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The American Heart Association tells us that Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure. The symptoms of CHF vary, but include fatigue, low activity level, shortness of breath, and swelling of various body parts. The diagnosis of congestive heart failure is based on knowledge of the patient's medical history, a thorough physical examination, and various laboratory tests. The treatment of congestive heart failure can include lifestyle modifications, addressing potentially reversible factors, medications, heart transplant, and mechanical therapies. The course of congestive heart failure in any given patient is extremely variable.
Basic anatomy is that the heart has two atria (right and left atrium), and two ventricles (left and right ventricle). The ventricles are muscular chambers that pump blood when the muscles contract (the contraction of the ventricle muscles is called systole). Many diseases can impair the pumping action of the ventricles. The diminished pumping ability of the ventricles due to muscle weakening is called systolic dysfunction. After each ventricular contraction (systole) the ventricle muscles need to relax to allow blood from the atria to fill the ventricles. This relaxation of the ventricles is called diastole. Certain diseases can cause stiffening of the heart muscle and impair the ventricles' capacity to relax and fill; this is referred to as diastolic dysfunction. The most common cause of this is high blood pressure resulting in hypertrophy of the heart. Additionally, in some patients, although the pumping action and filling capacity of the heart may be normal, abnormally high oxygen demand by the body's tissues (for example, with hyperthyroidism) may make it difficult for the heart to supply an adequate blood flow (called high output heart failure).In some patients one or more of these factors can be present to cause congestive heart failure. Congestive heart failure can affect many organs of the body. The weakened heart muscles may not be able to supply enough blood to the kidneys, which then begin to lose their ability to excrete sodium and water. This diminished kidney function causes the body to retain more fluid. The lungs may become congested with fluid (pulmonary edema) and the person's ability to exercise is decreased. Fluid may also build up in the liver, impairing its ability to rid the body of toxins. (Porth 2007, and medicinenet.com)
Many diseases can impair the pumping action of the heart and cause congestive heart failure. The most common causes of congestive heart failure are: coronary artery disease, high blood pressure (hypertension), longstanding alcohol abuse, and disorders of the heart valves. Less common causes include viral infections, stiffening of the heart muscle, thyroid disorders, and disorders of the heart rhythm. (Ignatavicius 2006)
The symptoms of congestive heart failure vary among individuals. An early symptom of congestive heart failure is fatigue. The person's ability to exercise may also diminish. As the body becomes overloaded with fluid from congestive heart failure, swelling of the ankles and legs or abdomen may be noticed. In addition, fluid may build up in the lungs, causing shortness of breath, especially during exercise and when lying flat. Sometimes, patients are awakened at night, gasping for air. Some may be unable to sleep unless sitting upright. The extra fluid in the body may cause increased urination at night. Accumulation of fluid in the liver and intestines may cause nausea, abdominal pain, and decreased appetite. (Ignatavicius 2006)
The diagnosis of congestive heart failure is often based on the patient's medical history, physical examination, and laboratory tests. A thorough patient history may disclose the presence of one or more of the symptoms of congestive heart failure. In addition, a history of significant coronary artery disease, prior heart attack, hypertension, diabetes, or significant alcohol use can be clues. The physical examination can detect the presence of extra fluid in the body (via breath sounds, leg swelling, or neck veins), as well as characterizing the condition of the heart (pulse, heart size, heart sounds, and murmurs). Useful diagnostic tests include the electrocardiogram (ECG) and chest x-ray to explore the possibility of previous heart attacks, arrhythmia, heart enlargement, and fluid in and around the lungs. The most useful diagnostic test is the echocardiogram, in which ultrasound is used to image the heart muscle, valve structures, and blood flow patterns. The echocardiogram is very helpful in diagnosing heart muscle weakness. Heart catheterization allows the arteries to the heart to be visualized with angiography (using dye inside of the blood vessels that can be seen using x-ray methods). During catheterization the pressures in and around the heart can be measured and the heart's performance assessed. In rare cases, a biopsy of the heart tissue may be recommended to diagnose specific diseases. This biopsy can often be accomplished through the use of a special catheter device that is inserted into a vein and maneuvered into the right side of the heart. (Heart & Stroke Canada 2010)
After congestive heart failure is diagnosed, treatment should be started immediately. The most important but often neglected part of treatment involves lifestyle modifications. Restricting salt and fluid intake is often recommended because of the tendency of fluid to accumulate in the lungs and surrounding tissues. In patients with congestive heart failure, an intake of no more than 2 grams of sodium per day is generally advised. Likewise, the total amount of fluid consumed must be regulated. Although many patients with congestive heart failure take diuretics to aid in the elimination of excess fluid, the action of these medications can be overwhelmed by an excess intake of water and other fluids. Patients with more advanced cases of congestive heart failure should limit their total daily fluid intake from all sources to 2 quarts. The above guidelines for sodium and fluid intake may vary depending on the severity of congestive heart failure in any given patient and should always be discussed with the patient's physician. An important tool for monitoring an appropriate fluid balance is the frequent measurement of body weight. An early sign of edema is an increase in body weight. This may occur even before shortness of breath or swelling in the legs and other body tissues is detected. A weight gain of two to three pounds over two to three days should be of concern. Aerobic exercise has been shown to be beneficial in maintaining overall functional capacity, quality of life, and even improving survival. Each patient's body has its own unique ability to compensate for the failing heart. (American Heart Association 2001)
Medications have now been developed that both improve symptoms, and prolong survival.
Angiotensin Converting Enzyme (ACE) Inhibitors: These medications block the formation of angiotensin II, a hormone with many potentially adverse effects on the heart and circulation in patients with heart failure. Possible side effects of these drugs include: nagging dry cough, low blood pressure, worsening kidney function and electrolyte imbalances, and rarely, true allergic reactions. When used carefully, the majority of congestive heart failure patients tolerate these medications without problems. Examples of ACE inhibitors include: captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril, Prinivil), benazepril (Lotensin), and ramipril (Altace). For those patients who are unable to tolerate the ACE inhibitors, an alternative group of drugs, called the angiotensin receptor blockers (ARBs), may be used. These drugs act on the same hormonal pathway as the ACE inhibitors, but instead block the action of angiotensin II at its receptor site directly. Possible side effects of these drugs are similar to those associated with the ACE inhibitors, although the dry cough is much less common. Examples of this class of medications include: losartan (Cozaar), candesartan (Atacand), telmisartan (Micardis), valsartan (Diovan), and irbesartan (Avapro).
Beta-blockers: Certain hormones, such as epinephrine (adrenaline), nor epinephrine, and other similar hormones, act on the beta receptors of various body tissues and produce a stimulative effect. The effect of these hormones on the beta receptors of the heart is a more forceful contraction of the heart muscle. Beta-blockers are agents that block the action of these stimulating hormones on the beta receptors of the body's tissues. The key to success in using beta-blockers in congestive heart failure is to start with a low dose and increase the dose very slowly. At first, patients may even feel a little worse and other medications may need to be adjusted. Possible side effects include: fluid retention, low blood pressure, low pulse, and general fatigue and light-headedness. Beta-blockers should generally not be used in people with certain diseases of the airways or very low resting heart rates.
Digoxin: Digoxin (Lanoxin) has been long used in the treatment of congestive heart failure. Digoxin stimulates the heart muscle to contract more forcefully. This drug is useful for many patients with significant CHF symptoms, even though long-term survival may not be affected. Potential side effects include: nausea, vomiting, heart rhythm disturbances, kidney dysfunction, and electrolyte abnormalities. These side effects, however, are generally a result of toxic levels in the blood and can be monitored by blood tests. The dose of digoxin may also need to be adjusted in patients with significant kidney impairment.
Diuretics: Diuretics are often an important component of the treatment of congestive heart failure to prevent or alleviate the symptoms of fluid retention. These drugs help keep fluid from building up in the lungs and other tissues by promoting the flow of fluid through the kidneys. When hospitalization is required, diuretics are often administered by IV because the ability to absorb oral diuretics may be impaired when CHF is severe. Potential side effects of diuretics include: dehydration, electrolyte abnormalities, particularly low potassium levels, hearing disturbances, and low blood pressure. It is important to prevent low potassium levels by taking supplements, when appropriate. Such electrolyte disturbances may make patients susceptible to serious heart rhythm disturbances. Examples of various classes of diuretics include: furosemide (Lasix), hydrochlorothiazide (Hydrodiuril), bumetanide (Bumex), torsemide (Demadex), spironolactone (Aldactone), and metolazone (Zaroxolyn). (Lilley 2007)
It is important to note that in patients with underlying heart disease, taking certain medications can lead to the development or worsening of congestive heart failure. This is especially true for those drugs that can cause sodium retention or affect the power of the heart muscle. Examples of such medications are the commonly used NSAIDs, which include ibuprofen (Motrin) and naproxen (Aleve) as well as certain steroids, some diabetic medication, and some calcium channel blockers. (medicinenet.com)
In some cases, despite the use of various therapies, the patient's condition continues to deteriorate. In selected patients, heart transplantation is a viable treatment option. Given the limitations associated with heart transplantation, much attention has recently been directed towards the development of mechanical assist devices that are designed to assume part or all of the pumping function of the heart. There are several devices available for use and many more are actively being developed. The current major limitation of these devices is the risk of infection, especially at the site where the device exits the body through the skin to communicate with its external power source. A less invasive tool is the biventricular pacemaker. This device has proved valuable in appropriate types of patients with heart failure and impaired ventricles by improving the synchrony of contraction. (pubmed.gov)
As nurses, our care plans for clients with CHF should include interventions such as (Ignatavicius 2006):
Place the patient in Fowler's position and give him supplemental oxygen to help him breathe more easily.
Organize all activity to provide maximum rest periods.
Weigh the patient daily, and check for peripheral edema. Also, monitor I.V. intake and urine output.
Assess vital signs and mental status.
Auscultation for abnormal heart and breath sounds.
Medication Management and frequent monitoring of lab work
To prevent deep vein thrombosis from vascular congestion, help the patient with range-of-motion exercises. Apply anti-embolism stockings as needed. Check for calf pain and tenderness.
Health Teaching: explain the disease process so that the patient understands the need for the prescribed medications, activity restrictions, diet, fluid restrictions, and lifestyle changes.
Counselling: Helping the patient work through and verbalize these feelings may improve psychological well-being.
Assess abnormal response to increased activity
Increase of activity when no complaint of Dyspnea
Increase the time down from the bed to 15 minutes per shift
Self care assistance
Early detection and proper treatment are essential. Although CHF is serious, many patients live for several years after diagnosis.