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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