Congestive Cardiac Failure-1

CONGESTIVE CARDIAC FAILURE
DEFINITION
Congestive heart failure is a disorder that the heart

is unable to maintain satisfactory cardiac output to
meet the metabolic needs of the body (systolic failure)
or is unable to receive blood in the ventricles during
diastole (diastolic failure)
OR
Congestive heart failure is defined as inability of

the heart to maintain an output at rest or during
stress, necessary for the metabolic needs of the body
(systolic failure) and inability to receive blood into the
ventricular cavities at low pressure during diastole
(diastolic failure).
ETIOLOGY
The common causes of CCF is
1. Congenital heart disease

2. Other causes in the children include
• Other myocardial disorders such as

cardiomyopathies, dysarrythmias and hypertension.
• Pulmonary embolism or chronic lung disease
• Severe hemorrhage
• Adverse effect of anesthesia or surgery

•Adverse effect of infusion or transfusion
•Increased body demands resulting from fever infection

and arterio- venous fistula
•Adverse effect of drugs such as doxorubicin
•Severe physical and emotional] stress
•Excessive sodium intake
•About 80% of CCF cases In children occurs before one

year of age
CLINICAL FEATURES
Symptoms
•Poor weight gain- the infant takes small feds because of

easy fatigability and there is an excessive loss of calories
due to increased work of breathing due to the CCF.
•Difficulty in feeding- poor feeder-the baby takes only

small volume of feeds falls into an exhausted sleep. He
soon wakes up feeling hungry and the vicious cycle
repeats
•Shortness of breathe/breathes too fast
•Breathes better when placed upright

•Persistent cough and wheezing
•Irritability and restlessness-as the baby takes small

feeds, it IS constantly hungry and crying.
•Excessive perspiration, puffiness of face and pedal

edema.
SIGNS
•Left sided heart failure- tachycardia, tachypnea,

cough, wheezing. rhales in chest.
•Right-sided heart failure- hepatomegaly, facial edema,

jugular venous engorgement, edema feet.
•Failure of either side - cardiac enlargement, gallop

rhythm, peripheral cyanosis, low volume pulse, absence
of weight gain.
INVESTIGATION
•Hemoglobin -anemia
•Hematocrit- CBC, ESR-infections
•X-ray chest- cardiac enlargement/ cardiac defect
•Renal function test-BUN, serum creatinine, serum

electrolyte
•ECG, Color Doppler, cardiac catheterization, blood

cultures
STEP WISE MANAGEMENT OF CHF
The most important steps consist of in establishing the

cause of CCF. By treating the cause, CHF can be
eliminated.
STEP I- This step should be the use of frusemide with

amiloride or triameterine
STEP II- It consists of adding digoxin. If the patient

is still not doing well.
STEP III- Add ACE inhibitor. Stop potassium-

spraying diuretics.
STEP IV - Consists of adding isorbid nitrate (Do not
hydralazine as it has been shown to have adverse
effect).
STEP V- It is use of intermittent dobutamine or

dopamine combined with dobutamine (separate
infusion) if the blood pressure is low.
STEP VI- It consists of doing a myocardial biopsy and

adding immunosuppressive with steroids or beta
blockers depending on whether active myocarditis is
absent or absent.
STEP VII- It has to be considered if the patient does

not show any response to the above and consists of
cardiac transplantation it is necessary to emphasize
that step five; six and seven are meant mainly for
dilated Cardiomyopathies.
GUIDELINES FOR THE MANAGEMENT OF
CCF
Management can be broadly categorized as

follows
1)Rest in propped up position
2) Humidified oxygen
3) Salt restricted diet

Diet for infant- Infant in CCF lack sufficient
strength for effective suckling due to rapid
respiration and fatigue. Naso-gastric feeding with
caloric dense formula (0.8cal/ml) is recommended to
reduce fluid intake and to provide extra energy to
meet the enhanced metabolic requirement
4) Precipitating and aggravating factors for CCF

include anemia, electrolyte imbalance, infective
endocarditis, hypertension, arrhythmia and pulmonary
embolism.
Use of sedatives- if patient is dyspnoec or restless.
Morphine sulphate 0.05 mg/kg
Diazepam can be used.
Use of vasodilators- catolipril

Infant -0.5 to 6.0 mg /kg/ day in 3 divided dose per
oral.
Children- 12.5 mg every 12 hr per oral
Nefidepin ~ 0.3 mg/kg dose per oral every 6 hrs.
Digitalis
Digoxin -O.04 mg /kg/day
Maintenance dose-0.0l mg /kg/day
Newer ionotropic agent -Catecholamine ionotropic
agent like dopamine and dobutarnine.
Non catechol, non digitalis glycosides agents like
amirione milirione
Use of dopamine -5 microgram/kg/min- it causes

peripheral vasodilatation, increases myocardial
contractility and renal flow (natriuresis) and splanchic
blood flow 6 to 10 microgram/kg/min. it result in
peripheral vasoconstriction
> 15 microgram/kg/min- peripheral vasoconstriction
and reduced blood flow-hence not useful
Diuretic-Frusemide Oral 2-3 mg/kg/day (action

starts in 20 min) IUI mg/kg/day
NURSING MANAGEMENT
ASSESSMENT FINDINGS
Signs and symptoms of CHF vary somewhat depending

of the child age and on whether failure occurs on the
right and left sided CHF (the usual condition) may
include:
1. Respiratory distress, marked by tachypnea, dyspnea,

orthopnea, retraction, nasal flaring, grunting .
2. Cough
3. Tachycardia
4. Ventricular gallop
5.Pallor, mottling or cyanosis
6.Edema (peripheral and periorbital)
7.Feeding difficulties and failure to thrive
8.Restlessness and irritability
9.Weakness and easy fatigability
10.Unexplained weight gain
11.Abdominal distension
12.Neck vein distension hepatomegaly
13.Diaphoresis
14.Chest radiograph reveals cardiomegaly and
pulmonary congestion.
15.Laboratory study result commonly reveal dilutional

hyponatreamia, hypochloremia and hyperkalemia
16.Assess response to medical treatment plan.
17.Document vital signs and oxygen saturation
18.Observe infant or child during feeding or activity.

Assess for diaphoresis, need for frequent rest
period and inability to keep up with peers
19.Follow growth chart

NURSING DIAGNOSIS
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 related to decreased
cardiac output.
•Risk for infection related to pulmonary congestion
•Altered nutrition, less than body requirement

related to increased metabolic demands with
decreased calorie intake
•Anxiety related to child diagnosis and prognosis

NURSING INTERVENTION
IMPROVING MYOCARDIAL EFFICACY
1) Administer digoxin as prescribed.
Measure heart rate; hold medication and notify health

care provider for hemi rate less than 90bpm .
Check most recent potassium level. Hold medications

and notify health care provider for less than 3.5gm
potassium level.
Run lead II ECG if ordered to monitor PR interval. If
first degree A V block occurs, notify health care
provider and hold medication as ordered
Report signs of possible digoxin toxicity, vomiting,

nausea, visual changes, bradycardia.
Double check dose of digoxin with another nurse

before administering the dose. Make sure the digoxin
order has two signatures.
Administer after load reduction medications as
prescribed .
Measure BP before and after giving the patient the

medication. Hold the medication and notify the health
care provider for low BF (greater than 15mm of Hg
drop from baseline) .
Observe for other signs of hypotension, dizziness,

light headedness, syncope.
MAINTAINING FLUID AND ELECTROLYTE
BALANCE
1) Administer diuretics as prescribed

 Obtain daily weight.
 Keep strict intake and out put record.
 Monitor serum electrolyte –provide
 potassium supplement as needed.
2) Sodium restriction not usually needed in the

children: provide dietary assistance as needed.
3) Fluid restriction- not usually needed in children.

RELIEVING RESPIRATORY DISTRESS
1)Administer oxygen therapy as prescribed.
2) Elevate head end of bed

PROMOTING ACTIVITY TOLERANCE
1)Organize nursing care to provide periods of

uninterrupted sleep and rest
2) Avoid unnecessary activities
3) Respond efficiently to a crying infant. Provide

comfort and treat the source of distress: wet, dirty
diaper, hunger.
4) Provide divisional activities that require limited

expenditure of energy.
5) Provide small frequent feedings.

DECREASING RISK FOR INFECTIONS
•Ensure good hand washing by everyone.
•Avoid exposure to ill children/care taker.
•Monitor signs of infections; fever, cough, running

nose, diarrhea, vomiting.
PROVIDING ADEQUATE NUTRITION
1) For older child
Provide nutritious foods that the child likes, along with

supplemental high calories snacks (milk shake,
pudding).
2) For the infants
 High calorie formula (24-30 cal/oz)
 Supplement oral intake with naso-gastric feedings

allow intake through the day with continuous naso-
gastric feedings at night.
REDUCING FEAR AND ANXIETY
1. Communicate the care plan and family
2) Educate the family about CHF and provide home care

nursing referrals to reinforce teaching after
discharge
3) Encourage question: answer question as able to or

refer to another member of health care team.
FAMILY EDUCATION AND HEALTH
MAINTENANCE
1)Teach the signs and symptoms of CCF
2) Teach medication: brand name and generic name,

expected adverse effect, dose
3) Demonstrate medication administration
4) With the family, design a medication

administration time schedule
6.Provide guidelines for when to seek medical help
7.Teach infant and child cardio-pulmonary

resuscitation as needed
8.Reinforce dietary guidelines; provide a recipe to

the parents on how to. Prepare high calorie formula
9.Reinforce ways to prevent infection
10.Make sure that follow up visits with health care

providers is scheduled.
11.Educate the parents and family on infective

endocarditis guidelines a provide them with written
materials.
EVALUATION
1) Heart rate within normal range for age; adequate urine

output
2) No unexpected weight gain
3) Clear lungs, normal respiratory rate and effort
4) Participates in diversional activities

COMPLICATION
•Pulmonary edema
•Metabolic acidosis
•Failure to thrive
•URI
•Arrhythmias
•Death

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CONGESTIVE CARDIAC FAILURE

Congestive heart failure is a disorder that the heart

Congestive heart failure is defined as inability of

The common causes of CCF is

1. Congenital heart disease

• Other myocardial disorders such as

• Pulmonary embolism or chronic lung disease

• Adverse effect of anesthesia or surgery

•Increased body demands resulting from fever infection

•Adverse effect of drugs such as doxorubicin

•Severe physical and emotional] stress

•Excessive sodium intake

•About 80% of CCF cases In children occurs before one

•Poor weight gain- the infant takes small feds because of

•Difficulty in feeding- poor feeder-the baby takes only

•Shortness of breathe/breathes too fast

•Breathes better when placed upright

•Irritability and restlessness-as the baby takes small

•Excessive perspiration, puffiness of face and pedal

•Left sided heart failure- tachycardia, tachypnea,

•Right-sided heart failure- hepatomegaly, facial edema,

•Failure of either side - cardiac enlargement, gallop

•Hematocrit- CBC, ESR-infections

•X-ray chest- cardiac enlargement/ cardiac defect

•Renal function test-BUN, serum creatinine, serum

•ECG, Color Doppler, cardiac catheterization, blood

The most important steps consist of in establishing the

STEP I- This step should be the use of frusemide with

STEP II- It consists of adding digoxin. If the patient

STEP III- Add ACE inhibitor. Stop potassium-

STEP V- It is use of intermittent dobutamine or

STEP VI- It consists of doing a myocardial biopsy and

STEP VII- It has to be considered if the patient does

Management can be broadly categorized as

1)Rest in propped up position

3) Salt restricted diet

4) Precipitating and aggravating factors for CCF

Use of vasodilators- catolipril

Use of dopamine -5 microgram/kg/min- it causes

Diuretic-Frusemide Oral 2-3 mg/kg/day (action

Signs and symptoms of CHF vary somewhat depending

1. Respiratory distress, marked by tachypnea, dyspnea,

6.Edema (peripheral and periorbital)

7.Feeding difficulties and failure to thrive

8.Restlessness and irritability

9.Weakness and easy fatigability

10.Unexplained weight gain

12.Neck vein distension hepatomegaly

15.Laboratory study result commonly reveal dilutional

16.Assess response to medical treatment plan.

17.Document vital signs and oxygen saturation

18.Observe infant or child during feeding or activity.

19.Follow growth chart

Decreased cardiac output related to myocardial

Excess fluid volume related to decreased cardiac

Impaired gas exchange related to pulmonary venous

•Altered nutrition, less than body requirement

•Anxiety related to child diagnosis and prognosis