cardiovascular Nursing Congestive Heart Failure.pptx

Congestive Heart Failure.

1. Congestive Heart Failure (CHF) 1

2. Objectives At the end of this lesson the student will be able to: Define congestive heart failure. List the etiologic agents Describe the Epidemiology Describe the pathophysiology Identify the clinical manifestation Describe the diagnostic approach Discuss the medical management Discuss the nursing management 2

3. Heart Failure HF is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. HF is a clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion. It occurs in patients who, because of an inherited or acquired abnormality of cardiac structure and/or function, 3

4. Epidemiology More than 20 million people affected. The overall prevalence of HF in the adult population in developed countries is 2% Rising with age, and affects 6–10% of people over age 65 4

5. Classification This may be further subdivided into either systolic or diastolic heart failure. Systolic heart failure : there is reduced cardiac contractility Diastolic heart failure there is impaired cardiac relaxation and abnormal ventricular filling. Right side HF Vs Left side HF 5

6. Etiology Left ventricular systolic dysfunction (about 60% -70% of patients) 1. Decreased contractile function a. Valvular heart disease b. Coronary Heart Disease: Myocardial ischemia c. Myocardial Disease: Cadiomyopathy , Myocarditis 2. Increased after load a. Systemic hypertension 3. Abnormalities in preload a. Excessive preload b. Reduced preload 6

7. Precipitating factors These are relatively acute disturbances that place an additional load on myocardium that is chronically and excessively burdened. 7

8. Precipitating factors… Mnemonic, HEART FAILES H - Hypertension (systemic) E - Endocarditis (infections) A - Anemia R - Rheumatic fever and myocarditis T - Thyrotoxicosis and pregnancy F - Fever (infections) A - Arrhythmia I - Infarction (myocardial) L - Lung infection E - Embolism (pulmonary) S - Stress (emotional, physical, environment, dietary, fluid excess) 8

9. Right Vs left side HF? Heart failure can be classified as right-sided heart failure, left-sided heart failure, or biventricular heart failure. The ventricle is the area of the heart’s pumping system that commonly fails. Of the two ventricles, the left ventricle is typically the one to weaken first because it has the greatest workload 9

10. Left-Sided Heart Failure After load : amount of force must be generated by the left ventricle during a contraction to eject blood into the aorta through the aortic valve Peripheral vascular resistance(PVR) The pressure within the aorta and arteries Major Cause – Hypertension Blood backs up from the left ventricle into the left atrium and then into the four pulmonary veins and lungs (pulmonary edema) SOB, cyanosis 10

11. Right-Sided Heart Failure Conditions causing right-sided heart failure increase the work of the right ventricle. When the right ventricle hypertrophies or fails because of increased pulmonary pressures, it is referred to as cor pulmonale 11

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13. Symptoms Fatigue and shortness of breath (cardinal symptoms) Initially exertional and it ultimately may occur even at rest 13

14. Symptoms… Orthopnea - dyspnea occurring in the recumbent position Paroxysmal Nocturnal Dyspnea (PND) Acute episodes of severe shortness of breath and coughing that generally occur at night and awaken the patient from sleep Productive cough of pink/ frothy sputum Others Anorexia, nausea, abdominal pain and fullness Confusion, disorientation, and sleep and mood disturbance, lightheadedness, restlessness, and anxiety (advanced CHF) Oliguria and nocturia 14

15. Symptoms… Past Medical History Rheumatic fever, Alcohol use, hypertension, Angina, Previous history of MI, and Familial history of heart disease 15

16. Physical Examination General appearance : In sitting position, labored breathing, uncomfortable Tachycardia and Tachypnea Jugular Vein Distention (JVD) Pulmonary crackles ( rales or crepitations ) PMI shift laterally or below 5 th ICS S 3 is audible and palpable at the apex MR and Tricuspid regurgitation in advanced disease Hepatomegally Peripheral edema , usually symmetric and dependent ankles and the pretibial region in ambulatory patients Pre-sacral area edema Ascites Skin may be diaphoretic or cold, and cyanotic 16

17. Diagnostic Workup Chest x-ray Echocardiography Electrocardiogram (ECG) Laboratory tests: Hemoglobin, Urinalysis, BUN, Creatinine TSH, CBC count, 17

18. New York Heart Association Classification (NYHA) Functional Capacity Objective Assessment Class I Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, dyspnea , or anginal pain. Class II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea , or anginal pain. Class III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea , or anginal pain. Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. 18

19. Management of Heart Failure Principles of management 1. Identify and treat the precipitating factors 2. Control the congestive state 3. Improve myocardial performance 4. Prevention of deterioration of myocardial function (slowing progression of heart failure ) 19

20. A. General Measures Dietary sodium restriction < 3 g/d. Activity and life style modification: Meals should be small in quantity but more frequent. Reduce anxiety and emotional stress Avoid excess physical exertion (NB. exercise may be advised within the limit of the patient’s cardiac function) Weight loss in encouraged in obese patients. Cessation of smoking Avoid other CVD risk factors 20

21. B. Control Congestion Diuretics : are useful in relieving congestion and reduce or prevent edema. Usually a loop diuretic is required, with the addition of a Thiazide diuretic in patients refractory to the loop diuretic alone. 1 . Fursemide : Initial dose 20-40 mg PO 1-2 X daily or 20 mg IV Maximum dose 400 mg PO/day or 80 mg IV /day 2 . Hydrochlorothiazide : Initial dose 25 mg PO/day Maximum dose 100 mg PO/day N.B. Loop and thiazide diuretics are useful for symptomatic relief; however they have not been shown to improve survival. 21

22. Congestion… Spironolactone : is an aldosterone inhibitor, For patients with moderately severe or severe heart failure ( class IV symptoms ) Initial dose: 25 mg PO/day or every other day 22

23. C. Enhancement of Myocardial contractility 1. Digoxin : is a drug which has : Inotropic effect and acts by inhibiting the Na+-K+ ATPase and increase intracellular calcium. This increases myocardial contractility. Initial dose: 0.125 mg PO/day Maximum dose: 0.25 mg PO/day The use of digoxin can improve symptoms, reduce the duration and the need for hospitalization in patients with heart failure, but has no effect on long term survival. 23

24. Vasodilators May be useful in patients with severe acute heart failure who demonstrate systemic vasoconstriction despite ACE inhibitor therapy. Through vasodilatation they reduce the peripheral resistance and afterload and improve cardiac performance. Hydralazine Isosorbide dinitrate 24

25. D. Prevention of deterioration of myocardial function 1. ACE Inhibitors Afterload reduction and neurohormonal modulation with ACE inhibitors have been shown to improve mortality, symptoms, and hospitalizations. E.g . Captropil , enalapril 25

26. Cont… 2. Angiotensin -II Receptor blocker These drugs are useful in patients who cannot tolerate ACE inhibitors due to different side effects like cough angioedema and leukopenia . Lasortan : Dose:- 25-50 mg once or twice daily 3. Beta - blockers Improve symptoms of heart failure, the need for hospitalization and reduce mortality. Indicated for moderately severe heart failure. Not indicated in unstable heart failure, hypotensive states, severe fluid overload, sinus bradycardia , AV block and asthma. E.g. Atenolol , Labetolol , Metoprolol … 26

27. Nursing process Subjective Lung disease? How many flights of stairs can be climbed without dyspnea ? How many pillows used for sleeping? Dyspnea at rest or that awakens from sleeping? Any cardiac disease history? Can activities of daily living be performed? Any dizziness (vertigo) or fainting (syncope)? Daily sodium intake? Weight gain? Are shoes tight? Do ankles swell? Is appetite good? Any nausea, vomiting, or abdominal pain? Decrease in daytime urine output? Any change in behavior? Knowledge of condition? Coping skills? Objective Tachypnea , crackles, wheezing, respiratory effort, dyspnea with exertion Tachycardia, dysrhythmias , jugular vein distention, peripheral edema—degree of pitting Abdominal distention, ascites , hepatomegaly , splenomegaly Confusion, decreased level of consciousness, restlessness, impaired Memory Cold, clammy skin; pallor; cyanosis Weight 27

28. Nursing diagnoses Activity intolerance related to fatigue caused by oxygen imbalance Excess fluid volume related to heart failure and the secondary reduction in renal blood flow for filtration Disturbed sleep pattern related to nocturia and inability to lie down and sleep comfortably 28

29. Nursing Interventions Provide rest, space activities, and conserve energy. Assist as needed with activities of daily living (ADLs). Teach use of assistive devices and lifestyle changes. 29

30. Nursing Interventions Monitor for edema, weight gain, Jugular vein distention (JVD), Lung crackles. Decrease sodium intake as ordered. Administer diuretics or inotropics as ordered. Monitor intake and output. Identify barriers to sleep. Assist patient in identifying positions of comfort for sleeping. Teach patient cause of dyspnea at night. Encourage patient to recline for 30 to 60 minutes before bedtime. 30

31. Summary HF is most common cardiac disorder It is a condition in which the heart is unable to pump effectively to meet the body’s needs for blood and oxygen to the tissues. HF is due to impaired myocardial contraction or excessive workload. Goals of heart failure management are to reduce the workload and improve its function. Medical management includes medication use including ACE-Is, beta-blockers, diuretics, and vasodilators to reduce the cardiac workload. Nursing care is primarily supportive and educative, providing the patient and family with the necessary knowledge and resources to manage this chronic condition. 31

32. Case Study Mr. Birara , age 66, has a family history of cardiac disease. He has been hypertensive for 10 years and takes captopril daily. His baseline vital signs are blood pressure 122/78, pulse 80, respiration 18, height 165cm, and weight 75kg. During a visit to his physician, he states that he has been short of breath during his daily 2-mile walk and has been using two pillows at night for sleep. As he talks, the physician notes that he has an intermittent dry cough. His physical examination shows blood pressure 140/86, pulse 106, respiration 24, weight 78 kg, and bilateral crackles in the lung bases. 1. What signs and symptoms of heart failure does Mr. Birara have? 2. Do the signs and symptoms reflect right- or left sided heart failure? 3. Why are each of the signs and symptoms occurring? 4. Why is Mr. Birara using two pillows for sleeping? 32

33. Case… Mr. Birara’s chest x-ray examination shows an enlarged heart ( cardiomegaly ). 1. Why is Mr. Birara’s heart enlarged? 2. What is the significance of an enlarged heart? 33

34. Case… During Mr. Birara’s visit, the physician tells him to continue the ACE inhibitor, the diuretic, and a 2gm sodium diet. 1. Why is the ACE inhibitor continued? 2. Will the ACE inhibitor affect preload or afterload ? 3. Why is the diuretic ordered? 4. Why is a 2gm sodium diet ordered? 5. What is the overall goal of the ordered treatment? 34

35. Case… The nurse meets with Mr. Birara after the physician orders the ACE inhibitor to be continued, a diuretic, and 2gm sodium diet. 1. What information should the nurse teach Mr. Birara’s based on the prescribed treatment? 2. What types of foods should be included in Mr. Birara’s diet? 3. Why does the nurse instruct Mr. Birara’s to weigh himself daily? 4. Why does the nurse tell Mr. Birara’s to weigh himself at the same time of day, on the same scale, and with the same type of clothing? 35