A CASE PRESENTATION ON CONGESTIVE HEART FAILURE

Present to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

MADELO, DIVYNNE BLESS

MANLANGIT, NATASHA
MAYO, JOHANISAH
MEDINA, DONEVA LYN
MEJIA, AIRA SHANELLE
MIRA, MARIVY ELLA
MONTERO, AMBER DAWN
MUSTAPHA, JAWIA
NOOR, ABDUL HAMID
NUENAY, RIKEE AINAH ROSE

Presented to
BUCAYAN, LUCY MAY
GAYAO, KARLO
JANGULAN, EXERLYN
PONTILLAN, MEILEN

October 2021
 TABLE OF CONTENTS

I. TITLE PAGE

II. TABLE OF CONTENTS

III. LIST OF TABLES

PEROS

IV. LIST OF FIGURES

Concept Map

V. OBJECTIVES
General Objective
Specific Objectives

VI. DEFINITION OF TERMS

VII.INTRODUCTION

VIII. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

IX. CONCEPT MAP

X. HEALTH TEACHINGS
Before
During
After
General Health Teachings

XI. PROGNOSIS

XII. REFERENCE
 LIST OF TABLES

I. PHYSICAL ASSESSMENT
PEROS
 LIST OF FIGURES

I. CONCEPT MAP
 Objectives

General Objective

At the end of the case presentation, the student nurses will be able to develop and

apply specific knowledge, skills and attitude about Congestive Heart Failure (CHF).

Specific Objectives

At the end of the one and half-hour case presentation, the student nurses will be

able to:

1. Acquire knowledge on the background, statistics, treatment and complications of

CHF;

2. Define the medical terms related to the topic;

3. Distinguish the risk factors for a patient with congestive heart failure;

4. Trace the pathophysiology,etiology and the disease;

5. Classify the different clinical manifestations that can be manifested by the patient;

6. Recognize appropriate diagnostic test done to the patient with CHF, its normal

values and the nursing responsibilities before, during and after the procedure;

7. Apply the different nursing, medical and surgical management with different

responsibilities to prevent complications and reduce morbidity of the disease;

8. Determine the nursing diagnosis, interventions and formulate nursing care process.

9. Develop and implement a health teaching plan; and

10. Acknowledge the prognosis of the disease.

 Introduction

Congestive heart failure (CHF) is a complex clinical syndrome that can result

from any functional or structural cardiac disorder that impairs the ventricle’s ability to fill

with or eject blood. The syndrome of CHF arises as a consequence of an abnormality in

cardiac structure, function, rhythm, or conduction (Figueroa & Peters, 2006).

According to Hinkle & Cheever in 2018, many patients develop pulmonary or

peripheral congestion with edema, heart failure was previously referred to as congestive

heart failure. Heart failure is currently recognized as a clinical illness marked by signs

and symptoms of fluid overload or inadequate tissue perfusion. Fluid overload and

decreased tissue perfusion result when the heart cannot generate cardiac output (CO)

sufficient to meet the body's demands for oxygen and nutrients. The term heart failure

indicates myocardial disease in which impaired contraction of the heart (systolic

dysfunction) or filling of the heart (diastolic dysfunction) may cause pulmonary or

systemic congestion.

Two major types of heart failure are identified by assessment of left ventricular

function, usually by echocardiogram. The most common type is an alteration in

ventricular contraction called systolic heart failure, which is characterized by a weakened

heart muscle. A second type is diastolic heart failure, which is characterized by a stiff and

noncompliant heart muscle, making it difficult for the ventricle to fill. An assessment of

the ejection fraction is performed by echocardiogram to assist in determining the type of

heart failure. A reduced ejection fraction is a hallmark of systolic heart failure, the

severity of heart failure is frequently classified according to the patient’s symptoms. Left-

sided heart failure (foward heart failure) is the inability of the left ventricle to fill or eject

sufficient blood into the systemic circulation. Right-sided heart failure (backward heart

failure) is the inability of the right ventricle to fill or eject sufficient blood into the

pulmonary circulation. (Brunner & Suddarth, 2017). The New York Heart Association

(NYHA) introduced the classification of heart failure:

I. No limitation of physical activity. Ordinary activity does not cause undue fatigue,

palpitation, or dyspnea.
 II. Slight limitation of physical activity. Comfortable at rest, but ordinary physical

activity causes fatigue, palpitation, or dyspnea.

III. Marked limitation of physical activity. Comfortable at rest, but less than

ordinary activity causes fatigue, palpitation, or dyspnea.

IV. Unable to carry out any physical activity without discomfort. Symptoms of

cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is

increased.

Some cases of heart failure are reversible, depending on the cause. Most often, heart

failure is a chronic, progressive condition that is managed with lifestyle changes and

medications to prevent episodes of acute decompensated heart failure. These episodes are

characterized by increased symptoms, decreased CO, and low perfusion. These episodes

are also associated with increased hospitalizations, increased health care costs, and

decreased quality of life (Hinkle & Cheever, 2018).

Heart failure is a global pandemic affecting at least 26 million people worldwide

and is increasing in prevalence. Heart failure health expenditures are considerable and

will increase dramatically with an ageing population. The risk for developing heart

failure is 1 in 5, both men and women and affects approximately 1% of the population at

any given time. Their life span averages 4-5 years on diagnosis (Brito, 2019; Chhabra,

2019). As the incidence of heart failure increases with age, approximately 6 million

people in the United States have heart failure, and a hundred thousand cases are being

diagnosed each year. Although heart failure can affect people of all ages, it is most

common in people older than 75 years. Heart failure is the most common reason for

hospitalization of people older than 65 years and is the second most common reason for

visits to a physician’s office. (American Heart Association, 2015).

The Globe Health Organization (WHO) reported in its 2019 Global Health

Estimates that heart disease has remained the biggest cause of death in the world for the

past 20 years, "killing more people than ever before," and the Philippines is the worst in

Southeast Asia (SEA). Ischemic, or coronary, heart disease claimed the lives of 122 out

of every 100,000 Filipinos in 2019, up from 103 per 100,000 in 2015, the worst rate
among Southeast Asian countries where the disease was the leading cause of death. The

Philippines was followed by Malaysia (115 per 100,000), Singapore (91.2), Thailand

(73.7) and Brunei (68.1) (Yee, 2020).

According to Statista Research Department in 2017, Misamis Oriental province

held the highest number of heart disease cases in the Philippines' Northern Mindanao

region, amounting to approximately 1.1 thousand. The city of Cagayan de Oro is first on

the list (1,075 cases), followed by Bukidnon (1,026), and Iligan city (546).

Generally the treatment of heart failure helps to reduce the symptoms but the

specializing treatment depends on the progress of the disease. Treatment aims to relieve

symptoms and slow further damage. The exact plan depends on the stage and type of

heart failure, underlying conditions and the individual patient.

Congestive heart failure is a potential complication of many different diseases and

disorders. However, the development of CHF can spur further complications, increasing

the risk of illness, incapacitation, and death. Characteristic complications of CHF are

venous thromboembolism (blood clot) causing a pulmonary embolism that if it breaks off

and lodges in the brain, it can cause a stroke, kidney failure (reduced blood circulation

allows waste products to accumulate in the body), and liver, lung and heart valve damage.

Prolonged inflammation and heart damage can lead to severe arrhythmia, cardiac arrest,

and sudden death (Mhyre & Sifris, 2020).

 Definition of Terms

Anasarca. A general accumulation of serous fluid in various tissues and body cavities

characterized by swelling of the whole body.

Cardiac Resynchronization Therapy (CRT). It is a treatment for heart failure in which

a device paces both ventricles to synchronize contractions.

Congestive Heart Failure. A fluid overload condition (congestion) associated with heart

failure.

Cor Pulmonale. Pulmonary heart disease, also known as cor pulmonale, is the

enlargement and failure of the right ventricle of the heart as a response to increased

vascular resistance (such as from pulmonic stenosis) or high blood pressure in the lungs.

Diastolic Heart Failure. The inability of the heart to pump sufficiently because of an

alteration in the ability of the heart to fill; term used to describe a type of heart failure.

Ejection Fraction (EF). Percentage of blood volume in the ventricles at the end of

diastole that is ejected during systole; a measurement of contractility.

Heart Failure. A clinical syndrome resulting from structural or functional cardiac

disorders that impair the ability of a ventricle to fill or eject blood.

Increased Afterload. When afterload increases, there is an increase in end-systolic

volume and a decrease in stroke volume.

Increased Preload. Increasing preload increases stroke volume up to a certain point.

Left Sided Heart Failure. Inability of the left ventricle to fill or eject sufficient blood

into the systemic circulation.

Left Ventricular Overload. Thickening of the wall of main’s pumping chamber.

Paroxysmal Nocturnal Dyspnea (PND). Shortness of breath that occurs suddenly

during sleep.

Pulmonary Edema. An abnormal accumulation of fluid in the interstitial spaces and

alveoli of the lungs.

Peripheral Edema. Swelling of the lower legs or hands.

Pericardiocentesis. A procedure that involves aspiration of fluid from the pericardial sac.
Pulseless Electrical Activity (PEA). A condition in which electrical activity is present

on an electrocardiogram, but there is not an adequate pulse or blood pressure.

Pulsus Paradoxus. Systolic blood pressure that is more than 10 mm Hg lower during

inhalation than during exhalation; difference is normally less than 10 mm Hg.

Renin-Angiotensin-Aldosterone-System (RAAS). The renin–angiotensin–aldosterone

system (RAAS) is a critical regulator of blood volume and systemic vascular resistance.

While the baroreceptor reflex responds in a short-term manner to decreased arterial

pressure, the RAAS is responsible for more chronic alterations. It is composed of three

major compounds: renin, angiotensin II, and aldosterone.

Right Sided Heart Failure. Inability of the right ventricle to fill or eject sufficient blood

into the pulmonary circulation.

Right Ventricular Overload. Increase in muscle mass in right ventricular due to

pressure overload.

Systolic Heart Failure. Inability of the heart to pump sufficiently because of an

alteration in the ability of the heart to contract; term used to describe a type of heart

failure.

Ventricular Overload. Volume overload refers to the state of one of the chambers of the

heart in which too large a volume of blood exists within it for it to function efficiently.

Ventricular volume overload is approximately equivalent to an excessively high preload.

It is a cause of cardiac failure.

Ventricular Remodeling. Changes in the size, shape, structure, and function of the heart.
 PEROS (Physical Assessment and Review of Systems)

Areas Assessed Subjective Finding Objective Finding Problem/s Identified

LEFT CHF RIGHT CHF LEFT CHF RIGHT CHF

INTEGUMEN
TARY:

Cool and LCHF: Decreased Cardiac

Skin clammy Pale or ashen Jaundice Output consistent with hypo
perfusion related to altered
preload— evidenced by pale,
cool, clammy skin.

RCHF: Risk for impaired

Skin Integrity related to
buildup of bilirubin, a waste
material, in the blood as
evidenced by risk factors of
alteration associated
conditions of impaired
circulation.

Hair No problems identified

Nails Clubbing of  Risk for impaired Skin

fingers Integrity evidenced by
alteration in fluid
volume and associated
conditions of impaired
circulation.

Confusion  Ineffective cerebral

Neurology Tissue Perfusion
Restlessness
related to decreased
Fatigued
oxygen blood flow to
Weakness the brain, possibly
evidenced by hypoxia
and altered mental
status.
 Fatigue related to
imbalance between
oxygen supply and
demand.
 Activity Intolerance
related to imbalance
between oxygen
supply and demand,
 physical
deconditioning and
restlessness evidenced
by reported or
observed weakness,
fatigue.

HEAD

Head Syncope  Decreased Cardiac

Output related to
Dizziness altered contractility,
possibly evidenced by
dyspnea, and,
dizziness.

 Risk for Activity

Intolerance related to
risk factors of
imbalance oxygen
supply and blood
flow, and associated
condition of
circulatory problem
(dizziness, light-
headedness).
 Risk for fall related to
risk factors of
dizziness, restlessness.

Skull No problems identified

Face Facial edema  Excess Fluid Volume

related to failure of
regulatory mechanism
(inflammation of
glomerular membrane
inhibiting filtration),
evidenced by
anasarca.

Eyes and

Vision:

Eyebrows No problems identified

Eyelashes No problems identified

Eyelids No problems identified

Eyes Blurred vision Periorbital edema  Risk for injury related

to blurred vision or
reduced visual
acuity.

Ears and No problems identified

Hearing

Nose & No problems identified

Sinuses

Mouth  Impaired oral Mucous

Dry mouth Membrane related to
dehydration or
absence of oral intake,
pathological condition
(e.g. CHF) evidenced
by xerostomia (dry
mouth), insufficient
amount of blood
supply in the tongue.

Neck Jugular venous  Excess Fluid Volume

distention related to elevated
central venous
Central venous pressure— evidenced
pressure > 16 by edema or anasarca,
cm H2O weight gain, venous
weight gain congestion.
Thorax & Dyspnea Blood-tinged Congestion in  Ineffective airway
Lungs frothy sputum the peripheral clearance related to
tissues and retained secretions
Moist cough
Wheezing the viscera evidence by frothy
Chest x-ray
(cardiac predominates sputum
Orthopnea asthma)  Ineffective breathing
pattern related to
Bibasilar decrease lung
Paroxysmal crackles expansion
nocturnal  Excess Fluid Volume
dyspnea related to
compromised
(PND)
regulatory
mechanism, evidenced
Tachypnea by shortness of breath,
adventitious breath
sounds, pulmonary
congestion.
 Risk for impaired Gas
Exchange related to
alveolar-capillary
membrane changes
(fluid collection or
shifts into interstitial
space or alveoli).
 Risk for Sleep
Deprivation related to
sudden interruption by
shortness of breath,
and discomfort.
 Activity Intolerance
related to insufficient
oxygen for activities
of daily living
evidence by
respiratory condition
(cough, discomfort,
dyspnea), interruption
in usual sleep pattern)
 RCHF: Excess Fluid
Volume related to
compromised
regulatory
mechanisms—
decreased kidney
function, possibly
evidenced by weight
gain, edema, altered
electrolyte levels,
decreased Hb and Hct;
pulmonary congestion
on x-ray.
Heart Fatigue Weight gain S3 and S4 Portal LCHF: Activity Intolerance
heart sounds, hypertensionrelated to imbalance between
ECG Palpitation pulsus lead to cardiac
oxygen supply and demand,
alternans cirrhosis
evidenced by observed
Chest pain
Tachycardia S3 and S4 heart weakness, fatigue
sounds
Elevate LCHF: Acute Pain related to
LVEDP Congestion in decreased myocardial blood
Elevate the peripheral flow evidence by chest pain
PCWP tissues and
Elevated PAP the viscera
LCHF: Excess Fluid Volume
predominates
related to elevated left
ventricular end-diastolic
Jugular venous
pressure, severe left
distention
ventricular failure or severe
mitral stenosis, tachcardia, S3
heart and S4, evidence by
increase congestion.

RCHF: Excess Fluid Volume

related to reduced glomerular
filtration rate (GFR),
increased antidiuretic
hormone production, and
sodium and water retention,
evidenced by abnormal
breath sounds, S 3 heart,
congestion in the peripheral
tissues, and hypertension

RCHF: Decreased Cardiac

Output related to decreased
myocardial contractility,
possibly evidenced by ECG
changes, and jugular vein
distention
GI System Loss of Pain in the Ascites LCHF: Risk for imbalanced
Apetite upper increase Nutrition: less than body
abdomen pressure on the requirements related to loss of
stomach and appetite as evidenced by
GI distress intestines associated conditions of
Tenderness inability to absorb adequate
Weight gain nutrients (anorexia).

Hepatomegaly RCHF: Excess Fluid Volume

related to compromised
Internal regulatory mechanism with
Hemorrhoids changes in hydrostatic
pressure and increased
activation of the renin-
angiotensin-aldosterone
system, evidenced by ascites,
weight gain.

RCHF: Risk for impaired

Tissue Integrity related to
inflammation, or altered
circulation, possibly
evidenced by warmth, edema,
tenderness, and
gastrointestinal distress.
 Urinary Hypotension Increase  Hypokalemia related
System aldosterone to aldosterone
deficiency and
decreased renal
perfusion related to
decrease glomerular
filtration
from hypotension.

Extremities Weakness Dependent,  Excess Fluid Volume

pitting edema related to sodium and
water retention
evidenced by
Leg varicosities generalized edema.
 Ineffective tissue
perfusion related to
decrease cardiac
output evidence by
pitting edema on both
forearms and hands.
 Impaired Walking
related to pain or
discomfort evidenced
by weakness, and
generalized edema.

Muscles Muscle  Risk for impaired

wasting or physical Mobility
weakness possibly evidenced by
risk factors of
neuromuscular
impairment (muscle
wasting, weakness).
Hematology  Activity Intolerance
Polycythemia related to impaired
Increase oxygen transport
BUN secondary to
diminished red blood
cell count.
 MODIFIABLE RISK NON- MODIFIABLE RISK
FACTORS FACTORS
STRESS GENETIC FACTORS
HYPERTENSION AGE (65 YEARS OLD AND
CONGESTIVE HEART
COCAINE ABOVE)
FAILURE
ALCOHOL GENDER (MEN AT ALL AGES)
DIABETES MELLITUS RACE/ETHNICITY (AFRICAN-
SMOKING AMERICANS, HISPANICS, SOUTH-
PHYSICAL INACTIVITY ASIANS)
OBESITY FAMILY HISTORY
HIGH BLOOD CHOLESTEROL
HIGH FAT/ CHOLESTEROL DIET
RIGHT-SIDED HEART FAILURE
LEFT-SIDED HEART FAILURE  COR PULMONALE
 ISCHEMIC HEART DISEASE  RIGHT-SIDED VALVULAR
 MYOCARDITIS CREATES COMPENSATORY MECHANISMS HEART DISEASE
 VALVULAR HEART DISEASE  RIGHT-SIDED MYOCARDIAL
 RESTRICTIVE PERICARDITIS DISEASE
 PULMONARY
RESULTS TO HYPERTENSION
ANGIOTENSIN
RECEPTOR-
NEPRILYSIN
INHIBITORS (ARNIs)

INCREASED MYOCARDIAL CAN BE TREATED BY

CAN BE TREATED BY ACTIVATION OF ACTIVATION OF RENIN- RESULTS TO
CONTRACTILITY NOREPINEPHRINE, ATRIAL ANGIOTENSIN-ALDOSTERONE-
NATRIURETIC PEPTIDE (ANP) SYSTEM

CAUSES CAUSES ANGIOTENSIN I

INCREASED CARDIAC BETA BLOCKERS ACE INHIBITORS
WORKLOAD TACHYCARDIA LUNGS
SODIUM &
WATER RETENTION STIMULATES CAN BE
ANGIOTENSIN II TREATED BY
CAUSES LEADS TO
LEADS TO CAUSES
CELLS STRETCHING MYOCARDIUM STRESS ALDOSTERONE
MYOCARDIUM STRESS PERIPHERAL SECRETIONS
VASOCONSTRICTION
LEADS TO CAUSES
CAN BE
RESULTS TO
COMPENSATORY HYPERTROPHY ROUTINE URINALYSIS TREATED BY SODIUM &
AND DILATATION COMPLETE BLOOD COUNT INCREASED WATER RETENTION
ARB AFTERLOAD
LEADS TO
LEADS TO
EDEMA
DECREASED
CARDIAC OUTPUT

ECHOCARDIOGRAM INCREASED
IMPLANTATION OF CARDIAC  EJECTION FRACTION 55-65% PLASMA VOLUME
DEVICES 12-LEAD ECG
 IMPLANTABLE MRI
CARDIOVERTER
INCREASED
DEFIBRILLATORS
PRELOAD
 PACEMAKERS
 BIVENTRICULAR DEVICES
 CARDIAC LOOP RECORDERS RESULTS TO
CONGESTIVE INCREASED CARDIAC
HEART TRANSPLANTATION HEART FAILURE WORKLOAD
(PATIENTS WITH END-STAGE HF)

SERUM ELECTROLYTES
LEADS TO Na- 135-145 mEq/L
Mg-1.7 - 2.2 mg/dL
K- 3.5 - 5.0 mmol/L
 MYOCARDIAL INFARCTION  LEFT-SIDED HEART FAILURE
 HYPERTENSION  PULMONARY EMBOLISM
 AORTIC STENOSIS  CONGENITAL DEFECTS
 MITRAL STENOSIS  RIGHT VALVULAR INFECTION

CAUSES CAUSES

DECREASED MYOCARDIAL DECREASED MYOCARDIAL

CONTRACTILITY CONTRACTILITY

INCREASED CARDIAC WORKLOAD INCREASED CARDIAC WORKLOAD

 DECREASED DECREASED
DIASTOLIC FILLING DIASTOLIC FILLING

OBSTRUCTION OF LEFT OBSTRUCTION OF RIGHT

ATRIAL EMPTYING ATRIAL EMPTYING

INCREASED LEFT ATRIAL INCREASED RIGHT

PRESSURE ATRIAL PRESSURE

RESULTS TO RESULTS TO

CAN BE TREATED BY LEFT-SIDED BRAIN NATRIURETIC RIGHT-SIDED

DOBUTAMINE PEPTIIDE <100 pg/mL HEART FAILURE
HEART FAILURE

LEADS TO
BLOOD DUMPS BACK FROM RIGHT
VENTRICLE TO RIGHT ATRIUM

BLOOD COMES BACK INTO DECREASED STROKE

PULMONARY CAPILLARY BED VOLUME
INCREASED PRESSURE
IN CAPILLARY BED

INCREASED PRESSURE DECREASED TISSUE BLOOD UREA NITROGEN LEADS TO

IN CAPILLARY BED PERFUSION Normal 5-20 mg/dL
CREATININE INCREASED PRESSURE IN CAN BE TREATED BY FUROSEMIDE
Normal 0.6-1.2 mg/dL VENOUS CIRCUIT (VENOUS
(LASIX)
BACKUP)
FLUID SHIFTING IN INTRA
ALVEOLAR AND INTER
ALVEOLAR SPACES
INCREASED CELLULAR DECREASED BLOOD
HYPOXIA  JUGULAR VENOUS DISTENTION
RESULTS TO FLOW IN KIDNEYS
 INCREASED CAPILLARY CAN BE DIAGNOSED BY
CAN BE TREATED BY HYDROSTATIC PRESSURE
SUPPLEMENTAL OXYGEN PULMONARY EDEMA CHEST X-RAY  DEPENDENT EDEMA
 HEPATOMEGALY LIVER FUNCTION TEST
RENIN-ANGIOTENSIN-  WEIGHT GAIN
ALDOSTERONE-SYSTEM  SACRAL EDEMA
CAN BE DIAGNOSED BY
 DYSPNEA  PITTING EDEMA
 LOW OXYGENTAION SATURATION  ASCITES
LEVEL  ANOREXIA
 COUGH VASOCONSTRICTION AND  NAUSEA
 PULMONARY CRACKLES CAN BE DIAGNOSED BY REABSORPTION OF SODIUM & WATER
 ORTHOPNEA
 SHORTNESS OF BREATH CAN BE DIAGNOSED BY
 DIFFICULTY OF SLEEPING
 INADEQUATE TISSUE PERFUSION INCREASED EXTRACELLULAR
 OLIGURIA FLUID VOLUME IMBLANCED NUTRITION: LESS EXCESS FLUID VOLUME
 DIZZINESS THAN BODY REQUIREMENTS RELATED TO BLOOD PULLING
 LIGHTHEADEDNESS RELATED TO INADEQUATE FOOD IN THE PULMONARY SYTEM OR
 CONFUSION INTAKE; SELF-INDUCED VOMITING SYSTEMIC CIRCULATION
 RESTLESSNESS CAUSED BY PULMONARY
INCREASED TOTAL VOLUME
 ANXIETY CIRCULATION
 PALE OR ASHEN
RESULTS TO
 COOL AND CLAMMY SKIN INDEPENDENT
 TACHYCARDIA  SUPERVISE THE PATIENT DURING
 FATIGUE INCREASED SYSTEMIC MEALTIMES AND FOR A INDEPENDENT
 NOCTURIA BLOOD PRESSURE SPECIFIED PERIOD AFTER MEALS.  RECORD INTAKE AND OUTPUT.
 LIQUIDS ARE MORE ACCEPTABLE  WEIGH PATIENT DAILY AT THE
THAN SOLID. SAME TIME EACH DAY.
CAN BE DIAGNOSED BY  MEASURE VITAL SIGNS AND
 EXPECT WEIGHT GAIN OF ABOUT
1LB (0.5KG) PER WEEK. INVASIVE HEMODYNAMIC
IMPAIRED GAS EXCHANGE INEFFECTIVE AIRWAY INEFFECTIVE BREATHING  IF EDEMA OR BLOATING OCCURS PARAMETERS.
RELATED TO ALVEOLAR CLEARANCE RELATED TO PATTERN RELATED TO FATIGUE  RECORD OCCURRENCE OF
AFTER THE PATIENTS HAS
EDEMA SECONDARY TO RETAINED SECRETION AS CAUSED BY PULOMONARY EXERTIONAL
RETURNED TO NORMAL EATING BREATHLESSNESS, DYSPNEA
INCREASED VENTRICULAR EVIDENCE BY PRODUCTIVE CONGESTION BEHAVIOR, REASSURE HER THAT
PRESSURE COUGH AT REST, OR PAROXYSMAL
THIS PHENOMENON IS NOCTURNAL DYSPNEA.
TEMPORARY.  NOTE PRESENCE OF EDEMA.
 MEASURE ABDOMINAL GIRTH.
INDEPENDENT  PROVIDE FOR SODIUM
INDEPENDENT INDEPENENT  POSITION PATIENT IN RESTRICTIONS IF NEEDED.
 POSITION THE PATIENT IN A  ASSIST THE PATIENT TO AN OPTIMAL BODY ALIGNMENT  PATIENT WILL VERBALIZE
HIGH FOWLER’S POSITION WITH  ELEVATE EDEMATOUS
OPTIMAL UPRIGHT POSITION. IN SEMI-FOWLER’S POSITION UNDERSTANDING OF EXTREMITIES, CHANGE
THE HEAD OF THE BED  INSTRUCT THE PATIENT ON FOR BREATHING. NUTRITIONAL NEEDS. POSITION FREQUENTLY.
ELEVATED UP TO 90°. THE CORRECT USE OF THE  ASSIST PATIENT TO USE  CLIENT WILL ESTABLISH A  PLACE IN SEMI-FOWLER’S
 KEEP BACK DRY. INCENTIVE SPIROMETER AND RELAXATION TECHNIQUES. DIETARY PATTERN WITH CALORIC POSITION, AS APPROPRIATE.
 PROMOTE ADEQUATE REST
  PROMOTE ADEQUATE REST
PERIODS
 KEEP THE ENVIRONMENT
ALLERGEN-FREE
PATIENT WILL BE ABLE TO
DEMONSTRATE IMPROVEMENT IN GAS
EXCHANGE AS EVIDENCED BY NORMAL
BREATH SOUNDS, AND SKIN COLOR,
PRESENCE OF EUPNEA, HEART RATE 100
BPM OR LESS, AND SP02 LEVEL OF 95%
ABOVE.
THE USE OF THE FLUTTER
VALVE AS ORDERED.
 ENCOURAGE THE CLIENT TO
COUGH AND DEEP BREATHE.
 COLLABORATE WITH
RESPIRATORY THERAPISTS.
 ENCOURAGE ADEQUATE
FLUID
INTAKE, IF NOT
CONTRAINDICATED
 THE PATIENT WILL MAINTAIN A
CLEAR AIRWAY
 THE PATIENT WILL HAVE CLEAR
LUNG SOUNDS
 THE PATIENT WILL
DEMONSTRATE EFFECTIVE
WAYS TO REMOVE SECRETIONS
REGAIN/MAINTAIN AN  PROMOTE EARLY
APPROPRIATE WEIGHT. AMBULATION.
 CLIENT WILL DEMONSTRATE  OBSERVE SKIN AND MUCUS
SHORT TERM: WEIGHT GAIN TOWARD THE MEMBRANE.
THE PATIENT SHALL HAVE  DIGITALIS THERAPY
INDIVIDUALLY EXPECTED RANGE.
DEMONSTRATED APPROPRIATE  CHECK THE HEART RATE
BEFORE GIVING THE
COPING BEHAVIORS AND
METHODS TO IMPROVE MEDICATION (DIGITALIS) NOT
LESS THAN 60 OR BELOW , NOT
BREATHING PATTERN.
MORE THAN 120 BPM
 MONITOR SERUM LEVELS
LONG TERM:  EVALUATE EFFECTIVENESS
THE PATIENT SHALL HAVE (INCREASE CO, INCREASE OF
APPLIED TECHNIQUES THAT DRUG (DIGITALIS)
IMPROVED BREATHING PATTERN
AND BEFREE FROM SIGNS AND
SYMPTOMS OF RESPIRATORY SHORT TERM:
DISTRESS AEB RESPIRATORY GOALS MET.
PATIENT WAS ABLE TO UNDERSTAND
RATE WITHIN NORMAL RANGE,
HOW TO LESSEN FLUID VOLUME
ABSENCE OF CYANOSIS,
EFFECTIVE BREATHING AND EXCESS BY REDUCING SALT INTAKE,
MINIMAL USE OF ACCESSORY ELEVATING THE EDEMATOUS PART OF
THE BODY ABOVE THE LEVEL OF THE
HEART AND IMPORTANCE OF TAKING
ANTIHYPERTENSIVE AND DIURETICS.

ANXIETY RELATED TO
BREATHLESSNESS FROM INADEQUATE
OXYGENATION
INDEPENDENT
 INTERACT WITH PATIENTS IN A CALM,
PEACEFUL MANNER.
 FAMILIARIZE PATIENTS WITH THE
ENVIRONMENT AND NEW EXPERIENCES OR
PEOPLE AS NEEDED.
 ADMINISTER OXYGEN DURING THE ACUTE
STAGE.
 WHEN THE PATIENT DISPLAYS ANXIETY,
PROMOTE PHYSICAL COMFORT AND
PSYCHOLOGICAL SUPPORT.
 WHEN THE PATIENT IS COMFORTABLE,
TEACH WAYS TO CONTROL ANXIETY AND
AVOID ANXIETY-PROVOKING SITUATIONS.
 ASSIST IN IDENTIFYING FACTORS THAT
CONTRIBUTE TO ANXIETY.
 SCREEN FOR DEPRESSION, WHICH OFTEN
ACCOMPANIES OR RESULTS FROM
ANXIETY.
 ALLOW THE PATIENT TO TALK ABOUT
ANXIOUS FEELINGS AND EXAMINE
ANXIETY-PROVOKING SITUATIONS IF THEY
ARE IDENTIFIABLE..
 EXPLAIN ALL ACTIVITIES, PROCEDURE,
AND ISSUES THAT INVOLVE THE PATIENT;
USE NON-MEDICAL TERMS AND CALM,
SLOW SPEECH. DO THIS IN ADVANCE OF
PROCEDURES WHEN POSSIBLE, AND
VALIDATE THE PATIENT’S
UNDERSTANDING.
 TEACH PATIENTS TO VISUALIZE OR
FANTASIZE ABOUT THE ABSENCE OF
ANXIETY OR PAIN, SUCCESSFUL
EXPERIENCE OF THE SITUATION,
RESOLUTION OF CONFLICT, OR OUTCOME
OF THE PROCEDURE.
 EDUCATE PATIENT FAMILY ABOUT THE
SYMPTOMS OF ANXIETY.
ACTIVITY INTOLERANCE
RELATED TO IMBALANCE
BETWEEN OXYGEN SUPPLY/DEM
AND EVIDENCE BY FATIGUE AND
PALLOR
INDEPENDENT
 MONITOR AND EVALUATE THE PATIENT’S
RESPONSE TO ACTIVITIES.
 CONSIDER THE USE OF THE 6-MINUTE WALK
TEST TO DETERMINE THE PATIENT’S PHYSICAL
ABILITY.
 EVALUATE ACCELERATING ACTIVITY
INTOLERANCE.
 ASSIST WITH SELF-CARE ACTIVITIES AS
NECESSARY. ENCOURAGE INDEPENDENCE
WITHIN PRESCRIBED LIMITS.
 ORGANIZE NURSING CARE ACTIVITIES TO
ALLOW REST PERIODS.
 ENCOURAGE PATIENT TO HAVE ADEQUATE BED
REST AND SLEEP.
 INITIATE INTERVENTIONS AND SAFEGUARDS
TO PROMOTE SAFETY AND PREVENT RISK FOR
INJURY DURING ACTIVITY.
 ENCOURAGE THE CLIENT TO MAINTAIN A
POSITIVE ATTITUDE; PROVIDE EVIDENCE OF
DAILY OR WEEKLY PROGRESS.
 PATIENT WILL PARTICIPATE IN
DESIRED ACTIVITIES; MEET OWN
SELF-CARE NEEDS.
 ACHIEVE MEASURABLE INCREASE IN
ACTIVITY TOLERANCE, EVIDENCED
BY REDUCES FATIGUE AND
WEAKNESS ANG BY VITAL SIGNS
WITHIN ACCEPTABLE LIMITS DURING
ACTIVITY.
DECREASED CARDIAC OUTPUT
RELATED TO REDUCED BY STOKE
VOLUME CAUSED BY MECHANICAL,
STRUCTURAL, OR ELECTROCARDIO
PHYSIOLOGIC
INDEPENDENT
 PROVIDE A RESTFUL ENVIRONMENT AND
ENCOURAGE PERIODS OF REST AND SLEEP; ASSIST
WITH ACTIVITIES.
 ENCOURAGE REST, SEMIRECUMBENT IN BED OR
CHAIR. ASSIST WITH PHYSICAL CARE AS NEEDED.
 PROVIDE A QUIET ENVIRONMENT: EXPLAIN
THERAPEUTIC MANAGEMENT, HELP THE PATIENT
AVOID STRESSFUL SITUATIONS, LISTEN AND
RESPOND TO EXPRESSIONS OF FEELINGS.
 REPOSITION PATIENT EVERY TWO (2) HOURS.
 MEASURE CARDIAC OUTPUT AND OTHER
FUNCTIONAL PARAMETERS AS INDICATED.
 COMPLY PRESCRIBED DIET.
 TAKE THE MEDICATION AS PRESCRIBED AND
REGIOUSLY.
 MAINTAIN AN APPROPRIATE ACTIVITY LEVEL
COLLABORATIVE
 MONITOR SERIAL ELECTROCARDIOGRAM AND
CHEST X-RAY CHANGES.
 PATIENT WILL DEMONSTRATE
ADEQUATE CARDIAC OUTPUT AS
EVIDENCE BY VITAL SIGNS WITHIN
ACCEPTABLE LIMITS.
 PATIENT WILL PARTICIPATE IN
ACTIVITIES THAT REDUCE CARDIAC
WORKLOAD.
LONG TERM:
GOALS PARTIALLY MET. PATIENT NO
LONGER HAD LEG EDEMA AFTER
FOLLOWING APPROPRIATE DIET AND
MEASURES ON HOW TO REDUCE
EDEMA AND COMPLIANCE OF
MEDICATION. HOWEVER, VITAL SIGNS
ARE STILL NOT STABLE, SPECIFICALLY
RESPIRATORY RATE AND PULSE RATE.
EXCESS FLUID VOLUME RELATED TO
REDUCED GLOMERULAR FILTRATION
RATE
INDEPENDENT
 WEIGH THE PATIENT DAILY AND COMPARE TO
THE PREVIOUS MEASUREMENT.
 PROVIDE SMALL, FREQUENT, EASILY
DIGESTIBLE MEALS.
 INSTRUCT PATIENT REGARDING FLUID
RESTRICTIONS AS APPROPRIATE.
 MAINTAIN FLUID AND SODIUM RESTRICTIONS AS
INDICATED.
 CONSULT WITH A DIETITIAN.
 MONITOR CHEST X-RAY
 PATIENT CAN VERBALIZE UNDERSTANDING OF
INDIVIDUAL DIETARY/FLUID RESTRICTIONS.
 DEMONSTRATE STABILIZED FLUID VOLUME
WITH BALANCED INTAKE AND OUTPUT, VITAL
SIGNS WITHIN ACCEPTABLE RANGE, AND
STABLE WEIGHT.

RISK FACTORS NURSING DIAGNOSIS DIAGNOSTIC TEST

 PATIENT WILL IDENTIFY STRATEGIES
TO REDUCE ANXIETY. PATHOPHYSIOLOGY INTERVENTIONS MEDICAL MANAGEMENT
 PATIENT WILL DEMONSTRATE
IMPROVED CONCENTRATION. SURGICAL MANAGEMENT
SIGNS AND SYMPTOMS EVALUATION
 PATIENT WILL MANAGE ANXIETY
AND COPING PATTERNS.
 Health Teachings

(I)Implantation of Cardiac Device

Before

Prepare the patient for Implantation of Cardiac Device (this is performed in a cardiac

catheterization laboratory)

Instruct patient to fast, usually 8-12 hours before procedure.

Inform patient about the expected duration of the procedure and advise that it will involve

lying on a hard table for less than 2 hours.

Reassure patient that IV medications are given to maintain comfort.

Inform patient about sensations that will be experienced during the procedure.
Explain occasional pounding sensation (palpitation) may be felt in the chest when

catheter tip touches the endocardium. Ask patient to cough and breathe deeply (coughing

help disrupt dysrhythmia.

Breathing deeply and holding breath help lower diaphragm for better visualization of the

heart structures.

Encourage patient to express fears and anxieties.

Provide education and reassurance to reduce apprehension.

During

Instruct the patient to remove any jewellery or other objects that may interfere with the

procedure.

Patient has one or more IV catheters for administration of fluids, sedatives, heparin and

other medications.

Monitor patient for chest pain or dyspnoea and for changes of BP and ECG (which is

indication of myocardial ischemia, hemodynamic instability, or dysrhythmias.

Resuscitation equipment must be readily available and staff must be prepared to provide

advanced cardiac life support as necessary.

Place the patient on their back on the procedure table.

Cleanse the incision site using antiseptic soap.

Reassure the patient throughout the procedure.

After

Observe catheter access site for bleeding or hematoma formation and assess peripheral

pulses in the affected extremity every 15 minutes for 1 hour, every 30 minutes for 1 hour,

and hourly for 4 hours or until discharge.

Assess BP and HR every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly

for 4 hours or until discharge.

Evaluate temperature, color, and capillary refill, of the affected extremity pain, numbness

or tingling sensations (this may indicate arterial insufficiency) by comparing examination

findings between affected and unaffected extremities.

Screen carefully for dysrhythmias by observing the cardiac monitor or by assessing the

apil and peripheral pulses for changes in rate and rhythm.

Maintain bed rest for 2-6 hours after the procedure.

If manual pressure or a mechanical device was used during a femoral artery approach, the

patient remains on bed rest for up to 6 hours with the affected leg straight and the head of

the bed is elevated no greater than 30°. The patient may be turned from side to side with

the affected extremity straight.

Instruct patient to report chest pain and bleeding or sudden discomfort from the catheter

insertion promptly.

Monitoring the patient for contrast-induced nephropathy by observing for elevations in

serum creatinine levels. IV hydration is used to increase urinary output and flush contrast

agent. Accurate oral and IV intake must be recorded.

Instruct patient to ask for help when getting out of bed for the first time after procedure.

Monitor the patient for bleeding from catheter access site and for orthostatic hypotension,

indicated by complaints of dizziness or light-headedness.

(II) Heart Transplantation

Before

Prepare the patient for Heart Transplant.

Perform a history and physical examination (x-ray, ECG; laboratory tests, including

coagulation studies; and blood typing and cross-matching.)

The nurse should assess the patient for disorders that could complicate or affect the

postoperative course, such as diabetes, hypertension, and lung disease.

Assessment should focus on obtaining baseline physiologic, psychological and social

formation because patients with impaired cognitive status will need more assistance after

surgery.

Instruct the patient to remove any jewellery or other objects that may interfere with the

procedure.

Reassure the patient that the fear of pain is normal, the some pain will be experienced,

that medication is to relieve pain will be provided, and that the patient will be closely

monitored.

Patient is instructed to shower with antiseptic solution chlorhexidine gluconate.

Inform the patient and family about the equipment, tubes and lines that will be present

after surgery and their purposes.

Stands near and touches patient during procedures and induction.

The nurse should give the patient and family time and opportunities to express their fears.

Nurse should explain deep breathing and coughing then practice the procedure with the

patient.

Reassure the patient throughout the procedure.

During
Maintain aseptic, controlled environment.
Astute intraoperative assessment is critical to prevent, detect, and initiate prompt

intervention for complications (low cardiac output, dysrhythmias, haemorrhage, organ

failure from shock and thromboembolic events including stroke).

Manage human resources, equipment and supplies for individualized patient care.

Transfer patient to operating room bed or table.

Position the patient based on functional alignment and exposure of surgical site.

Ensure sponge, needle and instrument counts are correct.

Apply grounding device to patient.

Before the chest incision is closed, chest tubes are inserted to evacuate air and drainage

from the mediastinum and the thorax.

Complete intraoperative documentation.

After

Assess the patient frequently of oxygen saturation, pulse volume and regularity, depth

and nature of respiration, skin colour and depth of consciousness.

Assess patient’s pain level, mental status, vital signs, cardiac rhythm, skin temperature,

colour and urine output.

Relieve pain and anxiety. Administer appropriate pain relief.

Assess the surgical site (observed for bleeding, type and integrity of dressing and drains).

Promoting patient adaptation to the transplant process.

Monitor cardiac function.

Continue close monitoring of patient’s physical and psychological response to surgical

intervention.

Provide relevant teaching.

Assist with discharge planning.

 General Health Teachings

Activity

Ask your healthcare provider about an exercise program. You can benefit from

simple activities such as walking or gardening. Exercising most days of the week can

make you feel better. Don't be discouraged if your progress is slow at first. Rest as

needed. Stop activity if you get symptoms such as chest pain, lightheadedness, or

significant shortness of breath. Find activities that you enjoy, such as brisk walking,

dancing, swimming, or gardening. These will help you stay active and strengthen your

heart. Ask your healthcare provider about cardiac rehab. This is a program that helps you

to exercise safely.

Diet

Follow a heart healthy diet. And make sure to limit the salt (sodium) in your diet.

Salt causes your body to hold water. This makes your heart work harder as there is more

fluid for the heart to pump. Limit your salt as directed by your healthcare provider by

doing the following :

 Limit canned, dried, packaged, and fast foods.

 Don't add salt to your food.

 Season foods with herbs instead of salt.

 Watch how much liquids you drink. Drinking too much can make heart failure

worse. Talk with your healthcare provider about how much you should drink each

day.

 Limit the amount of alcohol you drink. It may harm your heart. Women should

have no more than 1 drink a day. Men should have no more than 2 a day.

 When you eat out, ask that your meals have no added salt.

Tobacco

If you smoke, it's key to quit. Smoking increases your chances of having a heart

attack by harming the blood vessels that provide oxygen to your heart. This makes heart
failure worse. Quitting smoking is the number one thing you can do to improve your

health. Enroll in a stop-smoking program to improve your chances of success. Talk with

your healthcare provider about medicines or nicotine replacement therapy. Ask your

healthcare provider about smoking cessation support groups.

Medicine

Take your medicines exactly as prescribed. Learn the names and purpose of each

of your medicines. Keep an accurate medicine list and current dosages with you at all

times. Don't skip doses. If you miss a dose of your medicine, take it as soon as you

remember. If you miss a dose and it's almost time for your next dose, just wait and take

your next dose at the normal time. Don't take a double dose. If you are unsure, call your

doctor's office. Make sure not to mix up your medicines or forget what you've taken the

same day. Refill your prescriptions before you run out of medicine. Talk with your

healthcare provider if you have trouble with the cost of your medicines.

Weight monitoring

Weigh yourself every day. A sudden weight gain can mean your heart failure is

getting worse. Weigh yourself at the same time of day and in the same kind of clothes.

Ideally, weigh yourself first thing in the morning after you empty your bladder, but

before you eat breakfast. Your healthcare provider will show you how to track your

weight. He or she will also tell you when you should call if you have a sudden,

unexpected increase in your weight.

In general, your healthcare provider may ask you to report if your weight goes up

by more than 2 pounds (0.9 kg) in 1 day, 5 pounds (2.27 kg) in 1 week, or whatever

weight gain you were told by your doctor. This is a sign that you are retaining more fluid

than you should be. Clues to weight gain include checking your ankles for swelling, or

noticing you are short of breath when you lie down.

Follow-up care

Have follow-up appointment. Depending on the type and severity of heart failure

you have, you may need follow-up as early as 7 days from hospital discharge. Keep

appointments for checkups and lab tests that are needed to check your medicines and

condition.

Recognize that your health and even survival depend on you following your medical

recommendations.
 Prognosis

Prognosis depends on the stage and cause of CHF, as well as a person’s age, sex,

and socioeconomic status. Stages of CHF range from A to D.

 Stage A: High risk for heart failure, but without structural heart disease or

symptoms of heart failure

 Stage B: Structural heart disease, but without signs or symptoms of heart failure

 Stage C: Structural heart disease with prior or current symptoms of heart failure

 Stage D: Advanced heart failure

The table below shows five-year mortality data for each of the four stages of CHF.

Stage 5-year survival rate

Stage A 97%
Stage B 95.7%
Stage C 74.6%
Stage D 20%
 References

Brunner & Suddarth’s. (2017, November 15) Medical-Surgical Nursing 14th Edition

Volume 1.

Figueroa, S., & Peters, J. (2006, April). Congestive Heart Failure: Diagnosis,

Pathophysiology, Therapy, and Implications for Respiratory Care.

Mhyre, J., & Sifris, D. (2020, November 18). What Is Congestive Heart Failure?

https://www.verywellhealth.com/congestive-heart-failure-
4582224#:~:text=Characteristic%20complications%20of%20CHF%20include%3
A%20Venous%20thromboembolism%2C%20which,in%20the%20brain%2C%20
it%20can%20cause%20a%20stroke

Schiller, R. ( 2021, March 09). How Long Can You Live with Heart Failure?

https://www.verywellhealth.com/congestive-heart-failure-life-expectancy-
prognosis-5089374

Minsasyan, Z. (2014, October 13). Cardiovascular System, HTN, Coronary artery

disease, heart failure, Vascular disorders.

https://www.hopkinsmedicine.org/health/treatment-tests-and-
therapies/pacemaker-insertion