Nursing Care of CHF(Congestive

Heart Failure)
By Group 4:

AIZAL ANWAR
ELFI SUSANTI
IRWAN YUHANDA PUTRA
KARTIKA AGUSTIN
NANDANI
RAHMAT HIDAYAT
Definition of CHF (Congestive Heart
Failure)
Heart failure (HF) or Congestive Heart Failure (CHF)
is a physiologic state in which he heart cannot pump
enough blood to meet the metabolic needs of the
body. Heart failure results from changes in systolic or
diastolic function of the left ventricle. The heart fails
when, because of intrinsic disease or structural it
cannot handle a normal blood volume or, in absence
of disease, cannot tolerate a sudden expansion in
blood volume. Heart failure is not a disease itself;
instead, the term refers to a clinical syndrome
characterized by manifestations of volume overload,
inadequate tissue perfusion, and poor exercise
tolerance. Whatever the cause, pump failure results in
hypoperfusion of tissues, followed by pulmonary and
systemic venous congestion.
 Causes of CHF
Weakness of the left ventricle can be caused by:
 Longstanding uncontrolled hypertension
 Heart attacks — damage to the heart muscle due
to coronary artery disease (blocked arteries)
 Valvular heart disease — longstanding leaking or
narrowing of the aortic or mitral valves
 Viral, toxic or metabolic disturbances damaging the
heart muscle. Alcohol is the commonest culprit
 Longstanding rapid heart beating (racing) due to
some form of arrhythmia
 Congenital abnormalities e.g. ventricular septal
defect (a hole between the left and right ventricles)
Cont’...
Weakness of the right ventricle may be caused by:
 Failure of the left ventricle
 High blood pressure within the lungs
 Valvular heart disease — pulmonary valve stenosis
(narrowing)/tricuspid valve leaking
 Right ventricular infarction (heart attack) due to
coronary artery disease
 Congenital abnormalities e.g. atrial septal defect (a
hole between the left and right atria)
 Disease affecting the sac surrounding the heart (the
pericardium) such as fluid accumulation (effusion)
or abnormal thickening (constriction)
 Classification of CHF
There are many different ways to categorize
heart failure, including:
• the side of the heart involved (left heart
failure versus right heart failure)
• whether the abnormality is due to
insufficient contraction (systolic
dysfunction), or due to insufficient
relaxation of the heart (diastolic
dysfunction), or to both.
Cont’...
 whether the problem is primarily increased
venous back pressure (preload), or failure
to supply adequate arterial perfusion
(afterload).
 whether the abnormality is due to low
cardiac output with high systemic vascular
resistance or high cardiac output with low
vascular resistance (low-output heart
failure vs. high-output heart failure).
Cont’...
 the degree of functional impairment
conferred by the abnormality
 the degree of coexisting illness: i.e. heart
failure/systemic hypertension, heart
failure/pulmonary hypertension, heart
failure/diabetes, heart failure/renal failure,
etc.
 Functional classification generally relies on the New York Heart
Association functional classification. The classes (I-IV) are:

Class Physical Activity Example

I (none) Normal physical activity does not cause Jog/walk 8km/h

fatigue, palpitations and dyspnoea

II (slight) Normal physical activity causes fatigue, Walk 7km/h on level ground
dyspnoea and palpitations/angina
III (moderate) Comfortable at rest, light physical Walk 4km/h
activity causes fatigue, dyspnoea and
palpitations/angina

IV (Severe) Symptoms present at rest; any physical Unable to perform any of the
activity increases discomfort above activities
 CLINICAL MANIFESTATIONS AND UNDERLYING
AETIOLOGY

Common clinical manifestations of CHF are presented below:

Signs Aetiology
Dyspnoea Pulmonary venous congestion causes inadequate blood oxygenation
and fluid extravasation into pulmonary tissues with secondary pleural
effusion causing symptoms.
Orthopnoea Recumbent position reduces blood pooling in the extremities,
improving venous return that exacerbates pulmonary congestion.
Paroxysmal Improved venous return, reduced ventricular adrenergic innervation
nocturnal during sleep and nocturnal depression of respiratory
dyspnoea

Fatigue Reduced CO - poor perfusion of skeletal muscles leads to fatigue

Underperfusion of kidneys during the day, adequate perfusion restored

Nocturia
by supine position at night.
 CONT’...

Symptoms Aetiology

Venous congestion of abdominal viscera leads to fluid

Ascites
extravasation into peritoneal cavity.
Generalised oedema (anasarca), Peripheral vascular congestion alters Starling forces in
dependent oedema tissues, causing fluid extravasation into interstitial spaces.
Hepatic congestion and fluid extravasation cause
Right upper quadrant pain
hepatomegaly, stretching the hepatic capsule, causing pain.
Elevated Jugular venous Blood congestion and decreased right ventricular output
pressure (JVP) increases atrial filling, giving a higher JVP.
 Pathophysiology
Heart failure is caused by any condition
which reduces the efficiency of the
myocardium, or heart muscle, through damage
or overloading. As such, it can be caused by a
wide number of conditions, including
myocardial infarction (in which the heart
muscle is starved of oxygen and dies),
hypertension (which increases the force of
contraction needed to pump blood) and
amyloidosis (in which protein is deposited in
the heart muscle, causing it to stiffen).
Cont’...
Over time these increases in workload will produce
changes to the heart itself:
 Reduced force of contraction, due to overloading of
the ventricle.
 A reduced stroke volume, as a result of a failure of
systole, diastole or both. Increased
 Reduced spare capacity
 Increased heart rate, stimulated by increased
sympathetic activity in order to maintain cardiac
output.
 Hypertrophy (an increase in physical size) of the
myocardium, caused by the terminally
 Enlargement of the ventricles, contributing to the
enlargement and spherical shape of the failing heart
Fictitious Case
Mr. Solomon is a 63-year old gentle man who has been
under your care for a variety of medical problems during the past
5 years. He has been treated for two myocardial infarctions,
hypertension, non-insulin dependent diabetes and stasis dermatitis
of the left leg. He had an aorto-coronary bypass one year ago.
Today he presents in the office with shortness of breath
which has been progressive over the past five days. He has,
however, experienced episodes of shortness of breath during the
past four months, especially when exerting himself. He fatigues
easily and has lost "all my energy to do anything." He also
complains of anorexia. Last night he awoke suddenly from sleep
because "I couldn’t catch my breath" and developed a dry cough.
The breathing problem improved when he sat on the edge of his
bed for an hour. He generally sleeps with two, sometimes three
pillows. He has not experienced chest pain, leg pain or fainting
spells.
Cont’...
Examination in the office reveals an undernourished man
who appears depressed and older than his stated age. He is
unkept and unshaven. His shoes are untied. His breathing is
labored and his lips have a blue tinge.
Vital Signs: Blood Pressure 98/82mmHg in the right
arm; Heart Rate 110/min; Respiratory Rate 26/min;
Temperature 98oF. Examination of the lungs reveals dullness
to percussion in both bases with decreased excursion of
the diaphragms. Course rhonchi and moist, inspiratory
crackles are heard bilaterally in the lower lung fields.
Examination of the cardiovascular system: Neck
veins are prominent and distended to the mandible when
the patient is sitting upright. The apical pulse is palpated in
the 5ICS, left of the MCL. S3 is palpable at the apex. S1 and
S2 are diminished. S3 is heard at the apex. A grade 3/6
holosytolic murmur is heard best at the apex; it radiated to
the left axilla.
Cont’...
Examination of the abdomen: The anterior wall
is round and soft. The liver edge is palpable and
tender. The spleen is not palpable. Examination
of the extremities revealed diminished
peripheral pulses. There is an irregular pulse.
There is pitting edema of both lower
extremities.
The patient is hospitalized.
Nursing Care of CHF
Nursing Diagnosis:
1.Activity intolerance related to fatigue due to a
decrease of cardiac output and pulmonary congestion
as manifested by dyspnoea, tachycardia, and feelings of
weakness and shortness of breath.
Nursing Interventions and Rationales:
 Encourage alternative rest as well as activity periods
to reduce cardiac workload.
 Provide emotional and physical rest to reduce oxygen
consumption and to relieve dyspnoea and tiredness.
 Observe cardiorespiratory response to activity to
establish amount of activity that can be performed.
 Educate patient and significant other the particular
approaches of self-care to decrease much needed
oxygen consumption.
Cont’...
Assist to decide on activities in keeping with physical,
psychological and social capabilities to establish the amount of
activity that can be carried out.
 Work with the help of healthcare professional, physiotherapist
and even recreational therapists to plan and observe action plan.
Goal / Outcome:
 Oxygen saturation within expected range in response to activity.
 Heart rate within expected rate in response to activity.
 Respiratory rate within expected rate in response to activity.
 ECG within normal limits.
 Skin colour within normal limits.
 Reported activities of daily living performance.
 Systolic blood pressure in expected range in response to activity.
 Diastolic blood pressure in expected range in response to
activity.
2. Altered Tissue Perfusion and Impaired Gas Exchange
Nursing Diagnosis:
 Altered tissues perfusion and impaired gas exchange
due to insufficient heart contractility.
 Modified tissue perfusion describes a scenario where
the actual cells don't receive sufficient oxygen and so
the tissues where they're located in the body tend to
receive less oxygenation and in danger for damage
tissue.
 Gas exchange occurs within the alveoli of the lungs
and when heart failure occurs, the lungs can become
congested consisting blood as a result it reduces its
capability to function the gas exchange process thus
results in an altered tissues perfusion.
Cont’...
Nursing Interventions and Rationale:
 It is important to administer oxygen as ordered by physician to
increase tissue oxygenation and therefore prevents hypoxia and
hypoxemia
 Auscultate (listen) to breathe sounds noting areas of reduced or
absent ventilation as well as presence of adventitious sounds
within the lungs in order to assess congestion promptly.
 Ensure that you maintain the delivery device of oxygen from
mask to nasal prongs while the patient is doing activity of daily
living in order to sustain the level of oxygen to the tissues.
 Monitor the effectiveness of oxygen delivery by evaluating
oxygen saturation in order to identify hypoxaemia and
determine oxygen saturation.
 Ensure that the patient’s bed position in the head area is elevated
(semi fowler position) to alleviate anxiety, improve ventilation
and decreasing venous return to the heart therefore allowing the
patient to breathe easily in a comfortable position.
Cont’...
 If the patient is mobilizing less due to activity intolerance or
movement intolerance as a result of inability to breathe properly
make sure that you inspect for any skin wounds or pressure
ulcer areas to prevent further complications such as infections
or sepsis. When the cell tissues receive less oxygen there may
be a high risk of infection especially when wound occurs in the
body.
 Reassure the patient frequently as providing reassurance helps
the patient feel comforted and thus reduces anxiety.
 Ensure that the patient’s call bell is within reach and side rails of
the bed is up in placed to prevent falls or if in any case the
patient develops confusion due to hypoxia (decreased oxygen in
the tissue) the patient might suddenly get up on his/her own
therefore this prevents accident or falls to occur.
 Ensure that the patient is on restricting fluids if ordered by a
physician, therefore it prevents excess fluid volume in the cells.
 Instruct patient’s food intake to avoid consumption of high
sodium (salt) intake in his/her diet to prevent hypernatraemia
(elevated sodium level in the blood).
Cont’...

Goal / Outcome:
 The expected outcome of the nursing
interventions for congestive heart failure is
that the patient’s gas exchange in the lungs
is able to function well allowing the patient
to receive sufficient oxygenation in the
tissues.
3. Excess fluid volume related to cardiac heart
failure
Nursing Diagnosis:
Excess fluid volume related to cardiac
heart failure as evident by dyspnoea,
tachycardia, increased weight gain and oedema
in ankles or other parts of the body.
Nursing Interventions and Rationales:
 Monitor patient’s serum electrolyte levels
to assess the underlying condition and
therefore preventing electrolyte imbalances.
Cont’...
 Monitor patient’s weight by weighing daily as
ordered to determine if patient’s weight is
increasing drastically possibly due to fluid
retention and if this occurs inform the
doctor in order to start an assessment or
order by a physician.
 Monitor respiratory breathing pattern to
determine if symptoms of respiratory
difficulty occurs and for early detection of
pulmonary congestion.
 Monitor for renal function including intake
and output in order to determine fluid
balance
4. Anxiety
Nursing Diagnosis:
 Anxiety related to dyspnoea as evident by expressions
of feeling scared, irritability and restlessness.
Nursing Interventions and Rationales:
 Ensure that each procedure administered by a nurse
ordered by a physician must be thoroughly explained in
an appropriate manner in order to promote sense of
comfort and security.
 Encourage and educate patient by using relaxation
techniques in order to alleviate anxiety.
 Always reassure patient in a calm and appropriate
approach to maximize patient’s confidence and relieve
anxiety.
 Develop an atmosphere suitable for a patient in order to
facilitate trust between patient and nurse relationship.
WOC OF CHF