right and left congestive heart failure
DESCRIPTION
Right and Left Congestive Heart Failure, its prevention, management, medical treatment and its pathophysiology.TRANSCRIPT
Presented by: Dave Jay S. Manriquez RN.
CONGESTIVE HEART FAILURE
A state of circulatory congestion produced by myocardial dysfunction MI compromises myocardial function by reducing contractility and
producing abnormal wall motion. The ability of the ventricle to empty lessens, the stroke volume falls,
residual volume increases. Heart failure is the inability of the heart to pump the amount of
oxygenated blood necessary to affect venous return and to meet the metabolic requirements of the body.
GENERAL INCIDENCE RATE
- CHF is present in 2 percent of persons age 40 to 59, more than 5 percent of persons age 60 to 69, and 10 percent of persons age 70 and older.
- Prevalence is at least 25 percent greater among the black population than among the white population.
- Prevalence at each age increased substantially between two periods surveyed nationally: 1976-80 and 1988-91
WORLD HEALTH ORGANIZATION
- More than 22 million people worldwide suffer from congestive heart failure.
INCIDENCE IN THE PHILIPPINES
- Out of the 86,241,697 people in the Philippines, 1,521,912 have Congestive Heart Failure
- CHF is the 6th leading cause of mortality in the Philippines, affecting males more often than females.
TYPES OF CONGESTIVE HEART FAILURE
Right Ventricular Failure, Left Ventricular Failure Because the two ventricles of the heart represent two separate
pumping systems, it is possible for one to fail alone for a short period.
Most heart failure begins with left ventricular failure and progresses to failure of both ventricles
Acute pulmonary edema, a medical emergency, results from left ventricular failure.
If pulmonary edema is not treated, death will occur from suffocation because the client literally drowns in his or her own fluids
Forward Failure, Backward Failure In forward failure, an inadequate output of the affected ventricle
causes decreased perfusion to vital signs. In backward failure, blood backs up behind the affected ventricle,
causing increased pressure in the atrium behind the affected ventricle.
Low Output, High Output In low-output failure, not enough cardiac output is available to
meet the demands of the body. High-output failure occurs when a condition causes the heart to
work harder to meet the demands of the body.
Systolic Failure, Diastolic Failure Systolic failure leads to problems with contraction and ejection of
blood. Diastolic failure leads to problems with the heart relaxing and
filling with blood.
CAUSES OF CONGESTIVE HEART FAILURE
Intrinsic Myocardial Infarction Cardiomyopathy/myocarditis Congenital heart disease Valvular heart defects Percarditis/cardiac tamponade
Extrinsic Systemic hypertension Chronic obstructive pulmonary disease Pulmonary embolism Anemia Thyrotoxicosis Metabolic/respiratory acidosis Blood volume excess/polycythemia Drug toxicity Cardiac dysrhythmias
Metabolic diseases
PATHOPHYSIOLOGY (see separate page for pathophysiology)
Congestive Heart Failure Left-sided CHF Right-sided CHF
SIGNS AND SYMPTOMS OF CONGESTIVE HEART FAILURE
Comparison of Left and Right CHFLeft-sided Congestive Heart Failure Right-sided Congestive Heart Failure
Signs of pulmonary congestion
Dyspnea Tachypnea Crackles in
the lungs Dry, hacking
cough Paroxysmal
nocturnal dyspnea Increased BP
(from fluid volume excess)
Dependent edema (legs and sacrum)
Jugular vein distention Abdominal distention Hepatomegaly Splenomegaly Anorexia and nausea Nocturnal diuresis Swelling of the fingers and
hands Increased BP (from fluid
volume excess)
*** Assessment Findings of Acute Pulmonary Edema Severe dyspnea and orthopnea Pallor Tachycardia Expectoration of large amounts of blood-tinged, frothy sputum Wheezing and crackles on auscultation Bubbling respirations Acute anxiety, apprehension, restlessness Profuse sweating Cold, clammy skin Cyanosis Nasal flaring Use of accessory breathing muscles Tachypnea Hypocapnia, evidenced by muscle cramps, weakness, dizziness and
paresthesias
COLLABORATIVE MANAGEMENT
Medications Digitalis Therapy
Major therapy for CHF Has positive inotropic (strengthens force of cardiac
contractility) and negative chronotropic effects (decreases heart rate)
DOC: Lanoxin (Digoxin) Antidote for Toxicity: Digibind Nursing Responsibilities
Assess heart rate before administration; if below 60 bpm or above 120 bpm, withhold the drug.
Monitor serum potassium Assess for signs of Digitalis toxicity
- Bradycardia- GI manifestations (anorexia, nausea, vomiting and
diarrhea)- Dysrhythmias- Altered visual perceptions- In males: gynecomastia, decreased libido and
impotence
Diuretic Therapy To decrease cardiac workload by reducing circulating
volume and thereby reduce preload
Commonly used diuretics: Thiazides: Chlorthiazide (Diuril) Loop diuretics: Furosemide (Lasix) Potassium-Sparing: Spironolactone (Aldactone)
Nursing Responsibilities Assess for signs of hypokalemia when administering
loop and thiazide diuretics. Give potassium supplement and potassium-rich
foods. Administer early in the morning or early in the
afternoon to prevent sleep pattern disturbance related to nocturia.
Vasodilators To decrease afterload by decreasing resistance to
ventricular emptying Commonly used vasodilators:
Nitroprusside (Nipride) Hydralazine (Apresoline) Nifedipine Captopril (Capoten)
Other Drugs Sympathomimetics
Dopamine Dobutamine
TREATMENT
Diet: sodium-restricted diet to prevent fluid excess Activity: balanced program of activity and rest Oxygen Therapy: to increase oxygen supply
NURSING MANAGEMENT
Providing Oxygenation Administer oxygen therapy per nasal cannula at 2-6 LPM as
ordered Evaluate ABG analysis results Semi-Fowler’s or High-Fowler’s position to promote greater lung
expansion
Promoting Rest and Activity Bed rest or limited activity may be necessary during the acute
phase Provide an overbed table close to the patient to allow resting the
head and arms Use pillows for added support when in High-Fowler’s position Administer Diazepam (Valium) 2-10 mg 3-4x a day as ordered to
allay apprehension Gradual ambulation is encouraged to prevent risk of venous
thrombosis and embolism due to prolonged immobility Activities should progress through dangling, sitting up on a chair
and then walking in increased distances under close supervision Assess for signs of activity intolerance (dyspnea, fatigue and
increased pulse rate that does not stabilize readily)
Decreasing Anxiety Allow verbalization of feelings Identify strengths that can be used for coping Learn what can be done to decrease anxiety*** Anxiety causes increased breathlessness which may be perceived by the client as an increase in the severity of the heart failure and this in turn increases anxiety.
Facilitating Fluid Balance Control of sodium intake Administer diuretics and digitalis as prescribed Monitor I and O, weight and V/S Dry phlebotomy (rotating tourniquets)
Providing Skin Care Edematous skin is poorly nourished and susceptible to pressure
sores Change position at frequent intervals Assess the sacral area regularly Use protective devices to prevent pressure sores
Promoting Nutrition Provide bland, low-calorie, low-residue with vitamin supplement
during acute phase Frequent small feedings minimize exertion and reduce
gastroistestinal blood requirements There may be no need to severely restrict sodium intake of the
client who receives diuretics. “No added salt” diet is prescribed. No processed foods in the
diet.
Promoting Elimination Advise to avoid straining at defecation which involves Valsalva
manoeuvre. Administer laxative as ordered Encourage use of bedside commode
Facilitating Learning Teach the client and his family about the disorder and self-care Monitor signs and symptoms of recurring CHF (weight gain, loss
of appetite, dyspnea, orthopnea, edema of the legs, persistent cough and report these to the physician)
Avoid fatigue, balance rest with activity Observe prescribed sodium restrictions SFF rather than 3 large meals a day Take prescribed medications at regular basis Observe regular follow-up care as directed
*** If acute pulmonary edema occurs in the client with CHF, the following are the appropriate management:
High-fowler’s position Morphine Sulfate 10-15mg/IV as ordered to allay anxiety, reduce
preload and afterlaod Oxygen therapy at 40-70% by nasal cannula or face mask
Aminophylline IV to relieve bronchospasm, increase urinary output and increase cardiac output
Rapid digitalization Diuretic therapy Dopamine and Dobutamine Monitor serum potassium. Diuresis may result to hypokalemia.
PROGNOSIS
- The prognosis depends on the patient's age, the severity of the heart failure, the severity of the underlying heart disease and other factors.
- When congestive heart failure develops suddenly and has a treatable underlying cause, patients can sometimes return to normal heart function after treatment.
- With appropriate treatment, even individuals who develop congestive heart failure as a result of long- standing heart disease can often enjoy many years of productive life.
PATHOPHYSIOLOGYOF
CONGESTIVE HEART FAILURE
PATHOPHYSIOLOGY OF LEFT-SIDED CONGESTIVE HEART FAILURE
CAUSES Heart Damage Ventricular Overload Decreased Ventricular Contraction
TachycardiaVentricular Dilatation
Myocardial Hypertrophy
Decreased Cardiac Output
Decreased Renal Perfusion
Increased Sodium Restriction
Increased Osmotic Pressure
Increased ADH
Increased Water Reabsorption
Fluid Overload Edema
CAUSES: MI HPN Aortic Stenosis/ Insufficiency Mitral Stenosis/ Insufficiency
Reduced Myocardial ContractilityIncreased Cardiac WorkloadDecreased Diastolic Filling
Obstruction of Left Atrial Emptying
Increased Left Atrial Pressure
Left-Sided Congestive Heart Failure
Blood damns back into the pulmonary capillary bed
Pressure of blood into the pulmonary capillary bed increases
Fluid shifts into the intra- and interalveolar spaces
Pulmonary Edema
Decreased stroke volume
Decreased tissue perfusion
Increased cellular hypoxia
Signs and symptoms of LSCHF
Decreased blood flow to the
kidneys
Signs and Symptoms of LSCHF: Dyspnea Paroxysmal Nocturnal
Dyspnea Orthopnea Rales/Crackles Moist Cough Blood Tinged Frothy Sputum Wheezing/ Cardiac Asthma Dizziness Syncope Fatigue Weakness Anorexia Hypokalemia Clubbing of Fingers Polycythemia S3S4 Heart Sounds or Pulsus
Alternans
Decreased blood flow to the kidneys
RAAS Stimulation
Vasoconstriction and Reabsorption of Sodium and WaterIncreased ECF Volume
Increased Total Blood Volume
Increased Systemic BP
PATHOPHYSIOLOGYOF
RIGHT-SIDED CONGESTIVE HEART FAILURE
CAUSES: LSCHF Pulmonary Embolism Right Ventricular Infarction Congenital Septal Defects
Reduced Myocardial ContractilityIncreased Cardiac WorkloadDecreased Diastolic Filling
Obstruction of Right Atrial Emptying
Increased Right Atrial Pressure
Right-Sided Congestive Heart Failure
Blood drums back from the RV to RA
Increased Pressure in the Venous Circuit (Venous Back-
up)
Signs and Symptoms of RSCHF
Signs and Symptoms of RSCHF: Neck Vein Engorgement (Jugular
Vein Distention) Hepatomegaly Portal Hypertension leading to
Cardiac Cirrhosis Ascites Peripheral Edema (Pitting/
Dependent) Splenomegaly Jaundice Hemolytic Anemia Internal Hemorrhoids Leg Varicosities Weight Gain S3S4 Heart Sounds Elevated CVP Reading
***The RSCHF which results from pulmonary disorders is called COR PULMONALE.