Download Congestive Heart Failure

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: Dependent on the relationship between heart
rate and stroke volume.
: SV
X HR = CO
: Normal: 5,000 ml/min [5 L/min]
STROKE VOLUME:
Amount of blood ejected by ventricle during
systolic contraction.
HEART RATE:
The number of times the ventricle contracts per
minute
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: The volume of blood in the ventricles at the end of
diastole.
FRANK-STARLING LAW
OF THE HEART:
Stretching of muscle fibers during diastole,
Increases force of contraction during systole
LVEDP:
Index of the left ventricular preload.
CVP:
Index of the right ventricular preload.
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: The resistance against which the ventricles
must pump.
: The force of contraction generated by the
myocardium under given loading conditions.
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HIGH-OUTPUT FAILURE
:Uncommon type of Heart failure.
:Caused by an excessive need for cardiac output.
Causes:
a. Severe Anemia c. Arteriovenous shunt
b. Thyrotoxicosis d. Paget’s disease
LOW-OUTPUT FAILURE
:Caused by disorders that impair pumping ability
of the heart
Causes:
a. Ischemic Heart Disease
b. Cardiomyopathy
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BACKWARD FAILURE
:Failure of one of the ventricles to effectively empty
the heart during diastole.
:Blood backs up in the venous system
FORWARD FAILURE
:Characterized by impaired forward movement of
blood into the arterial system.
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SYSTOLIC DYSFUNCTION
:Decrease in cardiac contractility and ejection
fraction.
DIASTOLIC DYSFUNCTION
:Characterized by smaller chamber size, ventricular
hypertrophy, and poor ventricular compliance.
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RIGHT-SIDED HEART FAILURE
Clinical Findings:
SUBJECTIVE:
1. Abdominal pain
2. Fatigue
3. Bloating
4. Nausea
OBJECTIVE:
1. Dependent Pitting Edema subsides at night when
legs are elevated at night.
2. Ankle Edema (first sign)
3. Ascites
4. Anorexia
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LEFT-SIDED HEART FAILURE
Clinical Findings:
SUBJECTIVE:
1. Dyspnea
2. Orthopnea
3. Fatigue and Restlessness
4. Paroxysmal Nocturnal Dyspnea
OBJECTIVE:
1. Crackles
2. Peripheral Cyanosis
3. Cheyne-Stoke respiration
4. Frothy-blood-tinged sputum
5. Non-productive cough
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Manifestations:
1. Dyspnea
2. Expectoration of frothy, pink-tinged sputum
3. Pallor and Cyanosis
4. Hypotension
5. Obtundation
6. Confusion
Nursing Interventions:
1. Position the client in upright.
2. Oxygen Therapy [40%-60% via Face mask]
3. Administer Aminophylline as ordered
[Therapeutic level: 20 ug/ml]
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Manifestations:
1. Hypotension
2. Tachycardia
3. Oliguria
4. Impaired mentation
5. Peripheral vascular collapse
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1. Cardiomegally
2. Rapid Heart Rate
3. Pulsus Alternans
1. ECG
2. Echocardiography
- Ventricular Hypertrophy
- Dilation of Chambers
- Abnormal Wall motions
3. Chest X-ray
- Cardiomegally, Pleural Effusion
- Vascular Congestion
4. ABG Studies: Hypoxemia, Hyperventilation
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1. Hypokalemia
Hyperkalemia
2. Increase BUN, Creatinine and Uric Acid
3. Increase Bilirubin
1. Proteinuria
2. Increase Specific Gravity
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1. Removal of the underlying cause
2. Removal of Precipitating factor.
3. Treatment of the control of
cardiac failure
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MECHANISM OF ACTION: To eliminate excess body of water
and decrease ventricular pressure
: LOW SODIUM and FLUID RESTRICTIONS compliment this
therapy [1.6 to 2.8 g/day]
CLASSIFICATION:
1. LOOP DIURETICS – inhibit sodium and chloride
reabsorption from the Loop oh Henle and the distal tubule.
Example: FUROSEMIDE [Lasix]
Rapid-acting diuretics
Desired Effect: 5 to 10 minutes
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Nursing Responsibilities [LOOP DIURETICS]:
Monitor signs and symptoms of HYPOKALEMIA:
[Hyporeflexia, Drowsiness, Muscle cramps, Paresthesia]
May decrease lithium excretion [Lithium Toxicity :2 meq/L ]
Administer prescribed potassium supplement.
Administer IV doses slowly 1 – 2 minutes to prevent
hypotension and tinnitus.
When given IM, use Z-track method to minimize irritation.
2. THIAZIDE DIURETICS – increase water excretion by either
increasing the GFR or decreasing or inhibiting sodium
reabsorption from the tubules.
Example: CHLOROTHIAZIDE [Diuril]
HYDROCHLOROTHIAZIDE [Hydrodiuril]
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Nursing Responsibilities [THIAZIDE DIURETICS]:
Monitor for Lithium toxicity.
[ Fine Tremors, Anorexia, Dehydration (Diarrhea)]
Monitor for signs of HYPOKALEMIA.
Advise the patient o eat foods high in potassium.
Give the diuretic in the morning or early afternoon.
3. POTASSIUM-SPARING DIURETICS – act at the distal tubule
to cause excretion of sodium, bicarbonate, and calcium but
conserve potassium excretion.
Example: SPIRONOLACTONE [Aldactone]
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Nursing Responsibilities [K-SPARING DIURETICS]:
Monitor signs and symptoms of HYPERKALEMIA:
[Hyperexcitability, Arrhythmias, Muscle weakness,
Flaccid paralysis, Abdominal Distention, Diarrhea]
Avoid salt-substitutes and potassium-rich foods, except
with physician approval.
Monitor Digoxin Toxicity [2 ng/L]
MECHANISM OF ACTION: Increase the ability of the heart to
pump more effectively by improving the contractile
contractile force of the muscles.
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Example: MILRINONE, AMRINONE- Potent Vasodilators
DOPAMINE [Inotropin]- improves in renal blood
flow.
DOBUTAMINE- cardiac contractility & heart rate
Nursing Responsibilities [INOTROPIC AGENTS]:
Administer the drug through a large vein to prevent
extravasation.
Correct hypovolemia before infusing Dopamine.
MECHANISM OF ACTION: Improves cardiac function as follows:
a. Increase the force of myocardial contraction.
b. Increase CO by enhancing the force of left ventricular
contraction.
c. Promotes diuresis by increasing cardiac output.
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Example: DIGOXIN [Lanoxin]
Nursing Responsibilities [CARDIAC GLYCOSIDE]:
Assess patient’s apical pulse, serum drug and electrolyte
levels, and renal function.
Withhold drug: PULSE RATE: Below 60 beats/ minute
Monitor signs of DIGITALIS TOXICITY:
[ Fatigue, Malaise, Depression, Vomiting, Anorexia, Nausea]
Significant Sign: COLORED VISION, XANTOPSIA
[Yellowish Spots]
Antidote: DIGOXIN IMMUNE FAB [Digibind, DigiFab]
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MECHANISM OF ACTION: Decreases workload of the heart by
dilating peripheral vessels in:
a. Relaxing capacitance vessels [veins & venues]
b. Relaxing resistance vessels [arterioles]
Examples:
NITRATES – dilates systemic veins
HYDRALAZINE [Apresoline] – reduces arteriolar tone
SODIUM NITROPRUSSIDE [Nipride] – affects arterioles
PRAZOCIN [Minipress] – balanced effects on both arterial and
venous circulation.
MORPHINE SULFATE – decreases venous return
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MECHANISM OF ACTION: It act by selectively suppressing
Renin-Angiotensin 1 enzyme thus causing arterial and
venous vessels
Examples: CAPTOPRIL [Capoten] QUINAPRIL [Accupril]
ENALAPRIL [Vasotec] MOEXIPRIL [Univasc]
Nursing Responsibilities [ACE INHIBITOR]:
Administer Captopril on an empty stomach, preferably
hour before meals for maximum effectiveness.
Advise the patient to avoid sudden position changes
to minimize orthostatic hypotension.
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MECHANISM OF ACTION: It blocks the conversion of
Angiotensin I to Angiotensin 2 in inhibiting its adverse
effect of vasoconstriction thereby reducing workload of
heart and increase cardiac output.
Examples: IRBESARTAN [Approvel]
TELMISARTAN [Pritor]
VALSARTAN [Diovan]
LOSARTAN [Cozaar]
MECHANISM OF ACTION: Decrease myocardial workload
and protect against fatal dysrrhythmias by blocking
norepinephrine effects of the SNS.
Examples: METROPOLOL [Neobloc, Betabloc]
CARREDILOL
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A. NO ADDED SALT DIET
Na/ day
- High Sodium foods are limited.
- ½ tsp. table salt is allowed
- 4 grams of
B. MILD-SODIUM RESTRICTIONS
- 2 grams of Na/ day
- High sodium foods are eliminated.
- ¼ tsp. table salt is allowed
C. MODERATE-SODIUM RESTRICTIONS
- 1 gram of Na/ day
- High sodium foods are eliminated.
- Table salt is not allowed.
- Canned or processed foods containing salt are omitted.
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D. STRICT SODIUM RESTRICTIONS
- 500 mg/ day
- High sodium foods are eliminated.
- Vegetables high in sodium are omitted
[Spinach, carrot, celery]
- Meat 6 oz daily.
E. SEVERE SODIUM RESTRICTIONS
- 250 mg/ day
- High sodium foods are eliminated.
- Foods in natural sodium are eliminated.
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Fluid Volume Excess related to increase sodium and water
retention, decreased organ perfusion, increased ADH
production.
Decreased Cardiac Output related to damaged
myocardium, decreased contractility, myocardial ischemia,
ventricular hypertrophy
Impaired gas exchange related to ventilation/
perfusion imbalance caused from excess fluid in alveoli and
reduction of air exchange in lungs.
Risk for Impaired Skin Integrity related to decrease tissue
perfusion, edema, altered metabolic rate, decreased
peripheral tissue perfusion
Anxiety related to fear of death, threat to body image,
threat role functioning
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No Signs of Pulmonary Venous
Congestion
Expected Hospital Mortality: 0 – 5%
Moderate Heart Failure, rales in lungs,S3 Gallop,
Tachypnea or signs of RSHF
Expected Hospital Mortality: 10 – 20%
Severe Heart Failure and Pulmonary Edema
Expected Hospital Mortality: 35 – 45%
Shock with SP less 90 mmHg & evidence op
peripheral vasoconstriction, cyanosis, oliguria
Expected Hospital Mortality: 83 – 95%
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Without Limitations to Physical Activity
Slight Limitations of Physical Activity
Marked Limitations of Physical Activity
Inability to carry out any physical activity without
discomfort
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Physical Activity need not to be restricted
No severe or competitive effect
Ordinary Activity moderately restricted
Complete Bed Rest with Bathroom
Privileges
Complete Bed Rest without Bathroom
Privileges
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
The nursing assessment of a client diagnosed with congestive heart
failure reveals moderate dyspnea, clammy, very pale-skin, and cough
producing frothy blood-tinged sputum. Based on these findings, the
nurse would suspect the client is experiencing:
A. Angina
B. Early congestive heart failure
C. Pulmonary Edema
D. Cardiac Tamponade
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The priority nursing intervention for the client experiencing severe
pulmonary edema would be:
A. Call the physician
B. Assess airway, patency, and administer oxygen via face mask.
C. Prepare rotating tourniquets in case they are needed to decrease
venous return
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D. Administer an extra dose of digitalis.

Which of the following data would indicate that a client diagnosed with
congestive heart failure is being compliant with the various aspects of
discharge teachings?
A. Demonstrating better nutrition habits by gaining 10 lbs.
B. Returning to the hospital as an inpatient less frequently.
C. Significantly improving his or her activity level
D. Attending all the classes.

While performing discharge teaching for a client with chronic CHF, the
nurse should be sure to stress which of the following topics?
A. The need for a structured exercise program.
B. The use of high sodium and lo potassium foods.
C. Signs and symptoms of pulmonary edema
D. Possible surgical procedures.
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
The nursing assessment for a 46-year-old client with CAD reveals
noncompliance with the medication regimen and three hospitalizations
in the last 6 months for CHF. When planning discharge teaching, the
nurse best course of action for this client would be to:
A. Reteach the client about the medication schedule, and give
pamphlets to read
B. Collect more data to help identify reasons for noncompliance.
C. Teach the family about the medication schedule and the importance
of compliance.
D. Arrange for outpatient follow-up to ensure compliance.
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The major goal of therapy for client with CHF would be to:
A. Increase cardiac output
B. Improve respiratory output.
C. Decrease peripheral edema
D. Enhance comfort
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
What position should the nurse place the head of the bed to obtain the
most accurate reading of jugular vein distention?
A. High fowlers
B. Raised 10 degrees
C. Raised 30 – 45 degrees
D. Supine position
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Which of the following parameters should be checked before
administering Digoxin [Lanoxin]?
A. Apical pulse
B. Blood pressure
C. Radial pulse
D. Respiratory rate
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
Which of the following symptoms is most commonly associated with
Left-sided Heart Failure?
A. Crackles
B. Arrhythmias
C. Hepatic engorgement
D. Hypotension

Which of the following classes of medication maximizes cardiac
performance in clients with heart failure by increasing ventricular
contractility:
A. Beta-adrenergic blockers
B. Calcium-channel blockers
C. Diuretics
D. Inotropic agents
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
The nurse is performing her admission assessment on a patient. When
grading arterial pulses, a 1+ indicates:
A. Above normal perfusion
B. Absent perfusion
C. Normal perfusion
D. Diminished perfusion

The nurse is preparing the client with CHF to go home. The nurse
should instruct the client to:
A. Monitor urine output daily.
B. Maintain bed rest for at least 1 week
C. Monitor daily potassium intake
D. Weigh daily.
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
The nurse can best assess the degree of edema in an extremity by:
A. Checking for pitting
B. Weighing the client
C. Measuring the affected area
D. Observing intake and output
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The client will require careful skin care, primarily because an
edematous client is prone to develop:
A. Itchy skin
B. Decubitus ulcer
C. Electrolyte imbalance
D. Distention of weakened veins
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