Congestive Heart Failure By Dr. Hanan Said Ali

Objectives Define congestive heart failure. Enumerate causes of congestive heart failure. Explain how to assess patients physically and physiologically. Identify principles of care. Identify nursing care for patients with congestive heart failure.

Congestive Heart Failure Definition Acute heart failure is pump failure due to ischemia or infarction. Causes Myocardial infarction Drugs as Beta blocker Dysrhythmias Valve dysfunction Ventricular septal defect

Causes Cont. Pericardial tamponade Constrictive pericarditis Haemorrhage and anaemia Pulmonary embolus Cardiomyopathy Hypertension Thyrotoxic crisis Wet beri – beri ( vitamin B deficiency) myocaditis

Assessment ( Signs & Symptoms.) Physical assessment Skin Cyanosis, pallor, and sweating. Organ hypoperfusion produces cold. Peripheral oedema. Respiration The patient may be tachypnoeic. Blood- stained frothy sputum as a result of pulmonary oedema. Wheeze

Physical assessment Cont. General The patient may show signs of generalized weakness and fatigue. Auscultation Fourth heart sound may be heard. Crepitation may be heard at the lung bases in left heart failure.

Physiological Assessment CVP will be high with right- sided heart failure. Blood pressure may be low, normal, or high. Heart rate tachycardia will usually be evident unless bradycardia is the main cause of failure. Renal function urine output may be reduced and renal dysfunction evident from blood urea and creatinine levels

Neurological/Psychological assessment The patient may exhibit anxiety and distress, drowsiness, confusion as a result of poor cardiac output and cerebral hypoperfusion.

Investigations 12- lead ECG Chest x- ray Blood investigation ( urea, electrolytes, haemoglobin, glucose, cardiac enzymes, and brain type natriuretic peptide, this released into bloodstream from the ventricle when it is excessively stretched.

Priorities of care Basic resuscitation measures are aimed at restoring an adequate circulation as quickly. Administration of high – flow, high- concentration oxygen. vasodilators, and diuretics

Priorities of care Diamorphine 2.5mg IV, reassurance, information and comfort. Mechanical ventilation.

Principles of care Monitoring Continuous ECG monitoring. Pulse oximetry and frequent BP monitoring. Invasive arterial pressure and CVP monitoring. Rest The heart can be rested by reducing the work of breathing through mechanical ventilation.

Principles of care Optimizing intravascular fluid volume The circulating volume should be optimized before introducing other drugs. Supporting the cardiac output. In low- output states the tissues compensate for the decrease in oxygen delivery by extracting more oxygen .

Principles of care Therapies Diuretic Cause an initial vasodilatation followed, 20- 30 min later, by a diuresis. Nitrates Can be given rapidly either by oral or sublingual while an infusion is being prepared. ( A drop in blood pressure on a low- dose infusion is suggestive of hypovolaemia)

Principles of care Calcium sensitizer agent Improves ventricular contractility and vasodilates peripherally without having a major impact on cardiac work. Mechanical ventilation

Nursing care plan Activity intolerance related to fatigue secondary to cardiac insufficiency. Expected outcome Nursing intervention Tolerate activity, have needs met to satisfaction Have the patient rest in bed (high fowler's position) or chair when tired Provide emotional and physical rest to reduce oxygen consumption and relieve dyspnea and fatigue. If in bed teach leg exercise to prevent DVT Assess patient daily for dyspnea fatigue, pulse rate to determine level of activity

Nursing care plan Impaired gas exchange related to increased preload mechanical failure or immobility. Expected outcome Nursing intervention Have respiratory rate of 12-18/ min Elevate head of bead to high fowlers position to improve ventilation. Support patients arms on pillows to move arm off and away from chest to facilitate breathing. Administer oxygen by nasal cannula to improve O2 saturation. Auscultate for lung and heart sounds& use pulse oximetry.

Nursing care plan Fluid volume excess related to pump failure. Expected outcome Nursing intervention Have reduced or absence of oedema Evaluate degree of peripheral oedema and measure abdominal girth daily Administer digitalis ( Digoxin)to improve cardiac output and contractility & diuretics to mobilize oedematous fluid. Assess intake and output & and weight patient daily. Provide salt restricted diet. Observe for hypokalemia.

Nursing care plan Sleep pattern disturbance related to nocturnal dyspnea. Expected outcome Nursing intervention Feel rested after sleep Explain etiology of nocturnal dyspnea to reduce fear . Explore with patient alternative position of comfort such as sleeping with two or more pillow to relieve dyspnea. Have patient take diuretics early in the day to decrease urination during night.

Nursing care plan Potential impaired skin integrity related to oedema or immobility Expected outcome Nursing intervention Have no break down of skin at oedematous areas Identify location and severity of oedema. Handle oedematous skin gently. Pad bony prominences to reduce pressure and skin breakdown. Perform passive ROM exercise to extremities to facilitate venous return of fluid.

Nursing care plan Anxiety related to dyspnea or perceived threat to death Expected outcome Nursing intervention Express feeling less apprehensive about condition and prognosis. Asses facial expression and behaviour for feeling of apprehension Allow patient to ask questions to relieve anxiety. Demonstrate calm behaviour to improve confidence.. Use measures to decrease dyspnea.

Nursing care plan Self care deficit related to dyspnea and fatigue Expected outcome Nursing intervention Achieve ADL with assistance as necessary Assist patient with all ADL to meet patient needs and to relieve anxiety. Give small, easy digested food. Advise family of patients fluctuating abilities regarding self care activities.

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