Pathophysiology for Heart Failure

• Heart failure (HF) is also referred to as congestive heart failure (CHF).
• Its onset can be chronic or acute heart failure (pulmonary edema or cardiogenic shock).
• It refers to the inability of the heart to pump sufficient blood to meet the needs of tissues for oxygen and nutrients.
• The incidence and prevalence of CHF increase with age.

Etiology: Damage to the heart, regardless of the cause, leads to decreased cardiac output and decreased tissue perfusion. Fluid overload or inadequate tissue perfusion results in altered ventricular filling and emptying.
• Types:
—Left-sided heart failure
Left ventricle is unable to pump blood effectively into systemic circulation and thus blood returns back into pulmonary circulation
—Right-sided heart failure
Right ventricle is unable to effectively pump blood into pulmonary circulation and blood returns back into systemic circulation

—High-output failure Cardiac output is adequate but exceeded by metabolic needs of the tissues
—Biventricular failure Both ventricles fail to function adequately
• Classification according to New York Heart Association criteria:
—Class I Normal activity does not initiate symptoms
—Class II Normal activity does initiate symptoms but symptoms subside with rest
—Class III Minimal activity initiates symptoms but symptoms subside with rest
—Class IV Any activity initiates symptoms and symptoms are present at rest

Precipitating factors: Underlying cardiac disease, pulmonary disease, hyperthyroidism, anemia, or pregnancy.

Signs and Symptoms:
• Left heart failure (pulmonary symptoms remember “Left and Lung”)—tachypnea, tachycardia, cough, bibasilar crackles, gallop rhythm, increased pulmonary artery pressure, hemoptysis, fatigue, cyanosis, dyspnea, orthopnea, nocturia, and paroxysmal nocturnal dyspnea (PND)
• Right heart failure (systemic symptoms remember “Right and Rest of the body”)—peripheral edema, hepatomegally, splenomegaly, ascites, jugular vein distension ( JVD), increased central venous pressure, weakness, anorexia, nausea, indigestion, weight gain, mental changes, bounding pulses, oliguria, and cool extremities
• Biventricular failure—symptoms of both right and left heart failure

Diagnosis: Clinical manifestations, chest X-ray, echocardiogram, increased CVP, increased pulmonary artery pressure, ABG analysis, and liver function test

Treatment: Reduce oxygen demands of the myocardium by eliminating and managing contributing factors. Decrease cardiac workload by decreasing afterload and preload, improve contractility, and manage symptoms

• Low-sodium diet
• Medications include angiotensin-converting enzyme (ACE) inhibitors, diuretics, digitalis, beta blockers, nitrates, antihypertensives, positive inotropes (dopamine, dobutamine), direct vasodilators, and morphine sulfate
• Physical and psychological rest

• If medical intervention is unsuccessful then mechanical assist devices (intra-aortic balloon pump [IABP], left ventricular assist devices), and heart transplant

Nursing Process Elements
• Monitor I&O
• Check weight daily
• Assess for signs of fluid overload
• Monitor level of consciousness
• Assess VS, heart and lung sounds
• Monitor for cardiac dysrhythmias
• Maintain bed rest with HOB elevated
• Instruct client to avoid valsalva maneuver
• Assess and record abdominal girth
• Monitor ABGs
• Oxygen as prescribed
• Provide emotional rest
• Monitor electrolytes
• Administer medications as ordered
• Provide client teaching
• Provide low-sodium diet as ordered

Client teaching for self-care
Instruct client
• to perform activity without adding to fatigue, so he/she should pace and prioritize daily activities
• to avoid extremes in temperature that would tax cardiac function
• to stop activity if experiencing lightheadedness or shortness of breath
• to plan for periods of rest alternating with periods of activity
• to maintain a low-sodium diet
• to take potassium replacement if taking a potassium depleting diuretic and/or include foods high in potassium in the diet, e.g., orange and tomato juice, bananas, raisins, figs, prunes, apricots, spinach, cauliflower, and potatoes
• to take diuretics at times that allow for uninterrupted sleep
• to adhere to medical regime
• to weigh self daily and report to physician a greater than 3-lb weight gain

• how to take pulse and report to physician if pulse is 60 bpm or 120 bpm
• to know S&S of complications or worsening of HF


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