes and medication for coronary heart disease to surgical procedures to correct heart defects. Self-treatment for congestive heart failure includes getting plenty of rest, moderate exercise under a doctor's guidance, a sodium-restricted diet to prevent edema, losing weight if appropriate and avoiding alcohol. When medications and self-treatment are no longer helpful, a heart transplant may be considered. This treatment option is currently limited by a shortage of donor hearts and is generally reserved for patients under age 65. An experimental procedure called cardiomyoplasty is being performed at some major medical centers. In this procedure, a muscle from the patient's back is wrapped around the heart, and a device is implanted that electrically stimulates the muscle to contract. Other research to improve the treatment of congestive heart failure includes a procedure to replace damaged heart cells with healthy ones, "combination" medications that perform several tasks at once, improved medications with fewer side effects than currently available drugs, improvements in heart transplantation and mechanical devices that help the failing heart to pump. 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 (CHF)

Heart Failure, also known asCongestive Heart Failure, is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricles ability to pump enough oxygenated blood to meet the bodys metabolic requirements. Compensatory mechanisms of increased heart rate, vasoconstriction, and hypertrophy eventually fail, leading to the characteristic syndrome of heart failure: Elevated ventricular or atrial pressures, sodium and water retention, decreased cardiac output, and circulatory and pulmonary congestion. Systolic dysfunction occurs when the left ventricle is unable to relax and fill sufficiently to accommodate enough oxygenated blood returning from the pulmonary circuit. Systolic dysfunction leads to increased vascular resistance and increased afterload. Diastolic dysfunction leads to pulmonary vascular congestion. Right ventricular failureoccurs when the right ventricle is unable to pump blood into the pulmonary circulation. Less blood is oxygenated and pressure increases in the right atrium and systemic venous circulation, which results in edema of the extremities. Left ventricular failureoccurs when the left ventricle in unable to pump blood into systemic circulation. Pressure increases in the left atrium and pulmonary veins; then the lungs become congested with blood, causing elevated pulmonary pressure and pulmonary edema. To compensate, the cardiac muscle hypertrophies eventually resulting in decreased ventricular compliance. Decreased compliance requires higher filling pressure to produce the same stroke volume. Increased muscle mass impedes oxygenation of the heart muscle, which leads to decreased contraction force and heart failure. As cardiac output fails, stretch receptors and baroreceptors stimulate the sympathetic nervous system, releasing catecholamines that increase the force and rate of myocardial contraction. This causes increased systemic resistance, increased venous return, and reduced blood flow to the limbs, viscera and kidneys. Sweating results from sympathetic cholinergic fibers, there is extra work for the heart muscle, and there is less systemic blood flow. The renal system responds by releasing renin-angiotensin, which sets off a chain of events vasoconstriction, leading to increased aldosterone release, causing sodium and water retention and, in turn, increasing preload. Finally, sodium and water retention becomes excessive, resulting in signs of systemic venous congestion and fluid overload.

Congestive Heart Failure A. Description

1. Congestive Heart Failure or CHF is a severe circulatory congestion due to decreased myocardial contractility, which results in the hearts inability to pump sufficient blood to meet the bodys needs. 2. About 80% of CHF cases occur before 1 year of age
B. Etiology

1. The primary cause of CHF in the first 3 years of life is CHD. 2. Other causes in children include: a. Other myocardial disorders, such as cardiomyopathies, arrhythmias, and hypertension b. Pulmonary embolism or chronic lung disease c. Severe hemorrhage or anemia d. Adverse effects of anesthesia or surgery e. Adverse effects of transfusions or infusions f. Increased body demands resulting from conditions such as fever, infection and arteriovenous fistula g. Adverse effects of drugs, such as doxorubicin h. Severe physical or emotional stress i. Excessive sodium intake 3. In general, causes can be classified according to the following: a. Volume overload may cause the right ventricle to hypertrophy to compensate for added volume. b. Pressure overload usually results from an obstructive lesion, such as COA c. Decrease contractility can result from problems such as sever anemia, asphyxia, heart block and acidemia. d. High cardiac output demands occur when the bodys need for oxygen exceeds the hearts output s seen in sepsis and hyperthyroidism.
C. Pathophysiology D. Assessment Findings

1. Clinical manifestations a. It is clinically difficult to differentiate right from left ventricular failure. Failure of one chamber causes reciprocal changes in the opposite chamber. b. Weakness and fatigue c. Poor feeding, resulting in weight loss d. Developmental delays e. Irritability f. Pallor and Cyanosis g. Dyspnea, tachypnea, orthopnea, wheezing, cough, weak cry, grunting, mild cyanosis and coastal retractions h. Tachycardia and gallop rhythm i. Hepatomegaly j. Weight gain from edema, ascites and pleural effusion k. Distended neck and peripheral veins. l. Sweating 2. Laboratory and diagnostic study findings

a. Chest radiography reveals cardiomegaly and pulmonary congestion b. CBC reveals dilution hyponatremia, hypochloremia, and hyperkalemia c. ECG reveals ventricular hypertrophy
E. Nursing Management

1. Monitor for signs of respiratory distress a. Provide pulmonary hygiene as needed b. Administer oxygen as prescribed c. Keep the head of the bed elevated d. Monitor ABG values. 2. Monitor for signs of altered cardiac output, including a. Pulmonary edema b. Arrhythmias, including extreme tachycardia and bradycardia c. Characteristic ECG and heart sound changes 3. Evaluate fluid status a. Maintain strict fluid intake and output measurements b. Monitor daily weights c. Assess for edema and severe diaphoresis d. Monitor electrolyte values and hematocrit level e. Maintain strict fluid restrictions as prescribed 4. Administer prescribed medications which may include: a. Antiarrhythmias to increase cardiac performance b. Diuretics, to reduce venous and systemic congestion c. Iron and folic acid supplements to improve nutritional status. 5. Prevent Infection 6. Reduce cardiac demands a. Keep the child warm b. Schedule nursing interventions to allow for rest c. Do not allow an infant to feed for more than 45 minutes at a time d. Provide gavage feedings if the infant becomes fatigued before ingesting an adequate amount 7. Promote adequate nutrition. Maintain a high-calorie, low-sodium as prescribed. 8. Promote optimal growth and development 9. As appropriate, refer the family to a community health nurse for follow up care after discharge.