NCLEX: Congestive Heart Failure

Focus topic: Congestive Heart Failure

Congestive heart failure occurs when the heart loses its ability to meet the body’s need for oxygen. There are some terms that you will want to be familiar with when reviewing the concept of congestive heart failure. One of these is cardiac output, which is the amount of blood that is pumped in one minute. If you multiply the stroke volume by the heart rate, you can determine the cardiac output. The ejection fraction is the stroke volume divided by the end-diastolic blood volume. A healthy heart has an ejection fraction of about 50%–70%.

Another term that is helpful to understand when discussing congestive heart failure is preload, which is the amount of stretch needed to force blood out of the ventricle at the end of diastole. Finally, afterload should be understood because it is the amount of force needed to eject the blood volume. If the heart is overstretched for an extended period of time, it loses its ability to recoil. Eventually, the heart fails and congestive heart failure occurs.

The nurse must monitor for signs of fluid retention. Left-sided congestive heart failure occurs when fluid backs into the lungs and is indicated by rales and blood-tinged sputum. Distended neck veins are also an indication, as well as the client’s report of needing to sleep on two or more pillows to breathe. Right-sided congestive heart failure occurs when the blood backs into the periphery causing peripheral edema, fatigue, and asites.

The diagnosis of congestive heart failure is made by the evaluation of the signs and symptoms as well as looking at the client’s cardiac function. This can be done by evaluation of the blood pressure, ECG, central venous pressure monitoring (CVP), pulmonary artery wedge pressure monitoring (PAWP), echocardiogram, atrial natriuretic peptide (ANP), and brain natriaretic peptide (BNP). The normal BNP is less than 100; a poor prognosis is determined if the levels exceed 400–500. Electrolyte evaluation is also helpful in determining the clinical picture.



Congestive Heart Failure



Treatment includes diuretics, inotropes, and a diet low in sodium. Other drugs might be prescribed to decrease preload and afterload. IV nitroprusside, milrinone (Primacor), or nitroglycerine nesiritide (natrecor) are often used to improve cardiac contractility. Other medications used to support cardiac function are angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, and beta blockers. These drugs increase the force of cardiac contractions. Morphine is often given to control pain as well as to treat preload.

If the client’s condition deteriorates despite the use of cardiac drugs, an intra-aortic balloon pump (IABP) might be inserted. The IABP is inserted into the aorta. A balloon is inflated during diastole and deflates just before systole, reducing the afterload. This procedure improves perfusion to the heart, brain, and lungs and decreases perfusion to the kidneys and lower extremities.

With use of the IABP, perfusion to the lower extremities and the kidneys could be impeded during inflation of the pump, so assessment of pulses distal to the pump insertion site and assessment of urinary output is essential.

Other management of CHF includes monitoring O2 saturation, pulmonary artery wedge pressure (PAWP) with an attempt to maintain PAWP between 15 and 20 mm/hg. Central venous pressure (CVP) monitoring and frequent checking of vital signs are essential nursing care for the client with CHF.

Congestive Heart Failure: Cardiogenic Shock

Focus topic: Congestive Heart Failure

There are three types of shock: cardiogenic shock, hypovolemic shock, and vasogenic or neurogenic shock. Cardiogenic shock occurs when the heart fails to pump enough blood to perfuse the tissues adequately. This type of shock might be due to a myocardial infarction, congestive heart failure, pericarditis, cardiac tamponade (fluid around the heart that constricts the heart muscle), severe vascular disease, or rupture of an abdominal aortic aneurysm. Hypovolemic shock occurs when there is insufficient blood flow to maintain blood pressure.

This results in decreased oxygenation to vital organs. Vasogenic or neurogenic shock occurs when there is trauma to the brain or spinal cord. This results in shock secondary to the nervous systems inability to maintain vasocon- striction. Chapter 10, “Care of the Client with Neurological Disorders,” discussses this type of shock in detail. In cardiogenic shock, there is necrosis of more than 40% of the left ventricle. Most of the clients experiencing cardiogenic shock complain of chest pain. Other symptoms include

  • Hypotension
  • Tachycardia
  • Tachypnea
  • Frothy, pink-tinged sputum
  • Restlessness
  • Orthopnea
  • Oliguria

The mortality rate of cardiogenic shock is extremely high if it is not detected early. Treatment includes oxygen therapy. The physician will order a pain reliever such as morphine sulfate. Diuretics, nitroglycerin, and other medications to reduce the preload are also parts of the treatment. In extreme situations, an intra-aortic balloon pump might be used to decrease the workload of the heart.

Congestive Heart Failure: Aneurysms

Focus topic: Congestive Heart Failure

An aneurysm is a ballooning of an artery. The greatest risk for these clients is rupture and hemorrhage. Aneurysms can occur in any artery in the body and might be the result of congenital malformations, arteriosclerosis, or secondary to hypertension. There are several types of aneurysms:

  • Fusiform: Affects the entire circumference of the artery
  • Saccular: An outpouching affecting only one portion of the arter
  • Dissecting: Bleeding into the wall of the vessel

The client with an abdominal aortic aneurysm will frequently complain of feeling “my heart beating in my abdomen” or low back pain. Any such complaint should be further evaluated. On auscultation of the abdomen, a bruit could be heard. Diagnosis can be made by ultrasound, computer tomography, arteriogram, or abdominal x-rays. If the aneurysm is found to be 5 centimeters or more, surgery might be scheduled. During surgery, the aorta is clamped above and below and a donor vessel is anastamosed in place.

When the client returns from surgery, pulses distal to the site should be assessed. Because the blood supply is stopped to the kidneys and lower extremities during surgery the nurse should monitor the client’s renal function and pedal pulses. Endovascular stents are now being used to relieve pressure on the aneurysm and reinforce the weakened vessel. The stents are threaded through an incision in the femoral artery. Postoperative care is much the same as that of the client who has undergone a cardiac catheterization.




Abdominal aortic aneurysm.

Congestive Heart Failure: Inflammatory Diseases of the Heart

Focus topic: Congestive Heart Failure

Inflammatory and infectious diseases of the heart often are a result of systemic infections that affect the heart. Inflammation and infection might involve the endocardium, pericardium, valves, or the entire heart.

Congestive Heart Failure: Infective Endocarditis

Focus topic: Congestive Heart Failure

Infective endocarditis, also known as bacterial endocarditis, is usually the result of a bacterial infections or collagen diseases. Endocarditis can also be related to cancer metastasis. As a result, the heart is damaged and signs of cardiac decompensation results. The client commonly complains of shortness of breath, fatigue, and chest pain. On assessment, the nurse might note distended neck veins, a friction rub, or a cardiac murmur.

Treatment involves treating the underlying cause with antibiotics, anti-inflammatory drugs, and oxygen therapy. Bed rest is recommended until symptoms subside. If the valve is severely damaged by infection, a valve replacement might have to be performed. Replacement valves are xenograft (bovine [cow] or porcine [pig]), cadaver, or mechan- ical. If the client elects to have a mechanical valve replacement, he will have to take anti-coagulants for life. Following surgery, the nurse must be alert for signs of complications. These include decreased cardiac output or heart failure, infection, and bleeding. The physician often will prescribe digoxin, anticoagulants, cortisone, and antibiotics postop- eratively.

Infective Endocarditis

 Congestive Heart Failure: Pericarditis

Focus topic: Congestive Heart Failure

Pericarditis is an inflammatory condition of the pericardium, which is the membrane sac around the heart. Symptoms include chest pain, difficulty breathing, fever, and orthopnea. Clients with chronic constrictive pericarditis show signs of right-sided congestive heart failure. During auscultation, the nurse will likely note a pericardial friction rub. Laboratory findings might show an elevated white cell count. ECG changes consist of an S-T segment and T wave elevation. The echocardiogram often shows pericardial effusion.

Treatment includes use of nonsteroidal anti-inflammatory drugs to relieve pain. The nurse should monitor the client for signs of pericardial effusion and cardiac tamponade that include jugular vein distention, paradoxical pulses (systolic blood pressure higher on expiration than on inspiration), decreased cardiac output, and muffled heart sounds. If fluid accumulates in an amount that causes cardiac constriction, the physician might decide to perform a pericardiocentesis to relieve the pressure around the heart.

Using an echocardiogram or fluoroscopic monitor, the physician inserts a large-bore needle into the pericardial sac. After the procedure, the nurse should monitor the client’s vital signs and heart sounds. In severe cases, the pericardium might be removed.



 Congestive Heart Failure: Peripheral Vascular Disease

Focus topic: Congestive Heart Failure

The term peripheral vascular disease (PVD) refers to a group of diseases affecting both arteries and veins. Peripheral arterial disease, the most common type of PVD, often results in amputations, kidney disease, and ulcerations of the extremities.

Signs of PVD include a decrease in pulse rate and strength, coldness of the extremity, intermittent claudication (burning and leg cramps on ambulation), and swelling of the extremity.

Treatment is aimed at restoring blood flow to the extremity. Treatment includes a sympathectomy to sever the sympathetic ganglia as a last resort, thereby resulting in vasodilation, vasodilating drugs, or femoropopliteal bypass graft. Stents can also be used to maintain an open vessel. If circulation to the extremity is not restored, an amputation might be required.

Congestive Heart Failure: Femoral Popliteal Bypass Graft

Focus topic: Congestive Heart Failure

When blood flow to the lower legs is interrupted, the physician might elect to perform to bypass the blockage in the vessel. Grafts can be made of synthetic materials such as polytetrafluoroethylene, Gore-Tex, and Dacron. Donor vessels can also be used.

Preoperatively, the nurse should assess renal function and the extremity for pulses, swelling, color, and temperature. If a Doppler is used to obtain pulses, it should be documented. Dye studies might also be ordered prior to the surgical procedure to determine the extent of the disease. The nurse should assess the client’s potential complications associated with dye procedures such as allergies to iodine.

During the graft procedure, the doctor removes the donor vessel and bypasses the block vessel. Following the procedure, the nurse should monitor for signs of graft rejection. These include redness at the site and signs of decreased oxygenation to the extremity. Other nursing care includes

  • Assessing color, temperature, and pulses
  • Assessing for pain and administering medication as ordered
  • Monitoring blood pressure
  • Instructing the client to keep the affected extremity straight and not to cross her legs at the knee
  • Assessing the incision site

At discharge, the client should be taught to avoid sitting at a 90° angle or crossing her legs and to take anticoagulants and vasodilating drugs as ordered. She should also be taught to report signs of decreased oxygenation to the extremity. If graft occlusion does occur, a thrombectomy, tissue plasminogen activator, or revision of the graft might be required.

 Congestive Heart Failure: Varicose Veins/Thrombophlebitis

Focus topic: Congestive Heart Failure

Varicose veins occur when the valves that serve to push blood back to the heart become weak and collapse. This allows blood to pool in the vein. The stagnant blood often clots and occlusion of the vessel occurs. If a clot breaks loose, it can travel to the heart or lungs resulting in a pulmonary emboli.

Thrombophlebitis occurs when a vein becomes inflamed and a clot forms. Most throm- bophlebitis occurs in the lower extremities, with the saphenous vein being the most commonly affected vein. Homan’s sign is an assessment tool used for many years by healthcare workers to detect deep vein thrombi. It is considered positive if the client complains of pain on dorsiflexion of the foot. Homan’s sign should not be performed routinely because it can cause a clot to be dislodged and lead to a pulmonary emboli. If a diagnosis of thrombophlebitis is made, the client should be placed on bed rest with warm, moist compresses to the leg. An anticoagulant such as enoxaparin, heparin, or sodium warfarin is ordered, and the client is monitored for complications such as cellulitis. If cellulitis is present, antibiotics are ordered.

Antithrombolitic stockings or compression devices are ordered to prevent venous stasis. When antithrombolitic stockings are applied, the client should be in bed for a minimum of 30 minutes prior to applying the stockings. The circumference and length of the extremity should be measured to prevent rolling down of the stocking and a tourniquet effect.


Congestive Heart Failure:  Raynaud’s Phenomenon

Focus topic: Congestive Heart Failure

Raynaud’s phenomenon occurs when there are vascular vasospasms brought on by expo- sure to cold. Raynaud’s is more common in women and has been linked to decreasing estrogen levels. The most commonly affected areas are the hands, nose, and ears. Management includes preventing exposure, stopping smoking, and using vasodilators. The client should be encouraged to wear mittens when outside in cold weather.

Congestive Heart Failure: Buerger’s Disease

Focus topic: Congestive Heart Failure

Buerger’s disease (thromboangiitis obliterans) results when spasms of the arteries and veins occur primarily in the lower extremities. These spasms result in blood clot formations and eventually destruction of the vessels. Symptoms associated with Buerger’s disease include pallor of the extremities progressing to cyanosis, pain, and paresthesia. As time progresses, trophic changes occur in the extremities. Management of the client with Buerger’s disease involves the use of Buerger-Allen exercises, vasodilators, and oxygenation. The client should be encouraged to stop smoking.




Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.