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CONGESTIVE HEART FAILURE

Learning Objective
Define Congestive Cardiac Failure (CCF)
Explain the pathophysiology of CCF
List the etiology of CCF
List the clinical manifestation of CCF
List the investigation done for CCF
List the medication for CCF
Identify nursing problem
Plan nursing care for the nursing problem

Congestive Cardiac Failure

Definition:
Inability of the heart to pump enough blood to meet the metabolic demands of the body
It is a progressive chronic condition and can be one sided or both sided failure

Etiology

Coronary artery disease

Myocardial infarction
Cardiomyopathy
Cardiac valve malfunction
Congenital heart disease
Hypertension
Anemia
Hyperthyroidism increase the metabolic rate
Inflammatory disease of the heart (Endacarditis, Mycarditis, Pericarditis)

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CCF Pathophysiology

As hearts pumping power is weaker than normal, blood moves through the heart and
body at a slower rate, and pressure in the heart increase

The chambers of the heart respond by stretching to hold more blood to pump through the
body. In time, the heart muscle walls weaken and are unable to pump as strongly

As a result, the kidneys often respond by causing the body to retain fluid (water) and
sodium thus the body becomes congested
Left Sided Heart Failure (LVF)
When Left ventricle muscle is damaged it fails to contract/pump with sufficient
force
When ventricle fails to circulate blood, the blood will back up in the lung
Increase pressure in the pulmonary circulation
Fluid moves into pulmonary tissue and alveoli

Right Sided Heart Failure (RVF)

When Right Ventricular fails, it cannot accept all the blood returning to the heart
The blood backs up to the tissue, causing congestion of viscera and peripheral tissue

Edema of leg, ankles, liver, abdominal cavity

Clinical manifestation
LEFT VENTRICULAR FAILURE
o Dyspnea (breathing difficulty)
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o Orthopnea difficulty in breathing at rest or when lying flat in bed (supine

position causes the fluid to back up in the lung)
o Cough or whezzing
o Frothy pink sputum
o Crackles can be heart in the lungs
o Paroxysmal Nocturnal Dyspnea waking up at night short of breath.
When patient lies down, there is an increase in venous return from extremities, causes congestion
of the heart, leading to pulmonary edema

Clinical Manifestations LVF

Cerebral hypoxia result of decreased cardiac output causes:
Anxiety
Irritability
Restlessness
Wheezing
Dizziness
Syncope
Fatigue
Weakness
Anorexia
Hypokalemia
Increase level of aldosterone
Clubbing of the fingers
Polycythemia
S3, S4 heart sound, Pulsus Alterans
Increase pulmonary arterial pressure, pulmonary capillary wall pressure
Confusion
Impaired memory
Insomnia (difficult to sleep)
Nocturia pass urine at night
Oliguria (less urine output 500 mls) late manifestation

Clinical Manifestations
RT VENTRICULAR FAILURE
Ankle edema to the legs, sacrum and scrotum
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Patient with severe peripheral edema may develop

Serous exudates and bulae (bulla)
Hepatomegaly liver congestion
Ascites due to liver congestion
Neck vein engorgement
Portal hypertension
Splenomegaly (enlarge of the spleen)
Jaundice yellowish color
Hemolytic anemia
Internal hemorrhoids
Leg varicosities
Weight gain
S3 and S4 heart sound
Elevated CVP (Centre Venous Pressure)reading

Investigations
Serum electrolytes, urea, and nitrogen
Liver function test
Arterial blood gases to evaluate gas exchange
Kidney function test
Chest X-Ray may show pulmonary vascular congestion, cardiomegaly
ECG ventricular enlargement
Echocardiography to evaluate left ventricular function
Pulse oximeter reading may be less than 95% indicating decrease oxygen saturation
Elevated PAP PCWP (LSF); elevated CVP (RSF)

Medications
To reduce cardiac work and improve cardiac function
Diuretics
Beta blockers (vasodilatation)
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Digitalis Digoxin
Inotropes Dopamine, Dobutamine
Angiotensin converting enzyme (ACE) inhibitors
Surgical Management

Heart Transplantation
Cardiomyoplasty

Nursing management
o Assessment of patient general condition and vital sign
o Spo2 monitoring
o O2 Support - to relieve hypoxia and dyspnea
o Position client - high fowler or chair to reduce pulmonary venous congestion
o Position of leg dependant
o Limit sodium and H2O intake for severe CCF, limit H2O to 1L/day
o RIB (Rest In Bed)/CRIB (Complete Rest In Bed)

Nursing Diagnosis
Decreased cardiac output
Impaired gas exchange
Altered fluid and electrolyte balance related to fluid volume excess
Altered nutrition: less than body requirements
Risk for impaired tissue integrity
Activity intolerance
Sleep pattern disturbance
Fear /Anxiety

Breathlessness related to impaired pulmonary gas exchanged

Assess and record respiratory pattern include rate depth and rhythm.
Observe color of patient lips and nails
Reassure patient during distress episodes
Put patient in upright position supported with by pillow encourage lung expansion
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Promote rest reduces oxygen demand

Administer Oxygen Therapy
Give medication as prescribed to reduce pulmonary oedema Diuretics
Strict intake and output chart
Decreased Cardiac Output
Assess patient for sign of decrease cardiac output e.g. confusion, dizziness, irritability
Vital sign - Blood Pressure, Pulse Rate, Spo2 monitoring
ECG monitoring monitor sign of dysrhythmias
Monitor lung sound sign of crackles and coughing
Monitor intake and output detect sign of reduced renal perfusion
Medication as prescribed to increase myocardial contractility e.g. Dopamine, Digoxin
Promote rest to reduce myocardial workload and oxygen demand
Self Care deficit related to fatigue / shortness of breath
Assess and record patients level of tolerance to activities of daily living
Encourage patient to verbalize activities that increase fatigue or shortness of breath
Provide rest period between and during activities
Keep frequently used items within reach of patient
Give encouragement and promotes independence in activities within patients limit
Assist patient in activities of daily living

Impaired Skin Integrity related to physical immobility

Assess and record skin integrity
Lift correctly to avoid dragging on the patients skin
Use pressure relieving mattress as necessary
Encourage patient to move position frequently
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If she/he is unable to do so, assist patient in changing position every 4 hourly and gently
massage pressure area to promote blood circulation
Ensure bedclothes are smooth and free from crumbs
Change pampers or bed sheet when soiled
Keep skin clean and dry at all time

Inadequate nutritional intake related to loss of appetite

Assess nutritional status
Record all intake and output chart strictly
Observe and record for nausea and vomiting
Note vomitus for frequency, amount and color
Refer to dietitian
Advise on dietary supplements
Avoid process and canned food
Offer small and frequent diet
Plan meals with patient with meals as needed
Ensure pleasant environment

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