Congestive Heart Failure

Pathophysiology Process: Congestive heart failure is a condition in which the heart is unable to adequately pump blood throughout the body and/or unable to prevent blood from "backing up" into the lungs.

In most cases, heart failure is a process that occurs over time, because the heart is overworked and eventually weakened by an underlying condition. Heart failure is characterized by shortness of breath and abnormal fluid retention, which usually results in edema in the feet and legs.

When the left ventricle cannot adequately pump blood out of the left atrium, or when one or more of the heart valves becomes leaky or stenosed, blood can "back up" into the lungs, causing "left-sided" heart failure. When this occurs, the lungs fill up with fluid, making it hard to breath and causing fatigue.

In right-sided heart failure, the flow of blood through the right ventricle, pressure in the blood vessels increases and fluid is forced from the blood vessels into body tissues. This causes swelling, usually in the feet and legs, and sometimes, in the abdomen.

Three expected Nursing Diagnoses:

Three appropriate interventions for each diagnosis:

1. Impaired gas exchange related to fluid in interstitial space of lungs, alveoli.
   1. Monitor for symptoms of respiratory failure. (e.g. low PaO2 and elevated PaCO2 levels and respiratory muscle fatigue.)
   2. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns.
   3. Monitor the client's behavior and mental status for the onset of restlessness, agitation, confusion, and extreme lethargy.
2. Decreased cardiac output related to impaired cardiac function.
   1. Monitor for symptoms of heart failure and decreased cardiac output; listen to heart sounds, lung sounds; note symptoms, including dyspnea, orthopnea, paroxysmal nocturnal dyspnea, Cheyne-Strokes respirations, fatigue, weakness, third and fourth heart sounds, and crackles in lungs.
   2. Observe for chest pain or discomfort; not location, radiation, severity, quality, duration, associated manifestations such as nausea, indigestion, and diaphoresis, also not precipitating and relieving factors.
   3. If chest pain is present, have client lie down, monitor cardiac rhythm, give oxygen, check vital signs, medicate for pain, and notify the physician.
3. Excess fluid volume related to impaired excretion of sodium and water.
   1. Weigh daily and monitor trends; maintain accurate intake and output record.
   2. Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea.
   3. Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea.

Major Concepts related to client's age/developmental level:

1. Erickson: Integrity vs. Despair: This stage of older adulthood begins about the time of retirement and continues throughout one's life. Reaching this stage is a sign of maturity while failing to reach this stage is an indication of poor development in prior stages through the life course. The most important event at this stage is achieving ego integrity. That means coming to accept one's whole life and reflecting on it in a positive manner. According to Erikson, achieving a sense of integrity means fully accepting oneself and coming to terms with death. Accepting responsibility for your life and being able to undo the past and achieve satisfaction with one's "self" is essential. The inability to do this results in a feeling of despair and this individual will begin to fear death.
2. Piaget: The formal operational stage is the fourth and final stage in Piaget's theory. It begins at approximately 11 to 12 years of age, and continues throughout adulthood; although Piaget does point out that some people may never reach this stage of cognitive development. The formal operational stage is characterized by the ability to formulate hypotheses and systematically test them to arrive at an answer to a problem. The individual in the formal stage is also able to think abstractly and to understand the form or structure of a mathematical problem. Another characteristic of the individual is their ability to reason contrary to fact. That is, if they are given a statement and asked to use it as the basis of an argument they are capable of accomplishing the task. For example, they can deal with the statement "what would happen if snow were black".
3. Kohlberg: Postconventional: the attainment of true morality. Think in rational terms, valuing the will of the majority and the welfare of society. His contention is that the attainment of Postconventional moral reasoning is associated with optimal personal and social adjustment. A sense of obligation to law because of one's social contract to make and laws for the welfare of all and for the protection of all people's rights. A feeling of contractual commitment, freely entered upon, to family, friendship, trust, and work obligations.