Nursing Management: Congestive Heart Failure

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Nursing Management Congestive Heart Failure

• Nurs1228
• Spring 2003
• By Nina Green, RN

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Congestive Heart Failure

• More than ½ 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

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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

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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

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Risk Factors for CHF

• Coronary artery disease
• Hypertension
• High cholesterol levels

• Advancing age
• Cigarette smoking
• Obesity
• Proteinuria
• Diabetes

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Normal mechanisms regulating Cardiac Output

• Preload volume
• Afterload volume
• Heart rate

• Myocardial contractility
• Metabolic state of the individual

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Major causes of CHF

• Underlying cardiac disease
• Congenital
• acquired

• Precipitating causes
• Increase workload of ventricles
• Leads to decreased myocardial function

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Acute cardiac disease causing CHF

• Acute MI
• Pulmonary Emboli
• Hypertensive crises
• Ventricular septal defect

• Arrhythmias
• Thyrotoxicosis
• Rupture of papillary muscle

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Chronic cardiac disease causing CHF

• Coronary artery disease
• Rheumatic heart disease
• Cor pulmonale
• anemia

• Hypertensive heart disease
• Congenital heart disease
• Cardiomyopathy
• Bacterial endocarditis

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Precipitating causes of CHF

• Anemia
• Thyrotoxicosis
• Arrhythmias
• Pulmonary embolism
• Pagets disease
• hypervolemia

• Infection
• Hypothyroidism
• Bacterial endocarditis
• Pulmonary disease
• Nutritional deficiencies

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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

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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

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Compensatory Mechanisms of the heart in CHF

• Ventricular dilation
• Increased sympathetic nervous system stimulation

• Ventricular hypertrophy
• Hormonal response (Renal response)

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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),

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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

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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 blood-
  tinged sputum

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Manifestations of Chronic CHF

• Fatigue
• Tachycardia
• Edema
• Nocturia
• Weight changes

• Dyspnea
• Skin changes
• Behavioral changes
• Chest pain

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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

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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

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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

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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.

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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

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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)

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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)

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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)

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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

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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?)

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Nursing Assessment

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

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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)

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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

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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

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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

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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

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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

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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

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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.

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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