Congestive heart failure and its management

1. CARE OF CONGESTIVE
HEART FAILURE(CHF)
PATIENTS
MonikaNegi
MSN
AIIMS,DELHI

2. Objectives
At the end of session, the learners will able to
• Define CHF
• Discuss the etiology of CHF
• Explain types of CHF
• Explain pathophysiology of CHF
• Describe clinical manifestations of CHF
• Describe diagnosis of CHF
• Describe medical and surgical management of CHF
• Discuss about the nursing management of CHF

3. INTRODUCTION
 Heart failure is the pathophysiologic state in
which an abnormality of cardiac function is
responsible for the failure of the heart to pump
blood at a rate adequate to meet the
requirements of the tissue or can do so only from
an elevated filling pressure.
 Heart failure referred to as congestive heart
failure (CHF) because many patient experience
pulmonary and peripheral congestion with edema

4. DEFINITION
Congestive Cardiac Failure (CHF) is defined as a
clinical syndrome that can result from any
structural & functional cardiac disorders that
impairs the ability of ventricles to fill with and
pump sufficient blood to meet the needs of the
tissues for oxygen and nutrients.

5. Incidence
According to AHA the number of adults living with
heart failure increase from about 5.7 million (2009-
2012) to about 6.5 million (2011-2014).
According to latest update no. of people
diagnosed with heart failure increase by 46% by
2030, resulting in more than 8 million people adults
with heart failure

6. Anatomy and physiology of heart

7.  Cardiac output
 Ejection fraction(EF)
Terminologies
 3 factors affects SV and ensure that the
left and right ventricle pump equal volume
of blood
1. Preload,
2. Contractility
3. Afterload
 Autonomic regulation of heart rate

8. Precipitating factors
• Abnormal heart loading
• Myocardial dysfunction
• Filling disorders
• Increased metabolic demand

9. Abnormal heart loading.
Conditions that increase preload
oHypervolemia
oMitral insufficiency
o Tricuspid
regurgitation
oAortic
insufficiency
oCongenital
defects

10. Conditions that increase afterload
Hypertension .
Aortic or pulmonary
stenosis
Increased blood
viscosity
Coarctation of
aorta

11. Decreased contractility
•Myocardial infarction
•Myocarditis
•Cardiomyopathy
•Ventricular aneurysm
•Endocrine & metabolic
disorders
•Cardiac depressant
• Arrhythmias
Abnormal muscle function

12. ventricular filling disorder
•Cardiac tamponade
•Mitral stenosis
•Tricuspid stenosis
•Constrictive pericarditis
Hypertrophic
cardiomyopathy

13. Increase metabolic demand
•Anemias
•Thyrotoxicosis
•Fever
• beri beri
•Paget’s disease
•A V fistulas
•Pulmonary emboli
•Systemic emboli

14. Mechanism
• cardiac reserve – heart’s ability to increase
output in response to stress.
• The normal heart increases its output up to 5
times the resting level.
• The failing heart ,even at rest, however, is
pumping near its capacity & thus has lost much
of its reserve.

15. Compensatory mechanisms
The compensatory responses to a decrease
in cardiac output are
• Ventricular hypertrophy
• Increased sympathetic nervous system
stimulation
• Activation of renin - angiotensin system.
• Counter –regulatory mechanism with ANP
& BNP

16. Ventricular Dilatation and
hypertrophy
• Lengthening of the muscle fibers that
increases the volume in the heart chambers.
• Dilatation causes an increase in preload &
thus cardiac output.
• STARLING’S LAW : a stretched muscle
contracts more forcefully
• But muscle stretched beyond certain point is
ineffective & also dilated heart requires more
oxygen.

17. Increased SNS stimulation
• Sympathetic stimulation leads to release of
catecholamine which cause venous & arteriolar
constriction, tachycardia & increased myocardial
contractility which further increases cardiac
output
• Sympathetic stimulation reduces renal blood flow
& stimulates renin-angiotensin system.

18. Stimulation of the Renin-
Angiotensin system
Blood flow through renal artery is decreased
↓
RENIN released into blood
Angiotensinogen → Angiotensin I → Angiotensin II
ACE
↓
arteriolar vasoconstriction
↓
release of aldosterone
← from renal medulla

19. vasoconstrictors
• Angiotensin II
• ADH
• catecolamines
• Endothelin
Countor regulatory mediators
• ANP
• BNP
• Bradykinin
• Dopamin
• Prostaglandin
• Nitric oxide(endothelium derived relaxing factors)

20. Pathophysiology

23. TYPES OF HEART FAILURE
Systolic vs diastolic heart failure
LVF vs RVF
Backward vs Forward
High output vs Low output
Acute vs Chronic

24. New York Heart Association (NYHA) Classification of Heart Failure
CLASSIFICATION
SYMPTOMS PROG-
NOSIS
I Ordinary physical activity does not Cause
undue fatigue, dyspnoea, Palpitations, or
chest pain. No pulmonary congestion or
Peripheral hypotension Patient is considered
asymptomatic Usually no limitations of
activities Of daily living.
Good
II Slight limitation on adls. Patient reports no
symptoms at rest But increased physical
activity will Cause symptoms Basilar
crackles and S3 murmur may be detected
Good
III Marked limitation on ADL Patient feels
comfortable at rest. But less than ordinary
activity Will cause symptoms
Fair
IV Symptoms of cardiac insufficiency At rest Poor

25. Clinical manifestations of CHF
Left sided failure
Dyspnea
Ventricular gallop S3
Orthopnea
Paroxysmal nocturnal dyspnea
Dry hacking cough
Crackles
Decrease UO
Weight gain
Altered digestion
Dizziness
Light headedness
Confusion
Restless and anxiety
Pale cold clammy skin
Tachycardia
Fatigue
insomnia

26. Right sided failure
• peripheral edema
• hepatomegaly
• abdominal pain
• cardiac cirrhosis
•Anorexia
•Ascites
•Bloating
• anxiety
• nausea
• depression
• hepatojugular reflex
•Cardiac cachexia
•Pitting edema
• Increased JVP.

28. Hepatojuglar reflex

29. Study of Fatigue and Associated Factors in
Patients with Chronic
Heart Failure
Background: Many factors may be involved in fatigue of patients with
chronic heart failure (CHF).
Objectives: The present study was conducted to determine fatigue and
associated factors in patients with heart failure.
Methods: The present descriptive-analytical study was conducted on
patients with CHF admitted to Imam Sajjad hospital of Ramsar in 2014.
Data collection tools included: 1) multidimensional assessment of
fatigue (MAF) scale, 2) the Pittsburgh sleep quality index (PSQI), 3) the
hospital anxiety and depression scale (HADS), and 4) demographic
characteristics form and the hemoglobin and ejection fraction (EF)
records. Data collection was done through interviews and
observations.

30. Results: The study was conducted on 100 CHF patients with a
mean age of 68.8 11.7 years. Overall, 69% of the patients
reported fatigue, and 60.6% claimed severe fatigue. Fatigue was
found to be significantly related to sleep disorders and anxiety,
but not to depression and hemoglobin. Fatigue was
predominantly affected by anxiety.
Conclusions: The results of the present study showed that a
high percentage of patients with CHF experience fatigue
.Fatigue is a subjective phenomenon that is often less attended
to and needs to be clinically assessed; to promote health care
in these patients, it is required to consider factors such as
mood disorders (anxiety and depression) and sleep disorders.
Continue…..

31. Diagnosis
FRAMINGHAM CRITERIA
Major Criteria
• Paroxysmal nocturnal dyspnea
• Neck vein distension
• Cardiomegaly
• Pulmonary edema
• Gallop
• Increased JVP
• Hepatojugular reflex

32. Diagnosis (contd….)
Minor Criteria
• Peripheral edema
• Night cough
• Dyspnea on exertion
• Tachycardia >120 bpm
• Pleural effusion
• Hepatomegaly
• Decreased vital capacity

33. Investigations
Noninvasive method of diagnosis
• Echocardiography coupled with Doppler flow studies
• Radionucliode ventriculography
• Chest X Ray
• ECG
• Cardiac stress test

34. Investigation
• Lab investigation
 Serum electrolytes
 BUN, creatinine
 LFT, TFT,CBC, BNP, routine urine
analysis
Invasive method of diagnosis
• Ventriculography as a part of cardiac
catheterization procedure

35. Medical management

36. Pharmacological therapy
• ACE inhibitors
• Angiotensin receptor blockers
• Hydralazine and isosorbide dinitrate
• Beta adrenergic blocking agent
• Diuretic
• Digitalis
• Milrinone
• Dobutamine
• Other medication statins , anticoagulants, antiarrythmic

38. Medical management
•Improve ventricular pump performance
Oxygen, digoxin, inotropes
•Reduce workload
Reduce afterload
Reduce preload
Position the client
Reduce fluid retention
Use Ventricular assist devices
Reduce Stress & risk for injury

39. Medical management
1. Improve ventricular pump performance
•Supplemental oxygen :
• partial rebreather masks with a flow rate of 8-10
L/min can be used to deliver O2 concentration of
40-70%.
•If still PaO2 is < 60 mm Hg, need for intubation
•For severe bronchospasm give bronchodilators
•Digoxin : Increase force of contraction, slows
conduction, increase CO

40. MEDICAL MANAGEMENT
Inotropes : facilitates myocardial contractility &
enhance stroke volume
• Dopamine –
 small doses (<4ug/kg/min)-vasodilatation
 mod doses ( 4-8 ug/kg/min)- increases HR
 high doses (>10 ug/kg/min)-vasoconstriction
• Dobutamine – synthetic derivative of Dopamine.
increases HR,AV conduction,
contractility
 Amrinone – positive inotrope, Increases renal flow &
GFR

41. Medical Management
2. REDUCE WORKLOAD
• REDUCE AFTERLOAD
Direct dilation of veins : nitroglycerine
Dilation of Arterioles : ACE inhibitors
Combined action on veins & arterioles : sodium –nitroprusside
Inhibit SNS : beta blockers
• REDUCE PRELOAD
Diuretics

42. Medical management (contd….)
• Position the client : High fowlers
position.
• Legs maintained in dependent position.
• Reduce fluid retention :
• Sodium restriction (2-4 g)
• Restrict fluid intake

43. NON SPECIFIC CARE
• Bed rest is necessary for heart failure grade
4 or acute heart failure.
• Heparin 5,000 units s/c every 12 hrs to
prevent thromboembolism.
• oxygen is given for patients with symptoms
of pulmonary congestion.

44. Medical management
• Ventricular assist devices
• IABP
• Implantable ventricular assist devices
• Artificial heart

45. Ventricular assist device

46. INTRA AORTIC BALLOON PUMP

48. Artificial heart
.

49. SURGICAL MANAGEMENT
• Heart transplantation
• Cardiomyoplasty

50. Lifestyle modifications
•Restriction of dietary sodium
•Avoidance of smoking
•Avoid excessive fluid and alcohol
intake
•Weight reduction
•Regular excercise

51. Complications
• Cardiogenic shock
• Dysrhythmias
• Thromboembolism
• Pericardial effusion & cardiac tamponade
• Pulmonary edema
• Pleural effusion

52. Nursing management

53. Impaired gas exchange r/t pulmonary
edema
• Identify & assess data pertaining to early diagnosis
• Assess risk factors
• Assess most typical physical findings
• Assess for alteration in lung functions like
hypoxemia, atelectasis, abnormal lung sound, work
of breathing.
• Assess characteristics of pain
• Monitor ABG

54. Continue…
• Administer oxygen therapy
• Position properly for maximum lung expansion
• Prepare & schedule activities to conserve energy
• Teach deep breathing & coughing exercise
• Chest physiotherapy

55. Fluid volume excess r/t decreased
cardiac output & altered renal
hemodynamics
• Assess daily weight, JVD, ascitis, abdominal girth,
edema
• Monitor intake-output
• Auscultate breath sound
• Restrict sodium & fluid as prescribed.
• Administer drug as prescribed.

56. Decreased CO r/t increased or
decreased preload, increased afterload,
decreased contractility.
• Assess s&s of decreased CO
• Weigh daily & keep record of I/O
• position the patient in semi fowler’s position.
• If increased preload is a problem restrict fluid as
ordered.
• If decreased preload is a problem increase IVF &
closely monitor to increase ECF

57. • Tell patient to avoid activities that create a
valsalva response
• Provide frequent ,small meals low in
sodium.
• Discourage smoking and intake of caffeine
containing foods and beverages and
gradually increase activities of daily living.

58. Continue….
• Administer medication as ordered : diuretics,
inotropics, vasodilators, ACEI,antiarrhythmics
• If conditions becomes acute or does not respond
to therapy, anticipate the following
• IABP
• VAD
• IV ionotrops
• Heart transplantation

59. Alternations in electrolyte balance r/t
increased total body fluid, diuretic
therapy.
• Monitor serum electrolytes ,fluid losses &
gains
• Assess for ECG changes
• Monitor digoxin levels
• Institute specific interventions for specific
electrolyte imbalances

60. Decreased activity tolerance r/t
decreased Cardiac output
• Assess pt’s current level of activity
• Assess potential for physical injury with activity
• Evaluate need for oxygen during physical activity
• Restrict strenuous activities
• Use slow progression of pt activity to prevent
sudden increase in cardiac workload

61. Impaired skin integrity r/t edema
• Observe conditions of skin; stage of pressure sores.
• Implement pressure relieving mattress
• Increase tissue perfusion by massaging around the
area
• Provide skin care
• Encourage adequate hydration & nutrition
• Encourage ambulation if pt is stable.

62. Altered nutritional status r/t
decreased appetite ,GI irritability
• Assess eating habits & calorie intake
• Assess compliance with drugs, weight, skin turgor,
GI status.
• If pt is experiencing decreased appetite alter
medication schedule if possible.
• Assist family & individual in adjustment to dietary
regimen.
• Provide simple written verbal instructions
• Provide emotional support.

63. Anxiety r/t dyspnea, role change,
threat of death , knowledge deficit
• Assess for S & S of anxiety.
• Assess causative factors, previous coping
mechanisms, response to interventions.
• Assess knowledge level & readiness to learn.
• Establish rapport
• Avoid excessive stimuli
• Impart knowledge

64. High risk for digitalis toxicity r/t
impaired excretion
• Assess pt’s clinical response to therapy.
• Monitor ECG and S&S of electrolyte imbalance
• Assess hydration status
• Monitor pt’s for factors that increase risk for
toxicity.
• Take pulse before administering drugs.
• Monitor for GI side effects like anorexia,nausea,
vomiting

65. Sleep pattern disturbances r/t anxiety,
physical discomfort, treatment
• Assess current sleep pattern & sleep history
• Assess for possible deterrents to sleep : nocturia,
fear of PND
• Avoid evening or bed time diuretic
• Adjust medication schedule to provide for
undisturbed night if possible
• Discourage day time napping & increase day time
activity

66. Self concept disturbances r/t illness
• Foster independence by identifying factors that
patient can change & control
• Encourage activities that may help patient reach
goals
• Provide private non hurried environment conducive
to expression of feelings
• Maintain patient’s dignity; do not judge or overlook
preferences.

67. Knowledge deficit r/t diagnosis,
treatment, new medication etc…
• Assess willingness & motivation of patient & others to learn.
• Educate pt & others about :
• Normal heart & functioning
• CHF disease process
• Factors that increase risk of disease progression
• Medications & goals of medical therapy
• Importance of medication adherence
• Dietary modifications
• Activity guidelines
• Psychological aspects & community resources

68. Non compliance r/t expensive therapy,
change in life style, lack of knowledge,
side effects of medications .
• Assess patients life-style & habits.
• Assess patients willingness to be compliant.
• Determine cause of noncompliance
• Explore with patients alternate coping strategies.
• Monitor & reinforce compliant behavior.

69. SUMMARY
• Definition
• Etiology
• Pathophysiology
• Types
• Clinical manifestations
• Diagnosis
• Medical & surgical management
• Nursing management

70. Conclusion
Congestive Heart failure is a common
disabling and deadly condition. Heart failure
is associated with significantly reduced
physical and mental health, resulting in a
markedly decreased quality of life. By
changing lifestyle it can be prevented and if it
already occurs early diagnosis and treatment
can prevents mortality associated with it

71. References
Joyce M. Black, jane hokanson hawks.
Medical surgical nursing. 7th edition.
Saunders.
Janice l. hinkle, Kerry h. cheever, Brunner &
Suddarth’s text book of medical surgical
Nursing.13th edition. New delhi. Wolters
Kluwer.2014.

72. • Susan L. woods, Erika sivarajan froelicher,Sandra
adams,. Cardiac nursing. 5th ed. Newyork.
Lippincott Williams & wilkins. 2015.
• Mahboobeh Nasiri,1 Behnaz Rahimian.et al. Study
of Fatigue and Associated Factors in Patients with
Chronic Heart Failure. Crit Care Nurs J. 2016.
9(3):e8124.
Continue….

73. THANK YOU