CONGESTIVE CARDIAC FAILURE

Rajesh Kumar Sharma

Asst professor
Himalayan College of Nursing
Swami Rama Himalayan University, Dehradun



CONGESTIVE CARDIAC FAILURE

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.
CONGESTIVE CARDIAC FAILURE Contd.
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.




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 6
th
leading cause of mortality in the
Philippines, affecting males more often than females.

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.
TYPES OF CONGESTIVE HEART FAILURE
Right-side heart failure occurs if the heart
can't pump enough blood to the lungs for
gas exchange.
Left-side heart failure occurs if the heart
can't 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.

TYPES OF CONGESTIVE HEART FAILURE
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.

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
hemochromatosis (iron overload) can cause
stiffening of the heart muscle and impair the
ventricles' capacity to relax and fill

CAUSES Contd
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 diseases
Infections, commonly viruses
CAUSES Contd
Other less common causes of heart failure,
- Variety of infections,
- Exposures to radiation or chemotherapy,
- Endocrine disorders
- Complications of other diseases, toxic effects,
and genetic predisposition.
Some time idiopathic, or unknown.
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)
PATHOPHYSIOLOGY OF CCF
PATHOPHYSIOLOGY.docx
SIGN & SYMPTOMS
It is a clinical syndrome characterized by
manifestations of volume overload,
inadequate tissue perfusion, and poor
exercise tolerance.
The most common signs and symptoms of
heart failure are:
Shortness of breath or trouble breathing
Fatigue (tiredness)
Swelling in the ankles, feet, legs,
abdomen, and veins in the neck

Causes
Jugular
venous
distension

External
jugular vein
marked by
an arrow.
DIAGNOSIS
Proper patient history (All)
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).

DIAGNOSIS
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.

DIAGNOSIS Contd
Blood tests: Low blood cell counts (anemia)
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.

DIAGNOSIS Contd
Echocardiography:
Echo also can identify size and shape of the
heart, areas of poor blood flow to the heart,
areas of heart muscle that aren't 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
NURSING 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 condition's 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.
MEDICAL MANAGEMENT Contd
1. 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.


MEDICAL MANAGEMENT Contd
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).
MEDICAL MANAGEMENT Contd
Potassium is found in foods like white potatoes
and sweet potatoes, greens (such as spinach),
bananas, many dried fruits, and white beans and
soybeans.
It's important to drink the correct amounts and
types of fluid. Drinking too much fluid can
worsen heart failure.
Patient shouldn't drink alcohol.
MEDICAL MANAGEMENT Contd
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're 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.

MEDICAL MANAGEMENT Contd
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.
MEDICAL MANAGEMENT Contd
Commonly used vasodilators:
Nitroprusside (Nipride)
Hydralazine (Apresoline)
Nifedipine
Captopril (Capoten)
Beta blockers: slow heart rate and lower blood
pressure to decrease heart's workload.
Digitalis therapy(Digoxin): Has positive inotropic
(strengthens force of cardiac contractility) and
negative chronotropic effects (decreases heart
rate).
MEDICAL MANAGEMENT Contd
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
Watch for signs e.g. weight gain
Getting medical care for other related conditions
like diabetes or high blood pressure. Check blood
sugar level and blood pressure regularly.
Try to avoid respiratory infections like the flu
and pneumonia. Get flu and pneumonia vaccines.
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, then following procedure need to
done - 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 heart's 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.
NURSING MANAGEMENT
Nursing Assessment:
Monitor vital signs/oxygenation/Neuro status
(report changes in heart and respiratory
rate/patterns as well as changes in LOC).
Daily weight (a 2.2 kg weight increase over a 1
day period is considered significant).
Breath sounds (monitor for increased crackles,
rhonchi or pulmonary congestion).
The presence of jugular vein distention (jugular
vein distention can be a sign of worsening right
sided heart failure).

NURSING ASSESSMENT Contd
Capillary refill (if greater than 3 seconds, assess
for signs of peripheral edema).
The presence of hepatomegaly (also a sign of
worsening right sided heart failure).
The presence of ascites (also a sign of worsening
right sided heart failure).
ECG changes
Evaluate electrolyte levels (sodium, potassium
and creatinine)
Digoxin levels (if patient taking Digoxin)
Pain level (degree, quality, source, location, onset
and relieving factors)

NURSING ASSESSMENT Contd
Intake and Output (monitor effects of diuretic
therapy and observe for signs and symptoms of
either fluid overload or deficit)
Assess degree of discomfort associated with
activity (provide a proper rest/activity balance.
Group nursing interventions when appropriate).
Monitor for restless, anxious behavior and
promote self care participation.
Maintain adequate bowel function (stool
softeners should be ordered to prevent
constipation).

NURSING DIAGNOSIS
1. Decreased cardiac output r/t ventricular
damage, ischemia and restriction secondary to
fluid overload.
2. Impaired gas exchange r/t increased
pulmonary interstitial fluid accumulation.
3. Altered tissue perfusion r/t imbalance between
oxygen demand and supply.
4. Ineffective breathing pattern r/t imbalance
between oxygen demand and supply.
NURSING INTERVENTIONS
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. 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 INTERVENTIONS Contd
Promoting Rest and Activity contd
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 simple to
complex.
Assess for signs of activity intolerance (dyspnea,
fatigue and increased pulse rate that does not
stabilize readily).
NURSING INTERVENTIONS Contd
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.

NURSING INTERVENTIONS Contd
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

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)
NURSING INTERVENTIONS Contd
Promoting Nutrition
Provide bland, low-calorie, low-residue with vitamin
supplement during acute phase
Frequent small feedings minimize exertion and
reduce gastrointestinal 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.



NURSING INTERVENTIONS Contd
Facilitating Learning
Teach the client and his family about the
disorder and self-care
Monitor S/S 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
SFF rather than 3 large meals a day
Take prescribed medications at regular basis
Observe regular follow-up care as directed

NURSING INTERVENTIONS Contd
In acute pulmonary edema:
High-fowlers position
Morphine Sulfate 10-15mg/IV as ordered to allay
anxiety, reduce preload and afterlaod
O2 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.
RESEARCH ARTICLE ON HEART FAILURE
KUMJ | VOL. 4 | NO. 3 | ISSUE 15 | JULY-SEPT,
2006
Could garlic be an useful adjuvant therapy in
adriamycin heart failure?
Das RN, Poudel N

Abstract:
50 year old suffering from breast carcinoma, treated
with adriamycin developed heart failure with
22.82% ejection fraction.
Added garlic pearl to routine anti-failure measures
for 9 months achieved 51.6% ejection fraction

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.

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