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Butuan Doctors’ College

Department of Nursing
Butuan City

Case Study

Submitted by:

Ian Leonard C. Celebrado


Submitted to:

Mr. Ryan Lister Flores, R.N.

Clinical Instructor
Congestive Heart Failure

Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't
pump enough blood to the body's other organs.

This can result from:

• narrowed arteries that supply blood to the heart muscle — coronary artery
• past heart attack, or myocardial infarction, with scar tissue that interferes with the
heart muscle's normal work
• high blood pressure
• heart valve disease due to past rheumatic fever or other causes
• primary disease of the heart muscle itself, called cardiomyopathy.
• heart defects present at birth — congenital heart defects.
• infection of the heart valves and/or heart muscle itself — endocarditis and/or

The "failing" heart keeps working but not as efficiently as it should. People with heart
failure can't exert themselves because they become short of breath and tired.

As blood flow out of the heart slows, blood returning to the heart through the veins
backs up, causing congestion in the tissues. Often swelling (edema) results. Most often
there's swelling in the legs and ankles, but it can happen in other parts of the body, too.
Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of
breath, especially when a person is lying down.

Heart failure also affects the kidneys' ability to dispose of sodium and water. The
retained water increases the edema.

o Predisposing Factors
o Infection.
o Anaemia.
o Thyrotoxicosis.

Pregnancy: Women with rheumatic valvular disease can first experience symptoms
during pregnancy and following delivery of the baby these symptoms may be resolved.

o Abnormal heart rhythms.

o Rheumatic fever.
o Infective endocarditis and Myocarditis.
o Hypertension (High Blood Pressure).
o Heart attack.
o Myocardial infarction.
o Pulmonary embolism.
o Overexercise.
o Sudden increase in salt in the diet.
o Excessive environmental heat or humidity.
o Emotional crises.

Ventricular aneurysm
Cardiac temponade

Tachycardia Fluid overload

Ventricular dilatation
Myocardial hypertrophy
Water reabsorption

Decrease cardiac output

Increase ADH

Decrease renal perfusion

Increase Osmotic pressure

Increase sodium retention

Anatomy and Physiology
To understand what occurs in heart failure, it is useful to be familiar with the anatomy of
the heart and how it works. The heart is composed of two independent pumping
systems, one on the right side, and the other on the left. Each has two chambers, an
atrium and a ventricle. The ventricles are the major pumps in the heart.

The external structures of the heart include the ventricles, atria, arteries, and veins.
Arteries carry blood away from the heart while veins carry blood into the heart. The
vessels colored blue indicate the transport of blood with relatively low content of oxygen
and high content of carbon dioxide. The vessels colored red indicate the transport of
blood with relatively high content of oxygen and low content of carbon dioxide.

The Right Side of the Heart

The right system receives blood from the veins of the whole body. This is "used" blood,
which is poor in oxygen and rich in carbon dioxide.

• The right atrium is the first chamber that receives blood.

• The chamber expands as its muscles relax to fill with blood that has returned
from the body.
• The blood enters a second muscular chamber called the right ventricle.
• The right ventricle is one of the heart's two major pumps. Its function is to pump
the blood into the lungs.
• The lungs restore oxygen to the blood and exchange it with carbon dioxide,
which is exhaled.
The Left Side of the Heart

The left system receives blood from the lungs. This blood is now oxygen rich.

• The oxygen-rich blood returns through veins coming from the lungs (pulmonary
veins) to the heart.
• It is received from the lungs in the left atrium, the first chamber on the left side.
• Here, it moves to the left ventricle, a powerful muscular chamber that pumps the
blood back out to the body.
• The left ventricle is the strongest of the heart's pumps. Its thicker muscles need
to perform contractions powerful enough to force the blood to all parts of the
• This strong contraction produces systolic blood pressure (the first and higher
number in blood pressure measurement). The lower number (diastolic blood
pressure) is measured when the left ventricle relaxes to refill with blood between
• Blood leaves the heart through the ascending aorta, the major artery that feeds
blood to the entire body.

The Valves

Valves are muscular flaps that open and close so blood will flow in the right direction.
There are four valves in the heart:

• The tricuspid regulates blood flow between the right atrium and the right
• The pulmonary valve opens to allow blood to flow from the right ventricle to the
• The mitral valve regulates blood flow between the left atrium and the left
• The aortic valve allows blood to flow from the left ventricle to the ascending

The Heart's Electrical System.

The heartbeats are triggered and regulated by the conducting system, a network of
specialized muscle cells that form an independent electrical system in the heart
muscles. These cells are connected by channels that pass chemically caused electrical
Left Sided Congestive Heart Failure


Reduced myocardial contractility
o Myocardial Infarction Increases cardiac workload
o Hypertension Decreased diastolic filling
o Aortic stenos is insufficiency Obstructions of left atrial emptying
o Mitral stenos is insufficiency

Bloods dams back into Left sided CHF Left atrial pressure
the pulmonary
capillary bed
Stroke volume decreases

Pressure at the Bloods flow to the kidneys

pulmonary capillary bed Tissue perfusion

RAAS stimulation
Pulmonary edema Cellular hypoxia

Vasoconstriction and
reabsorption of Na and water

ECF volume
Total blood volume
Systemic BP

Sign and Symptoms

Symptoms are dependent on two factors. The first is based on the side of the heart,
right or left, that is involved. The second factor is based on the type of failure, either
diastolic or systolic. Symptoms and presentation may be indistinguishable making
diagnosis impossible based on symptoms.

Left side of the heart pumps blood from the lungs to the organs, failure to do so leads to
congestion of the lung veins and symptoms that reflect this, as well as reduced supply
of blood to the tissues.
The predominant respiratory symptom is shortness of breath on exertion
(dyspnea) or in severe cases at rest - and easy fatigueability. Orthopnea is
increasing breathlessness on reclining, often measured in the number of pillows
required to lie comfortably. Paroxysmal nocturnal dyspnea is a nighttime attack of
severe breathlessness, usually several hours after going to sleep. Poor circulation to
the body leads to dizziness, confusion and diaphoresis and cool extremities at

Predominant left-sided clinical signs are tachypnea and increased work of breathing
(signs of respiratory distress not specific to heart failure), rales or crackles, which
suggests the development of pulmonary edema, dullness of the lung fields to
percussion and diminished breath sounds at the bases of the lung, which suggests the
development of a pleural effusion (fluid collection in the pleural cavity) that is
transudative in nature, and cyanosis which suggests hypoxemia, caused by the
decreased rate of diffusion of oxygen from fluid-filled alveoli to the pulmonary
Right Sided Congestive Heart Failure


LSCHF Reduced myocardial Increases cardiac
Pulmonary Embolism contractility workload
Right ventricular infarction
Congenital septal defects

Decreased diastolic filling

Obstruction of right atrial Contraction of right sided
emptying atrial filling

Increase right atrial pressure Right sided CHF Blood drains back from RV
to RA

s/s: Increased pressure in the veins

Neck vein engorgement
Portal hypertension
Peripheral edema