AN-Najah National UniversityFaculty of Nursing

Cardiovascular DiseasesManagement & Nursing Care

Prepared by : : Masoudeh Assaira

Fadia qasim Supervised by: Miss Shurouq qadose

2006

Heart failure is a condition in which the heart can’t pump enough blood throughout the body. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way that it should. The heart can’t fill with enough blood or pump with enough force, or both.

Heart failure develops over time as the pumping action of the heart grows weaker. It can affect the left side, the right side, or both sides of the heart. Most cases involve the left side where the heart can’t pump enough oxygen-rich blood to the rest of the body. With right-sided failure, the heart can’t effectively pump blood to the lungs where the blood picks up oxygen.

The weakening of the heart’s pumping ability causes:

1- Buildup Blood and fluid to "back up" into the lungs

2- The buildup of fluid in the feet, ankles, and legs

3- Tiredness and shortness of breath

Heart failure is a serious condition. About 5 million people in the United States have heart failure, and the number is growing. Each year, another 550,000 people are diagnosed for the first time. It contributes to or causes about 300,000 deaths each year.

Other names for heart failure

Congestive heart failure (when the poor pumping function results in symptoms)

Left-sided heart failure Right-sided heart failure Systolic heart failure Diastolic heart failure

The major causes of CHF may be divided in to two subgroups1- underlying diseases e.g.Coronary artery diseaseHypertensive heart diseaseCongenital heart diseaseAcute myocardial infarctionPulmonary emboli

2- Precipitating causes e.g.AnemiaInfectionBacterial endocarditicPulmonary embolismHypervolemia Nutritional deficiencies

Precipitating causes often increase the workload of the ventricles, causing a decompen -sated condition that leads to decreased myocardial function .

Pathology of ventricular failure

Heart failure can be described as systolic or diastolic :

Systolic failure , the most common cause of CHF, results from an inability of the heart to pump blood .

It is a defect in the ability of the ventricles to contract (pump) the left ventricle loses its ability to generate enough pressure to eject blood forward through the high pressure aorta.

Systolic failure is caused by impaired contractile ( e.g., myocardial infarction ) , increased after load (e.g., hypertension ), cardiomyopathy, and mechanical abnormalities ( e.g., valvular heart disease ) .

Diastolic failure is an impaired ability of the ventricles to fill during diastole. decreased filling of the ventricles will result in decreased stroke volume. In diastolic failure there is normal systolic function .

. It is characterized by high filling pressures and the resultant venous engorgement in both the pulmonary and systemic vascular . It is usually the result of left ventricular hypertrophy from chronic systemic hypertension, aortic stenosis, or hypertrophic cardiomyopathy .

Mixed systolic and diastolic failure

Systolic and diastolic failure of mixed origin is seen in disease states such as dilated cardiomyopathy, a condition in which poor systolic function is further compromised by dilated left ventricular walls that are unable to relax.

This patient often has extremely poor ejection fractions , high pulmonary pressures , and biventricular failure ( both ventricles may be dilated and have poor filling and emptying capacity ) .

Types of congestive heart failure

Left- sided failure results from left ventricle dysfunction,

which causes blood to back up through the left atrium and into the pulmonary veins .

Right – sided failureCauses back ward blood flow to the right

atrium and venous circulation .venous congestion in the systemic circulation result in peripheral edema, hepatomegaly, splenomegaly vascular congestion of the GT.

What Causes Heart Failure? Heart failure is caused by other diseases

or conditions that damage or overwork the heart muscle. Over time, the heart muscle weakens and is not able to pump blood as well as it should.

The leading causes of heart failure are: 1- High Coronary artery disease (CAD) CAD, including angina and heart attack is the

most common underlying cause of heart failure. People who have a heart attack are at high risk of developing heart failure.

2- Diabetes 3-High blood pressure Most people with heart failure also have high

Blood pressure, and about one in three has diabetes.

Other Causes of Heart Failure 1- Cardiomyopathy (a disease of the heart

muscle) 2- Diseases of the heart valves 3- Abnormal heartbeats or arrhythmias4- Congenital heart defects (a heart defect or

problem you are born with)

Other conditions that may injure the heart

muscle and lead to heart failure include: Treatments for cancer, such as radiation

and certain chemotherapy drugs

Thyroid disorders (having either too much or too little thyroid hormone in the body)

Alcohol abuse

HIV/AIDS

Cocaine and other illegal drug use

Who Is At Risk for Heart Failure? Heart failure can happen to anyone, but it’s

more common in:

People 65 years of age and older Heart failure is very common in people 65

years of age and older. It’s the #1 reason for a hospital visit in this age group.

African Americans African Americans are more likely to have

heart failure and suffer more severely why ?

Develop symptoms at an earlier age Have their heart failure get worse faster Have more hospital visits Die from heart failure

Men have a higher rate of heart failure than women. But in actual numbers, more women have heart failure because many more women live into their seventies and eighties, when heart failure is common.

Children with congenital heart defects can also have heart failure. Congenital heart defects happen when the heart, heart valves, and/or blood vessels near the heart do not develop correctly in babies when they are in the womb.

This can weaken the heart muscle and lead to heart failure. Children do not have the same symptoms or get the same treatment for heart failure as adults.

Clinical manifestations of congestive heart

failure

Fatigue Is one of the earliest symptoms of chronic

CHF.

Dyspnea Is a common manifestation of chronic

CHF. It is caused by increased pulmonary pressures secondary to interstitial and alveolar edema.

Tachycardia May be the first clinical manifestation of

CHF. One of the body's' first mechanisms to compensate for a failing ventricle is the increase the heart rate.

Edema It may occur in the legs, liver, abdominal

cavity, lungs .

Nocturia When the person lies down at night. Fluid

movement from interstitial spaces back into the circulatory system is enhanced . this causes increased renal blood flow and diuresis. The patient may complain of having to void six or seven times during the night .

Skin changes Because tissue capillary oxygen

extraction is increased in a person with CHF, the skin may appear dusky, may be cool to the touch from diaphoresis .

Behavioral changes

Cerebral circulation may be impaired with chronic CHF secondary to decreased CO. The patient may report usually behavior, including restlessness, confusion and decreased attention span or memory .

Chest pain Because of decreased coronary perfusion

from decreased CO and increased myocardial work.

Weight changes Many factors contribute weight

changes .Initially there may be a progressive weight gain from fluid retention. Abdominal fullness from ascites and hepatomegaly frequently cases anorexia and nausea .

The actual weight loss may be apparent until after the edema subsides .

Complications of congestive heart failure

- pleural effusion- Arrhythmias- Left ventricular thrombus- Hepatomegaly

Classification of congestive heart failure

The New York Heart Association has developed functional guidelines for classifying people with CHF. The classification is based on the persons' tolerance to physical activity .

Class 1 No limitation of physical activity.

Ordinary physical activity does not cause fatigue, dyspnea, palpitations, or anginal pain.

Class 2 Slight limitation of physical activity . No

symptoms at rest ordinary physical activity results in fatigue, dyspnea, palpitations or anginal pain .

Class 3Marked limitation of physical activity .

usually comfortable at rest. Ordinary physical activity causes fatigue, dyspnea, palpitation or anginal pain .

Class 4 Inability to carry on any physical activity

without discomfort. Symptoms of cardiac insufficiency or of angina may be present even at rest. If any physical activity is undertaken, discomfort in increased .

Nursing and collaborative management: A- For acute congestive heart failure.Goal: 1- Decreasing intravascular volume.

2- Decreasing venous return.

3- Decreasing after load.

4- Improving gas exchange and oxygenation.

5- Improving cardiac function.

6- Reducing anxiety.

B-For chronic congestive heart failure:

The main goal in the treatment of CHF is to:

1-Treat the underlying cause and contributing factors maximize CO.

2- Provide treatment to alleviate symptoms .

-Non pharmacologic therapy:New technique is the utilization of

biventricular pacing;. Cardiac resynchronization therapy coordinated right and lifts ventricle contractility through biventricular pacing.

- Cardiac transplantation:Is often the treatment of choice. However

the lack Of donor heartsand the challenges of care make it an

option for only a small number of patients with CHF.

Drug therapy :

1- Angiogenesis – converting enzyme inhibitors:

Inhibitors are useful in both systolic and diastolic heart failure. and they are the first treatment of CHF e.g., captopril , enalapril .

2- Diuretics are used in heart failure to mobilize edematous fluid ,reduce pulmonary venous pressure and reduce preload

- e.g., loop diuretics (lasix ) - potassium – sparing diuretic ( alductone ) .

3- Inotropic drugs: To improving cardiac contractility to increase CO, decrease LV diastolic pressure and decrease systemic vascular resistance

Examples: - Digoxin (lanoxin).- B- adrenergic agonists. (Dopamine,

dobutamine)- Calcium sensitizers (simdax).

- Vasodilator drugs . e.g., nitroprusside, nitroglycerin - B- adrenergic blockers e.g., carvedilol.

Nutritional therapy:Diet education and weight management:Are critical to the patient Control of

chronic CHF. The nurse should obtaindetailed diet history, determine not only

what but also the sociocultural value of food.

Nursing care plan for Congestive heart failure

1- Nursing diagnosis Activity intolerance related to fatigue secondary to cardiac insufficiency and pulmonary congestion as manifested by dyspnea, shortness of breath , weakness.

Nursing interventions:-

- Encourage alternate rest and activity periods to reduce cardiac workload

- Provide emotional and physical rest to reduce oxygen consumption and to relieve dyspnea and fatigue .

- Monitor cardio respiratory response to activity to determine level of activity that can be performed

- Teach patient techniques of self care to minimize oxygen consumption .

2-Nursing diagnosis excess fluid volume related to cardiac failure as manifested by edema, dyspnea on exertion, increased weight gain .

Nursing interventions:-

- Weigh daily and monitor trends to monitor fluid retention and weight reduction

-Monitor respiratory pattern for symptoms of respiratory difficulty.

- Monitor fluid intake and fluid output

- Monitor for therapeutic effect of diuretic to assess response to treatment .

- Monitor for serum electrolyte levels to assess as a response to treatment

3- Nursing diagnosis disturbed sleep pattern related to nocturnal dyspnea, nocturia as manifested by inability to sleep through the night .

Nursing interventions:-

- Determine patients / activity pattern to establish routine .

-Encourage patient to establish a bedtime routine to facilitate transition from wakefulness to sleep

- Adjust environment to promote sleep adjust medication administration schedule to support patients' sleep cycle

- Monitor patients' sleep pattern and number of sleep hours to determine hours of sleep .

4-Nursing diagnosis Impaired gas exchange related to increased preload , mechanical failure, or immobility manifested respiratory rate, dyspnea, shortness of breath .

Nursing interventions:-

- Monitor rate, depth, and effort of respirations

- Monitor for dyspnea and events that improve and worsen it .

- Administer oxygen supplemental as ordered to maintain oxygen levels .

- position to alleviate dyspnea( semi-fowler position )

- Monitor the effectiveness of oxygen therapy by measuring oxygen saturation .

5-Nursing diagnosis Anxiety related to dyspnea or perceived threat of death

Nursing interventions:-

-Explain all procedures, to promote sense of security .

- Instruct patient on the use of relaxation techniques to help alleviate anxiety

- Create an atmosphere to facilitate trust (e.g., make frequent checks )

6-Nursing diagnosis Deficient knowledge related to disease process as manifested by questions about the disease .

Nursing interventions:-

- Assess the patients' current level of knowledge about his condition

- Describe common signs and symptoms of the disease

- Instruct the patient on measures to prevent/minimize side effects of treatment for the disease

-Include family or significant others in teaching to provide support for the patient