Congestive Heart Failure 1.1

• occurs when cardiac output cannot meet the metabolic demands of the body.

  Congestive Heart Failure (CHF)
• It is the inability of the heart to pump sufficient amount of blood, thus oxygen and nutrients, to systemic circulation to meet metabolic needs of the body; a chronic disorder

  Congestive Heart Failure (CHF)
• Incidence and Etiology

  1. Occurs most frequently secondary to structural abnormalities, results fro excessive workload on heart

  2. May occur secondary to systemic disease involving renal or pulmonary systems

  3. Majority affected are infants, with 50% less than 1 month of age
• Clinical Manifestations

  1. Impaired myocardial function.

  ❑ Tachycardia, S3 gallop.

  ❑ Poor peripheral perfusion: weak peripheral pulses , cool extremities, delayed capillary refill.

  ❑ Pallor.

  ❑ Exercise or activity intolerance.

  2. Pulmonary congestion.

  ❑ Tachypnea

  ❑ Cyanosis

  ❑ Retractions, nasal flaring, grunting.

  ❑ Cough

  3. Systematic venous congestion.

  ❑ Hepatomegaly

  ❑ Peripheral edema: scrotal and orbital

  ❑ Water weight gain

  ❑ Decreases urine output
• Management

  1. Diuretics to reduce intravascular volume (furosemide, spironolactone).

  2. Digoxin to increase myocardial contractility.

  3. Afterload reduction to decreae the workload of the ailing myocardium (angiotensin-converting enzyme- inhibitors—captopril, enalapril, lisinopril[Prinivil]).

  4. Beta-adrenergic blockers to counteract thew increased sympathetic activity and reduce vascular resistance (metoprolol, carvedilol).

  5. Inotropic (alter the contractility of the heart) support as needed.
• Complications

  1. Pulmonary edema.

  2. Metabolic acidosis.

  3. Failure to thrive.

  4. URI’S

  5. Arrythmias – problems with rate or rhythm

  6. Death
• Nursing Assessment

  1. Assess response to medical treatment plan.

  2. Document vital signs and oxygen saturations.

  3. Observe infant or child during feeding or activity. Assess for diaphoresis, need for request periods, and inability to keep up with peers.

  4. Follow growth curve.
• Nursing Diagnoses

  ▪ Decreased Cardiac Output related to myocardial dysfunction

  ▪ Excess Fluid Volume related to decreased cardiac contractility and decreased excretion from the kidney

  ▪ Impaired Gas Exchange related to pulmonary venous congestion

  ▪ Activity Intolerance

  ▪ Risk for Infection related to pulmonary congestion

  ▪ Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands with decreased caloric intake.

  ▪ Anxiety related to child’s diagnosis and prognosis
• Improving Myocardial Efficiency

  1. Administer digoxin as prescribed

  2. Measure heart rate. Hold medication and notify health care provider for heart rate less than 90 beats/min

  3. Check most recent potassium level. Hold medication and notify health care provider for potassium less than 3.5 mEg/L

  4. Run lead II ECG, if ordered, to monitor PR interval. If first-degree AV block occurs, notify health care provider and hold medication as directed

  5. Report signs of possible digoxin toxicity: vomiting, nausea, visual changes, bradycardia

  6. Double-check dose of digoxin with another nurse before administering the dose. Make sure the digoxin order has two signatures
• Improving Myocardial Efficiency

  1. Administer afterload reduction medications as prescribed

  2. Measure BP before and after giving the patient the medication. Hold the medication and notify the healthcare provider for low BP (greater than a 15-mmHg drop from baseline)

  3. Observe for other signs of hypotension: dizziness, light-headedness, syncope
• Maintaining Fluid and Electrolyte Balance

  1. Administer diuretics as prescribed.

  ❑ Obtain daily weights.

  ❑ Keep strict intake and output record.

  ❑ Monitor serum electrolytes. Provide potassium supplements as needed.

  2. Elevate head of bed; infants may be more comfortable in an upright seat.
• Promoting Activity Tolerance

  1. Organisms nursing care to provide periods of uninterrupted sleep/rest.

  2. Avoid unnecessary activities.

  3. Respond efficiently to a crying infant. Provide comfort and treat the source of distress: wet or dirty diaper, hunger.

  4. Provide diversional activities that require limited expenditure of energy.

  5. Provide small, frequent feedings.
• Decreasing Risk of Infection

  1. Ensure good hand washing by everyone.

  2. Avoid exposure to ill children or caretakers.

  3. Monitor signs of infection: fever, cough, runny nose, diarrhea, vomiting.
• Providing Adequate Nutrition

  1. For the older child: provide nutritious foods that the child likes, along with supplemental high-calorie snacks (milkshake, pudding).

  2. For te infant:

  ❑ High-calorie formula (24 t0 30 cal/oz).

  3. Supplement oral intake through the day with continous nasogastric feedings at night.
• Reducing Anxiety and Fear

  1. Communicate the care plan to the child and family.

  2. Educate the family about CHF and provide home care nursing referral to reinforce teaching and after discharge.

  3. Encourage questions; answer questions s able or refer to another member of the health care team.