CARDIAC HEART FAILURE (CHF)

Wan Nishfa Dewi, Ph.D

Kuliah Pakar Keperawatan Medikal Bedah – Sistem Kardiovaskuler
STIKES Pekanbaru Medical Centre
10 Februari 2021
 Brief About Me
•  Job Title
Associate Professor in Medical Nursing
Faculty of Nursing, Universitas Riau

•  EducaOon
•  D3 - Polytechnic RI Padang
•  S1 - Universitas Padjadjaran Bandung, Indonesia
•  S2 - Master of Nursing: Flinders University, Adelaide,
Australia.
•  S3 - Doctor of Philosophy: University of South Australia
(UniSA), Australia.
•  Employment history:
Vice Dean of Academic, Student and Alumni Affair, Faculty of
Nursing, Universitas Riau (Feb 2018-Dec 2020)
Learning Objectives
01 DEFINITION

02 PATHOPHYSIOLOGY

03 TYPES OF CHF

04 NURSING CARE MANAGEMENT

Review Of Heart Anatomy

05
04
03
02
1
Key Concepts
•  CO = SV x HR àbecomes insufficient to meet metabolic
needs of bod

•  SV- determined by preload, afterload and myocardial

contractility
•  Ejection Fraction (EF) < 40%

•  Classifications HF
•  Systolic failure- decrease. contractility
•  Diastolic failure- decrease. filling
•  Mixed
90/140= 64% EF- 55-65 (75) normal
 Results from any structural or functional
abnormality that impairs the ability of the
ventricle to eject blood (Systolic Heart
Failure) or to fill with blood (Diastolic
Heart Failure).

Definition
Congestive Heart Failure
Congestive Heart Failure

Impaired cardiac pumping

•  Ventricular dysfunction
 Heart remodeling

•  Reduced exercise tolerance

 Diminished quality of life
 Shortened life expectancy

Associated with CAD and HTN

The Vicious Cycle of Congestive Heart Failure

LV Dysfunction causes Decreased Blood Pressure and

Decreased cardiac output Decreased Renal perfusion

Stimulates the Release

of renin, Which allows
conversion of
Angiotensin
to Angiotensin II.
Angiotensin II stimulates
Aldosterone secretion which
causes retention of
Na+ and Water,
increasing filling pressure
 Congestive Heart Failure
Risk Factors
•  Diabetes Mellitus, cigarette smoking, obesity, high serum
cholesterol

•  Major contributing factor

• HYPERTENSION
 Congestive Heart Failure
Pathophysiology
•  Systolic Failure
•  Defect in ventricular contraction
•  Left Ventricle loses ability to generate enough pressure to eject blood forward
through the high pressure aorta – Decreased ejection fraction
•  Afterload – hypertension, cardiomyopathy, and valvular heart disease

•  Diastolic Failure
•  Impaired ability of ventricles to fill
•  Decreased filling = decreased stroke volume
•  Pulmonary congestion, pulmonary hypertension, with normal ejection
fraction
Cogestive Heart Failure
 Congestive Heart Failure
Pathophysiology
Mixed Systolic & Diastolic Failure

•  Poor ejection fraction

•  High pulmonary pressures

 Both ventricles have poor filling and emptying capacity

•  Acute MI; cardiomyopathy, poorly controlled Hypertension

 Common Causes

01 Chronic 02 Acute
CAD Acute MI
Hypertensive HD Dysrhythmias
Rheumatic Heart Dis Pulmonary emboli
Congenital Heart Dis Thyrotixicosis
Cor pulmonale Hypertensive crisis
Cardiomyopathy Rupture of papillary muscle
Anemia VSD
Bacterial endocarditis Myocarditis
Valvular disorders
 Congestive Heart Failure
Pathophysiology
•  Left Venticular Failure – Most Common

•  Left ventricular function

•  Blood backup – left atrium & pulmonary veins
•  Increased pulmonary pressure
•  Fluid extravasation from pulmonary capillary bed to interstitium &
alveoli
•  Results: Pulmonary Congestion - Pulmonary Edema
 Congestive Heart Failure
Clinical Picture
Left Sided Heart Failure

Decreased Cardiac Output

•  Fatigue, weakness, oliguria during the day, angina, confusion, restlessness,
dizziness, tachycardia, palpitations, pallor, weak peripheral pulses, cool extremities
 Pulmonary Congestion
•  Hacking cough, worse at night, dyspnea, rales, expiratory wheezes, frothy, pink-
tinged sputum, tachypnea, S3/S4 summation gallop
Congestive Heart Failure
Pathophysiology
Congestive Heart Failure
Left Sided Ventricular Failure
 Congestive Heart Failure
Pathophysiology
•  Right Ventricular Failure

•  Backward flow of blood to right atrium and venous circulation

•  Systemic venous congestion in systemic circulation
•  Results: peripheral edema, hepatomegaly, splenomegaly, vascular congestion of
the GI tract, jugular vein distention

•  Primary Cause: left ventricular failure

•  Chronic pulmonary congestion & hypertension result in right ventricular failure

•  Cor pulmonale – ventricular dilation & hypertrophy
 Congestive Heart Failure
Clinical Picture
Right Sided Heart Failure
J  ugular vein distention
 Enlarged liver & spleen
 Anorexia & nausea
 Dependent edema (legs & sacrum)
 Distended abdomen
 Edematous hands and fingers
 Polyuria at night
 Weight gain
 Increased BP (excess volume) OR
 Decreased BP (from failure)
Right Sided
Congestive Heart Failure
 Congestive Heart Failure
Diagnostic Studies
 Goal: Assess the cause & degree of failure
History and Physical Exam
 Brain Natriuretic Peptide level (BNP).
•  elevated in acute and chronic heart failure
•  useful in following the response to treatment of congestive heart failure.
 Arterial Blood Gases (ABGs), Serum chemistries, Liver Function Test (LFTs)
 Chest x-ray
 ECG
 Echocardiogram
 Nuclear imaging studies
 Cardiac catheterization
 Hemodynamic monitoring
Congestive Heart Failure
 CHF
Remodeling or Hypertrophy
 Congestive Heart Failure
Classification
•  Class 1 – No limitation of physical activity

•  Class 2 – Slight limitation – fatigue, dyspnea, palpitations

•  Class 3 – marked limitation. Comfortable at rest; ordinary

activities cause symptoms

•  Class 4 – Inability to carry out any physical activity without

symptoms –
Pain/discomfort at rest
 CHF – Outcome Measures
•  Use of ß-blockers at discharge and during admission.
• 
Use of aspirin at discharge and during admission.
• 
Timely and appropriate acute reperfusion (thrombolysis or primary angioplasty).
• 
The use of angiotensin-converting enzyme (ACE) inhibitors for patients with
depressed left ventricular systolic function. Similarly, a minority of patients with
AMI are potential candidates for this care process,

•  The proportion of patients eligible for smoking-cessation counseling is relatively

small, and ascertainment can be difficult, given the variability in documentation as
well as practice.

•  Diet and exercise counseling

•  Cholesterol status assessment and management.
 Congestive Heart Failure
Complications
•  Pleural effusion

•  Dysrhythmias

•  Left ventricular thrombus

•  Hepatomegaly – impaired liver function

•  Acute Pulmonary Edema

CHF/ Pulmonary Edema
Congestive Heart Failure
Pulmonary Edema
Congestive Heart Failure
HemodynamicAssessment
Congestive Heart Failure
Arterial Monitoring
Congestive Heart Failure
Central Venous Pressure
Symptoms
Congestive Heart Failure
Nursing Diagnoses
  ctivity intolerance r/t fatigue secondary to cardiac insufficiency
A
 Excess fluid volume r/t cardiac failure
 Disturbed sleep pattern r/t nocturnal dyspnea
 Impaired gas exchange r/t increased preload and afterload
 Anxiety r/t dyspnea / fear of death
 Knowledge deficit r/t disease process
 Congestive Heart Failure
Medical Treatment Goals
•  Decreasing Intravascular Volume
•  Decreasing Venous Return
•  Decreases preload – decreases the volume to the left ventricle during diastole
•  Med: Diuretics – Lasix (furosemide)

•  Decreasing Afterload
•  Decrease systemic vascular resistance
•  CO increases
•  Pulmonary congestion decreases
•  Meds: Nitroglycerine (NTG); Morphine; Calcium Channel Blockers
 Congestive Heart Failure
Medical Treatment Goals
•  Improving Gas Exchange & Oxygenation
•  Supplemental oxygen
•  Morphine
•  Severe cases – intubation / ventilation
•  Improving Cardiac Function
•  Increase cardiac contractility without increasing cardiac oxygen consumption
•  Hemodynamic Monitoring:
•  pulmonary artery pressure; pulmonary artery wedge pressure (14-18mmg
HG)
•  Inotropic Meds: Digoxin
•  Inotropic meds used with hemodynamic monitoring:
•  Dobutamine
•  Inodilators: (inotropic & vasodilator): Milrinone
 Congestive Heart Failure
Medical Treatment Goals
Reducing Anxiety
•  Sedative action of IV Morphine
 Complication: respiratory depression

Determine & Treat Underlying Cause

•  Systolic or Diastolic failure
•  Aggressive drug therapy
 Congestive Heart Failure
Nursing Process
•  Assess: Hemodynamic status – CVP (Central venous
pressure), PAP (Pulmonary Artery Pressure),response to
medication cardiac rhythm, energy level; labs

•  Nsg Action: Administer medications, oxygen, supportive

treatment, community referral & home preparation

•  Pt/Family Education: Lifestyle modification, Medication

 Congestive Heart Failure
Nursing Process
•  Anatomy and Physiology
•  Pathophysiology
•  Diagnostics and Laboratorium
•  Pharmacology
Congestive Heart Failure
Case Study
 Daftar Bacaan

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Clinical management for positive outcome (6th ed.). Philadelphia: WB
Saunders Company.

•  Lewis, S. M., Heikemper, M. M.. & Dirksen, S.R. (2004). Medical surgical
nursing: Assessment and management of clinical problems (6th Ed). Missouri:
Mosby Inc.

•  McCance, K. L. & Huether, S. E. (2002). Pathophysiology: The biologic basic

for disease in adults & children (4th ed.). Missouri: Mosby Inc.

•  Woods, S. L., Froelicher, E. S. S. & Motzer, S. U. (2000). Cardiac nursing (4th

ed.). Philadelphia: Lippincott.

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THANK YOU
@wnd2021