Congestive Heart Failure or CHF is a severe circulatory congestion due to decreased myocardial contractility, which results in the heart’s inability to pump sufficient blood to meet the body’s needs.
About 80% of CHF cases occur before 1 year of age
The primary cause of CHF in the first 3 years of life is CHD.
Other causes in children include:
Other myocardial disorders, such as cardiomyopathies, arrhythmias, and hypertension
Pulmonary embolism or chronic lung disease
Severe hemorrhage or anemia
Adverse effects of anesthesia or surgery
Adverse effects of transfusions or infusions
Increased body demands resulting from conditions such as fever, infection and arteriovenous fistula
Adverse effects of drugs, such as doxorubicin
Severe physical or emotional stress
Excessive sodium intake
In general, causes can be classified according to the following:
Volume overload may cause the right ventricle to hypertrophy to compensate for added volume.
Pressure overload usually results from an obstructive lesion, such as COA
Decrease contractility can result from problems such as sever anemia, asphyxia, heart block and acidemia.
High cardiac output demands occur when the body’s need for oxygen exceeds the heart’s output s seen in sepsis and hyperthyroidism.
Right ventricular failure occurs when the right ventricle is unable to pump blood into the pulmonary circulation. Less blood is oxygenated and pressure increases in the right atrium and systemic venous circulation, which results in edema of the extremities.
Left ventricular failure occurs when the left ventricle in unable to pump blood into systemic circulation. Pressure increases in the left atrium and pulmonary veins; then the lungs become congested with blood, causing elevated pulmonary pressure and pulmonary edema.
To compensate, the cardiac muscle hypertrophies eventually resulting in decreased ventricular compliance. Decreased compliance requires higher filling pressure to produce the same stroke volume. Increased muscle mass impedes oxygenation of the heart muscle, which leads to decreased contraction force and heart failure.
As cardiac output fails, stretch receptors and baroreceptors stimulate the sympathetic nervous system, releasing catecholamines that increase the force and rate of myocardial contraction.
This causes increased systemic resistance, increased venous return, and reduced blood flow to the limbs, viscera and kidneys.
Sweating results from sympathetic cholinergic fibers, there is extra work for the heart muscle, and there is less systemic blood flow.
The renal system responds by releasing renin-angiotensin, which sets off a chain of events – vasoconstriction, leading to increased aldosterone release, causing sodium and water retention and, in turn, increasing preload. Finally, sodium and water retention becomes excessive, resulting in signs of systemic venous congestion and fluid overload.
Assessment
Right ventricular failure
Signs of right ventricular failure are evident in the systemic circulation
Pitting, dependent edema in the feet, legs, sacrum, back, and buttocks
Ascites from portal hypertension
Tenderness of right upper quadrant, organomegaly
Distended neck veins
Pulsus alternans (regular alteration of weak and strong beats noted in the pulse)
Abdominal pain, bloating
Anorexia, nausea
Fatigue
Weight gain
Nocturnal diuresis
Left ventricular failure
Signs of left ventricular failure are evident in the pulmonary system
Cough, which may become productive with frothy sputum
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Presence of crackles on auscultation
Tachycardia
Pulsus alternans
Fatigue
Pallor
Cyanosis
Confusion and disorientation
Signs of cerebral anoxia
Acute pulmonary edema
Severe dyspnea and orthopnea
Pallor
Tachycardia
Expectoration of large amounts of blood-tinged, frothy sputum
Wheezing and crackles on auscultation
Bubbling respirations
Acute anxiety, apprehension, restlessness
Profuse sweating
Cold, clammy skin
Cyanosis
Nasal flaring
Use of accessory breathing muscles
Tachypnea
Hypocapnia, evidenced by muscle cramps, weakness, dizziness, and paresthesias
Diagnostic Evaluation
Chest radiography reveals cardiomegaly and pulmonary congestion
CBC reveals dilution hyponatremia, hypochloremia, and hyperkalemia
ECG reveals ventricular hypertrophy
Primary Nursing Diagnosis
Decreased CO related to an ineffective ventricular pump
Medical Management
Initial management of the patient with HF depends on severity of HF, seriousness of symptoms, etiology, presence of other illnesses, and precipitating factors. Medication management is paramount in patients with HF. The general principles for management are treatment of any precipitating causes, control of fluid and sodium retention, increasing myocardial contractility, decreasing cardiac workload, and reducing pulmonary and systemic venous congestion. The physician may also prescribe fluid and sodium restriction in an attempt to reduce volume and thereby reduce preload.
Surgical Management
Coronary bypass surgery, PTCA, other innovative therapies as indicated (e.g, mechanical assist devices , transplantation)
Pharmacologic Intervention
Alone or in combination: vasodilator therapy (angiotensin-converting enzyme (ACE) inhibitors), angiotensin II receptor blockers (ARBs), select beta-blockers, calcium channel blockers, diuretic therapy, cardiac glycosides (digitalis), and others
Dobutamine, milrinone, anticoagulants, beta-blockers, as indicated
Possibly antihypertensives or antianginal medications and anticoagulants
Monitor for signs of respiratory distress
Provide pulmonary hygiene as needed
Administer oxygen as prescribed
Keep the head of the bed elevated
Monitor ABG values.
Monitor for signs of altered cardiac output, including
Pulmonary edema
Arrhythmias, including extreme tachycardia and bradycardia
Characteristic ECG and heart sound changes
Evaluate fluid status
Maintain strict fluid intake and output measurements
Monitor daily weights
Assess for edema and severe diaphoresis
Monitor electrolyte values and hematocrit level
Maintain strict fluid restrictions as prescribed
Administer prescribed medications which may include:
Antiarrhythmias to increase cardiac performance
Diuretics, to reduce venous and systemic congestion
Iron and folic acid supplements to improve nutritional status.
Prevent Infection
Reduce cardiac demands
Keep the child warm
Schedule nursing interventions to allow for rest
Do not allow an infant to feed for more than 45 minutes at a time
Provide gavage feedings if the infant becomes fatigued before ingesting an adequate amount
Promote adequate nutrition. Maintain a high-calorie, low-sodium as prescribed.
Promote optimal growth and development
As appropriate, refer the family to a community health nurse for follow up care after discharge.
Physical findings indicative of HF:Mental confusion,pale,cyanotic,clammy skin,presence of jugular vein distension and HJR,ascites,edema,pulmonary crackles or wheezes,adventitious heart sounds
Fluid intake and output,daily weights
Response to medications such as diuretics,nitrates,dopamine,dobutamine,and oxygen
Psychosocial response to illness
PREVENTION. To prevent exacerbations, teach the patient and family to monitor for an increase in shortness of breath or edema. Tell the patient to restrict fluid intake to 2 to 2.5 L per day and restrict sodium intake as prescribed. Teach the patient to monitor daily weights and report weight gain of more than 4 pounds in 2 days.
MEDICATIONS. Be sure the patient and family understand all medications, including effect, dosage, route, adverse effects, and the need for routine laboratory monitoring for drugs such as digoxin.
COMPLICATIONS OF HF. Tell the patient to call for emergency assistance for acute shortness of breath or chest discomfort that is not alleviated with rest.
Sources:
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
Lippincott’s Review Series – Pediatric Nursing
Handbook for Brunner & Suddarth’s ,Textbook of Medical-Surgical Nursing, 11th ed
Choose the letter of the correct answer. Good luck!
Congratulations - you have completed MSN Exam for Myocardial Infarction, Heart Failure & other Heart Diseases (PM)*.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.
Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.
Nursing Interventions
Assess for abnormal heart and lung sounds.
Rationale: Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.
Monitor blood pressure and pulse.
Rationale: Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.
Assess mental status and level of consciousness.
Rationale: The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
Assess patient’s skin temperature and peripheral pulses.
Rationale: Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
Monitor results of laboratory and diagnostic tests.
Rationale: Results of the test provide clues to the status of the disease and response to treatments.
Monitor oxygen saturation and ABGs.
Rationale: Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
Rationale: Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
Implement strategies to treat fluid and electrolyte imbalances.
Rationale: Decreases the risk for development of cardiac output due to imbalances.
Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.
Rationale: Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
Encourage periods of rest and assist with all activities.
Rationale: Reduces cardiac workload and minimizes myocardial oxygen consumption.
Assist the patient in assuming a high Fowler’s position.
Rationale: Allows for better chest expansion, thereby improving pulmonary capacity.
Teach patient the pathophysiology of disease, medications
Rationale: Provides the patient with needed information for management of disease and for compliance.
Reposition patient every 2 hours
Rationale: To prevent occurrence of bed sores
Instruct patient to get adequate bed rest and sleep
Rationale: To promote relaxation to the body
Instruct the SO not to leave the client unattended
Rationale: To ensure safety and reduce risk for falls that may lead to injury
Evaluation
After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.
After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.
Excess Fluid Volume
Assessment
The patient may manifest the following:
Edema of extremities
Difficulty of breathing
Crackles
Change in mental status
Restlessness and anxiety
Diagnosis
Excessive Fluid volume related to decreased cardiac output and sodium and water retention
Planning & Desired Outcomes
Patient will verbalize understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.
Patient will demonstrate adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema.
Nursing Interventions
Establish rapport
Rationale: To gain patient’s trust and cooperation
Monitor and record VS
Rationale: To obtain baseline data
Assess patient’s general condition
Rationale: To determine what approach to use in treatment
Monitor I&O every 4 hours
Rationale: I&O balance reflects fluid status
Weigh patient daily and compare to previous weights.
Rationale: Body weight is a sensitive indicator of fluid balance and an increase indicates fluid volume excess.
Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production
Rationale: When increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema
Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic.
Rationale: Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular absorption of sodium Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.
Follow low-sodium diet and/or fluid restriction
Rationale: The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.
Encourage or provide oral care q2
Rationale: Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatis pressure exceeds interstitial pressure, fluids leak out of ht ecpaillaries and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart.
Obtain patient history to ascertain the probable cause of the fluid disturbance.
Rationale: May include increased fluids or sodium intake, or compromised regulatory mechanisms.
Monitor for distended neck veins and ascites
Rationale: Indicates fluid overload
Evaluate urine output in response to diuretic therapy.
Rationale: Focus is on monitoring the response to the diuretics, rather than the actual amount voided
Assess the need for an indwelling urinary catheter.
Rationale: Treatment focuses on diuresis of excess fluid.
Institute/instruct patient regarding fluid restrictions as appropriate.
Rationale: This helps reduce extracellular volume.
Acute Pain
Assessment
Patient may manifest the following
Difficulty of breathing
Chest pain
Restlessness
Diagnosis
Planning & Desired Outcomes
Patient’s pain will be decreased.
Patient will demonstrate activities and behaviors that will prevent the recurrence of pain.
Nursing Interventions
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
Rationale: To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Administer or assist with self-administration of vasodilators, as ordered.
Rationale: The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
Assess the response to medications every 5 minutes
Rationale: Assessing response determines effectiveness of medication and whether further interventions are required.
Provide comfort measures.
Rationale: To provide nonpharmacological pain management.
Establish a quiet environment.
Rationale: A quiet environment reduces the energy demands on the patient.
Elevate head of bed.
Rationale: Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
Rationale: Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Teach patient relaxation techniques and how to use them to reduce stress.
Rationale: Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
Rationale: In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.
Ineffective Tissue Perfusion
Assessment
Pale conjunctiva, nail beds, and buccal mucosa
Generalized weakness
Chest pain
Difficulty of breathing
Abnormal pulse rate and rhythm
Bradycardia
Altered BP readings
With pitting edema on both forearms and hands
Bipedal pitting edema
Diagnosis
Ineffective tissue perfusion related to decreased cardiac output.
Planning & Desired Outcomes
Patient will demonstrate behaviors to improve circulation.
Display vital signs within acceptable limits, dysrhythmias absent/controlled,and no symptoms of failure
Nursing Interventions
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
Rationale: To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Administer or assist with self administration of vasodilators, as ordered.
Rationale: The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart.
Assess the response to medications every 5 minutes.
Rationale: Assessing response determines effectiveness of medication and whether further interventions are required.
Give beta blockers as ordered.
Rationale: Beta blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.
Establish a quiet environment.
Rationale: A quiet environment reduces the energy demands on the patient.
Elevate head of bed.
Rationale: Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
Rationale: Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered.
Rationale: Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain.
Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by physician.
Rationale: These enzymes elevate in the presence of myocardial infarction at differing times and assist in ruling out a myocardial infarction as the cause of chest pain.
Assess cardiac and circulatory status.
Rationale: Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.
Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.
Rationale: Notes abnormal tracings that would indicate ischemia.
Teach patient relaxation techniques and how to use them to reduce stress.
Rationale: Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
Rationale: In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.
Reposition the patient every 2 hours
Rationale: To prevent bedsores
Instruct patient on eating a small frequent feedings
Rationale: To prevent heartburn and acid indigestion
Hyperthermia
Assessment
Patient may manifest the following:
Pale palpebral
Conjunctiva and nail beds
Warm to touch
Weakness
Increased in body temperature
Fluid or electrolyte imbalance
Diaphoresis
Hot flushed skin
Diagnosis
Hyperthermia RT increased metabolic rate secondary to pneumonia
Planning & Desired Outcomes
Patient’s temperature will be on normal level.
Nursing Interventions
Assess vital signs, the temperature.
Rationale: Vital signs provide more accurate indication.
Monitor and record all sources of fluid loss such as urine, vomiting and diarrhea.
Rationale: For potential fluid and electrolyte losses.
Performed tepid sponge bath.
Rationale: To promote heat loss by evaporation and conduction.
Maintain bed rest.
Rationale: To reduce metabolic demands and oxygen consumption.
Remove excess clothing and covers.
Rationale: Decreases warmth and increase evaporative cooling.
Increase fluid intake.
Rationale: To prevent dehydration.
Provide adequate nutrition, a high caloric diet.
Rationale: The meet the metabolic demands.
Control environmental temperature.
Rationale: To prevent an increase in body temperature and prevent shivering of the patient.
Adjust cooling measures on the basis of physical response.
Rationale: Shivering, which burns calories and increases metabolic rate in order to produce heat.
Provide information regarding normal temperature and control.
Rationale: This is especially necessary for patients with conditions at risk for hyperthermia.
Explain all treatments.
Rationale: Patients’ S.O. needs to be oriented.
Administer antipyretics as ordered.
Rationale: To decrease body temperature.
Control excessive shivering with medications such as Chlorpromazine and Diazepam if necessary.
Rationale: Shivering increases metabolic rate and body temperature.
Provide ample fluids by mouth or intravenously as ordered.
Rationale: If the patient is dehydrated or diaphoretic, fluid loss contributes to fever.
Provide oxygen therapy in extreme cases as ordered.
Rationale: Hyperthermia increases metabolism.
Ineffective Breathing Pattern
Assessment
Patient may manifest the following:
weakness
rales on BLF
productive cough
frothy sputum
pursed lip breathing
tachypnea
Diagnosis
Ineffective breathing pattern related to fatigue and decreased lung expansion and pulmonary congestion secondary to CHF
Planning & Desired Outcomes
Patient’s respiratory pattern will be effective without causing fatigue
Nursing Interventions
Establish rapport
Rationale: To gain comfort feelings form the pt and pts SO
Monitor VS
Rationale: To gain baseline data
Inspect thorax for symmetry of respiratory movement
Rationale: Determines adequacy of breathing
Observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory phase and use of accessory muscles
Rationale: Identifies increased work of breathing
Measure tidal volume and vital capacity
Rationale: Indicates volume of air moving in and out of lungs
Assess emotional response
Rationale: Detects use of hyperventilation as a causative factor
Position patient in optimal body alignment in semi- fowler’s position for breathing
Assist patient to use relaxation techniques
Rationale: Reduces muscle tension, decreases work of breathing
Activity Intolerance
Assessment
Weakness
Limited range of motion
Abnormal pulse rate and rhythm
Diagnosis
Activity intolerance r/t imbalance O2 supply and demand
Planning & Desired Outcomes
Patient will use identified techniques to improve activity intolerance
Patient will report measurable increase in activity intolerance
Nursing Interventions
Establish Rapport
Rationale: To gain clients participation and cooperation in the nurse patient interaction
Monitor and record Vital Signs
Rationale: To obtain baseline data
Assess patient’s general condition
Rationale: To note for any abnormalities and deformities present within the body
Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes
Rationale: To prevent strain and overexertion
Instruct client in unfamiliar activities and in alternate ways of conserve energy
Rationale: To conserve energy and promote safety
Encourage patient to have adequate bed rest and sleep
Rationale: to relax the body
Provide the patient with a calm and quiet environment
Rationale: to provide relaxation
Assist the client in ambulation
Rationale: to prevent risk for falls that could lead to injury
Note presence of factors that could contribute to fatigue
Rationale: fatigue affects both the client’s actual and perceived ability to participate in activities
Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
Rationale: to determine current status and needs associated with participation in needed or desired activities
Give client information that provides evidence of daily or weekly progress
Rationale: to sustain motivation of client
Encourage the client to maintain a positive attitude
Rationale: to enhance sense of well being
Assist the client in a semi-fowlers position
Rationale: to promote easy breathing
Elevate the head of the bed
Rationale: to maintain an open airway
Assist the client in learning and demonstrating appropriate safety measures
Rationale: to prevent injuries
Instruct the SO not to leave the client unattended
Rationale: to avoid risk for falls
Provide client with a positive atmosphere
Rationale: to help minimize frustration and rechannel energy
Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms
Rationale: to indicate need to alter activity level