Nursing Management: Congestive Heart Failure

1. Nursing Management: Congestive Heart Failure Nurs1228 Spring 2003 By Nina Green, RN

2. Congestive Heart Failure “More than ½ deaths from heart disease are due to end stage CHF” “The American Heart Association estimates that 400,000 new cases of CHF occur each year” “The 5 year mortality rate for CHF is about 50%” Lewis

3. Congestive Heart Failure “In the past 15 years deaths from CHF have increased 116%” The rate of sudden cardiac death in a patient with CHF is 6 to 9 times higher than for the general population Lewis

4. Congestive Heart Failure “About 20% of individuals who have a heart attack will be disabled with heart failure within 6 years” “CHF is the single most frequent cause of hospitalization for people age 65 or older” Lewis

5. Risk Factors for CHF Coronary artery disease Hypertension High cholesterol levels Advancing age Cigarette smoking Obesity Proteinuria Diabetes

6. Normal mechanisms regulating Cardiac Output Preload volume Afterload volume Heart rate Myocardial contractility Metabolic state of the individual

7. Major causes of CHF Underlying cardiac disease Congenital acquired Precipitating causes Increase workload of ventricles Leads to decreased myocardial function

8. Acute cardiac disease causing CHF Acute MI Pulmonary Emboli Hypertensive crises Ventricular septal defect Arrhythmias Thyrotoxicosis Rupture of papillary muscle

9. Chronic cardiac disease causing CHF Coronary artery disease Rheumatic heart disease Cor pulmonale anemia Hypertensive heart disease Congenital heart disease Cardiomyopathy Bacterial endocarditis

10. Precipitating causes of CHF Anemia Thyrotoxicosis Arrhythmias Pulmonary embolism Paget’s disease hypervolemia Infection Hypothyroidism Bacterial endocarditis Pulmonary disease Nutritional deficiencies

11. Pathology of Ventricular Failure Systolic failure: causes ventricle not to empty properly (most common cause of CHF) Heart muscle has decreased ability to contract Also caused by increased afterload (hypertension), or mechanical abnormalities ( like valvular heart disease) Characterized by low forward blood flow

12. Pathology of Ventricular Failure Diastolic failure: causes ventricle not to fill properly Disorder of heart relaxation and ventricular filling Usually the result of ventricular hypertrophy Caused by chronic hypertension, aortic stenosis, or cardiomyopathy Commonly seen in older adults

13. Compensatory Mechanisms of the heart in CHF Ventricular dilation Increased sympathetic nervous system stimulation Ventricular hypertrophy Hormonal response (Renal response)

14. Types of CHF Left sided failure Back up of blood into the lungs Common causes are: CAD, HTN, cardiomyopathy and rheumatic heart disease Other causes can be: MI damage, ischemia, scar tissue (reducing contractility),

15. Types of CHF Right sided failure Backup of blood into the venous system and right side of the heart Primary cause is left sided failure Also caused by Cor pulmonale (caused by COPD, and pulmonary emboli) Also caused by MI damage, ischemia and scarring

16. Clinical manifestations of Acute CHF Pulmonary edema (Most prominent) Caused by left sided failure Evidenced by: Agitation Paleness or cyanosis Clammy cold skin Severe dyspnea with use of accessory muscles Respiratory rate > 30/min Coughing, wheezing, production of frothy blood- tinged sputum

17. Manifestations of Chronic CHF Fatigue Tachycardia Edema Nocturia Weight changes Dyspnea Skin changes Behavioral changes Chest pain

18. Complications of Congestive Heart Failure Pleural effusion Increased pressure in pleural capillaries Leakage of fluid from capillaries into pleural space. Arrhythmias Left ventricular thrombus Hepatomegaly Liver becomes congested with venous blood Leads to impaired liver function

19. Nursing Care in Acute CHF Decrease the intravascular volume With use of diuretics Decrease the venous return Reduces congestion in heart and lungs Sitting patient up facilitates breathing Decreasing the afterload Use of vasodilators (IV Nipride) Increasing myocardial contraction and CO Reducing pulmonary congestion

20. Nursing Care of Acute CHF Improve Gas Exchange and Oxygenation Give IV morphine Place on Oxygen Intubate and place on vent as needed Improve cardiac function Digitalis, or newer inotropic drugs (dobutamine) increase cardiac contractility Hemodynamic monitoring

21. Nursing Care of Acute CHF Reduce anxiety Give Morphine Approach patient calmly Remember: Nursing care will focus on continual physical assessment of the patient, hemodynamic monitoring, and monitoring the patient’s response to the treatment.

22. Nursing Care of Chronic CHF Treatment is aimed at resolving the underlying problem (Physicians job) Arrhythmias (medication, and defibrillator implants), hypertension (medication), valvular defects (surgery), ischemic heart disease (cardiac cath, CABG,…), Need for oxygen Need for physical and emotional rest

23. Nursing Care of Chronic CHF Drug therapy includes: Sodium-potassium-ATPase inhibitors Digitalis (Lanoxin) B-Adrenergic agonists Dopamine (Intropin) Dobutamine (Dobutrex) Phosphodiesterase inhibitors Amrinone (Inocor) Milrinone (Primacor)

24. Nursing Care of Chronic CHF Diuretics: Lasix, Edecrin, Bumex, and Demadex Aldactone and Dyrenium used also, because they are potassium sparing Vasodilators: Nipride (IV) (usually in ICU) and nitroglycerine (often in paste form)

25. Nursing Care of Chronic CHF Angiotensin-converting enzyme (Ace) inhibitors: Capoten, Vasotec, lisinopril (Prinivil, Zestril) Reduces angiotension II and plasma aldosterone levels Increases cardiac output due to vasodilitation Beta-adrenergic blocking agents: Coreg (is the only beta-blocker used in mild to moderate CHF)

26. Nursing Care of Chronic CHF Nutritional Therapy Sodium restriction with diet Teach patient what foods are high in sodium and to avoid them Severe CHF has the most sodium restrictive diet instruct family in reading labels on food items Fluids may be restricted in moderate to severe CHF

27. Nursing Assessment Subjective data: Past health history Medications Functional health patterns Health perception-health management: (fatigue?) Nutritional-metabolic: (usual sodium intake, etc…) Elimination: (nocturia?) Activity-exercise: (dyspnea?) Sleep-rest: (nocturnal dyspnea?) Cognitive-perceptual: (chest pain?)

28. Nursing Assessment Objective data: Skin Respiratory system Cardiovascular system Gastrointestinal system Neurologic system Lab values Hemodynamic monitoring Other tests: chest x-ray, echocardiogram, etc...

29. Nursing Diagnoses Activity intolerance r/t….. Sleep pattern disturbance r/t…. Fluid volume excess r/t… Risk for impaired skin integrity r/t… Impaired gas exchange r/t… Anxiety r/t… Ineffective management of therapeutic regimen r/t… (See Text pg 900-901)

30. Nursing Interventions Regular assessment of patients level of fatigue, dyspnea, heart rate, and weight Provide emotional and physical rest Provide frequent small feedings Teach patient energy expenditure and how to self monitor activities for appropriateness Teach patient reasons for nocturnal dyspnea

31. Nursing Interventions Help patient explore alternative positions for comfortable sleep and relief of dyspnea Teach patient to take diuretics early in day to prevent having to get up at night Give all meds as ordered Monitor intake and output Monitor for signs of peripheral edema or lung congestion

32. Nursing Interventions Instruct patient to weigh daily and to keep a record of their weights Monitor patient for signs and symptoms of hypokalemia Provide client with a diet that is sodium restricted as ordered by physician If patient has edema, measure and record Assess edematous sites for skin breakdown

33. Nursing Interventions Perform passive ROM to extremities q 4h Handle edematous skin gently Turn and reposition q 2 h Monitor for impaired breathing Position HOB up if having difficulty breathing Give O2 if needed by nasal cannula Use pulse ox prn

34. Nursing Interventions Assess heart and lung sounds q 4-8 h and prn Assess patient for anxiety. Medicate as needed Allow patient to ask questions and verbalize concerns. Explain all procedures to patient in understandable terms Respond to call light quickly

35. Nursing Interventions Use measures to decrease dyspnea for patient, thereby relieving anxiety r/t breathing difficulty Use calm behavior with patient Teach patient what to report to nursing staff, shortness of breath, edema/swelling in ankles, weight gain,…etc… Teach patient and family about sodium restricted diet

36. Ambulatory and Homecare Educate patient and family about the physiologic changes that have occurred Assist the patient to adapt to the physiologic and psychologic changes that have occurred. (Include family in this.) Home health nursing care is a vital factor in the prevention of future hospitalizations for these patients.

37. Ambulatory and Homecare The homecare nurse can follow up with ongoing clinical assessments of the patient, monitor vital signs, and response to therapy (including medication). See table 33-13 of Text on pg. 902