Nursing Management: Congestive Heart Failure

Nurs1228 Spring 2003 By Nina Green, RN

Congestive Heart Failure

More than deaths from heart disease are due to end stage CHF The American Heart Association estimates that 400,000 new cases of CHF occur each year The 5 year mortality rate for CHF is about 50% Lewis

Congestive Heart Failure

In the past 15 years deaths from

CHF have increased 116% The rate of sudden cardiac death in a patient with CHF is 6 to 9 times higher than for the general population Lewis

Congestive Heart Failure

About 20% of individuals who have a heart attack will be disabled with heart failure within 6 years CHF is the single most frequent cause of hospitalization for people age 65 or older Lewis

Risk Factors for CHF

Coronary artery disease Hypertension High cholesterol levels Advancing age Cigarette smoking Obesity Proteinuria Diabetes

Normal mechanisms regulating Cardiac Output

Preload volume Afterload volume Heart rate Myocardial contractility Metabolic state of the individual

Major causes of CHF

Underlying cardiac disease
Congenital acquired

Precipitating causes
Increase workload of ventricles Leads to decreased myocardial function

Acute cardiac disease causing CHF

Acute MI Pulmonary Emboli Hypertensive crises Ventricular septal defect Arrhythmias Thyrotoxicosis Rupture of papillary muscle

Chronic cardiac disease causing CHF

Coronary artery disease Rheumatic heart disease Cor pulmonale anemia Hypertensive heart disease Congenital heart disease Cardiomyopathy Bacterial endocarditis

Precipitating causes of CHF

Anemia Thyrotoxicosis Arrhythmias Pulmonary embolism Pagets disease hypervolemia Infection Hypothyroidism Bacterial endocarditis Pulmonary disease Nutritional deficiencies

Pathology of Ventricular Failure

Systolic failure: causes ventricle not to empty properly (most common cause of CHF)
Heart muscle has decreased ability to contract Also caused by increased afterload (hypertension), or mechanical abnormalities ( like valvular heart disease) Characterized by low forward blood flow

Pathology of Ventricular Failure

Diastolic failure: causes ventricle not to fill properly
Disorder of heart relaxation and ventricular filling Usually the result of ventricular hypertrophy Caused by chronic hypertension, aortic stenosis, or cardiomyopathy Commonly seen in older adults

Compensatory Mechanisms of the heart in CHF

Ventricular dilation Increased sympathetic nervous system stimulation Ventricular hypertrophy Hormonal response (Renal response)

Types of CHF
Left sided failure
Back up of blood into the lungs Common causes are: CAD, HTN, cardiomyopathy and rheumatic heart disease Other causes can be: MI damage, ischemia, scar tissue (reducing contractility),

Types of CHF
Right sided failure
Backup of blood into the venous system and right side of the heart Primary cause is left sided failure Also caused by Cor pulmonale (caused by COPD, and pulmonary emboli) Also caused by MI damage, ischemia and scarring

Clinical manifestations of Acute CHF

Pulmonary edema (Most prominent)
Caused by left sided failure Evidenced by:
Agitation Paleness or cyanosis Clammy cold skin Severe dyspnea with use of accessory muscles Respiratory rate > 30/min Coughing, wheezing, production of frothy bloodtinged sputum

Manifestations of Chronic CHF

Fatigue Tachycardia Edema Nocturia Weight changes Dyspnea Skin changes Behavioral changes Chest pain

Complications of Congestive Heart Failure

Pleural effusion
Increased pressure in pleural capillaries Leakage of fluid from capillaries into pleural space.

Arrhythmias Left ventricular thrombus Hepatomegaly

Liver becomes congested with venous blood Leads to impaired liver function

Nursing Care in Acute CHF

Decrease the intravascular volume
With use of diuretics

Decrease the venous return

Reduces congestion in heart and lungs Sitting patient up facilitates breathing

Decreasing the afterload

Use of vasodilators (IV Nipride) Increasing myocardial contraction and CO Reducing pulmonary congestion

Nursing Care of Acute CHF

Improve Gas Exchange and Oxygenation
Give IV morphine Place on Oxygen Intubate and place on vent as needed

Improve cardiac function

Digitalis, or newer inotropic drugs (dobutamine) increase cardiac contractility Hemodynamic monitoring

Nursing Care of Acute CHF

Reduce anxiety
Give Morphine Approach patient calmly

Remember: Nursing care will focus on continual physical assessment of the patient, hemodynamic monitoring, and monitoring the patients response to the treatment.

Nursing Care of Chronic CHF

Treatment is aimed at resolving the underlying problem (Physicians job)
Arrhythmias (medication, and defibrillator implants), hypertension (medication), valvular defects (surgery), ischemic heart disease (cardiac cath, CABG,),

Need for oxygen Need for physical and emotional rest

Nursing Care of Chronic CHF

Drug therapy includes:
Sodium-potassium-ATPase inhibitors
Digitalis (Lanoxin) B-Adrenergic agonists Dopamine (Intropin) Dobutamine (Dobutrex)

Phosphodiesterase inhibitors
Amrinone (Inocor) Milrinone (Primacor)

Nursing Care of Chronic CHF

Diuretics:
Lasix, Edecrin, Bumex, and Demadex Aldactone and Dyrenium used also, because they are potassium sparing

Vasodilators:
Nipride (IV) (usually in ICU) and nitroglycerine (often in paste form)

Nursing Care of Chronic CHF

Angiotensin-converting enzyme (Ace) inhibitors:
Capoten, Vasotec, lisinopril (Prinivil, Zestril) Reduces angiotension II and plasma aldosterone levels Increases cardiac output due to vasodilitation

Beta-adrenergic blocking agents:

Coreg (is the only beta-blocker used in mild to moderate CHF)

Nursing Care of Chronic CHF

Nutritional Therapy
Sodium restriction with diet Teach patient what foods are high in sodium and to avoid them Severe CHF has the most sodium restrictive diet instruct family in reading labels on food items Fluids may be restricted in moderate to severe CHF

Nursing Assessment
Subjective data:
Past health history Medications Functional health patterns
Health perception-health management: (fatigue?) Nutritional-metabolic: (usual sodium intake, etc) Elimination: (nocturia?) Activity-exercise: (dyspnea?) Sleep-rest: (nocturnal dyspnea?) Cognitive-perceptual: (chest pain?)

Nursing Assessment
Objective data:
Skin Respiratory system Cardiovascular system Gastrointestinal system Neurologic system Lab values Hemodynamic monitoring Other tests: chest x-ray, echocardiogram, etc...

Nursing Diagnoses
Activity intolerance r/t.. Sleep pattern disturbance r/t. Fluid volume excess r/t Risk for impaired skin integrity r/t Impaired gas exchange r/t Anxiety r/t Ineffective management of therapeutic regimen r/t (See Text pg 900-901)

Nursing Interventions
Regular assessment of patients level of fatigue, dyspnea, heart rate, and weight Provide emotional and physical rest Provide frequent small feedings Teach patient energy expenditure and how to self monitor activities for appropriateness Teach patient reasons for nocturnal dyspnea

Nursing Interventions
Help patient explore alternative positions for comfortable sleep and relief of dyspnea Teach patient to take diuretics early in day to prevent having to get up at night Give all meds as ordered Monitor intake and output Monitor for signs of peripheral edema or lung congestion

Nursing Interventions
Instruct patient to weigh daily and to keep a record of their weights Monitor patient for signs and symptoms of hypokalemia Provide client with a diet that is sodium restricted as ordered by physician If patient has edema, measure and record Assess edematous sites for skin breakdown

Nursing Interventions
Perform passive ROM to extremities q 4h Handle edematous skin gently Turn and reposition q 2 h Monitor for impaired breathing Position HOB up if having difficulty breathing Give O2 if needed by nasal cannula Use pulse ox prn

Nursing Interventions
Assess heart and lung sounds q 4-8 h and prn Assess patient for anxiety. Medicate as needed Allow patient to ask questions and verbalize concerns. Explain all procedures to patient in understandable terms Respond to call light quickly

Nursing Interventions
Use measures to decrease dyspnea for patient, thereby relieving anxiety r/t breathing difficulty Use calm behavior with patient Teach patient what to report to nursing staff, shortness of breath, edema/swelling in ankles, weight gain,etc Teach patient and family about sodium restricted diet

Ambulatory and Homecare

Educate patient and family about the physiologic changes that have occurred Assist the patient to adapt to the physiologic and psychologic changes that have occurred. (Include family in this.) Home health nursing care is a vital factor in the prevention of future hospitalizations for these patients.

Ambulatory and Homecare

The homecare nurse can follow up with ongoing clinical assessments of the patient, monitor vital signs, and response to therapy (including medication). See table 33-13 of Text on pg. 902