Right-Sided Congestive Heart Failure - Research Paper Example

RIGHT SIDED CONGESTIVE HEART FAILURE INTRODUCTION: Congestive heart failure or heart failure can be defined as the incapability of heart to supply adequate amount of blood to entire body’s metabolic needs. In other words, insufficient blood supply by heart to the body. It is a condition in which circulatory congestion occurs due to myocardial dysfunction. Myocardial dysfunction is characterized by reduced contractility and abnormal wall motion ensuing in decreased ability of ventricles to drain, fall in stroke volume and an increase in residual volume. (Faubion, 2004). According to World Health Organization (WHO), more than 22 million people suffer from congestive heart disease worldwide. Its prevalence is 2% in ages 40-59, more than 5% in ages 60-69 and 10% in ages 70 and above. McMurray JJ, Pfeffer MA (2005). In 2005 of an estimated 58 million deaths globally, cardiovascular diseases accounted for about 30%. About 10% of the patients which are diagnosed with congestive heart failure die within a year while around 50% of the patients survive only for 5 years. (Swierzewski, S., J. 2000). Heart failure is associated with impaired ventricular function and can be forward or backward failure, systolic or diastolic in nature and can be left sided or right sided. Heart being a pumping organ comprises of two atriums and two ventricles. The two ventricles represent separate pumping systems and it is possible for one to fail followed subsequently by the other resulting in either left sided congestive heart failure or right sided. Likewise in forward failure an insufficient output of affected ventricle results in decreased perfusion to vital signs. However in backward failure, blood tends to accumulate behind the affected ventricle causing increased pressure in atrium behind the affected ventricle. Low output of heart failure means an inadequate cardiac output while high cardiac output failure occurs when heart pumps harder to meet up the demands of the body. Systolic failure results in problems with contraction of heart and ejection of blood while diastolic failure is characterized by problems in relaxation of heart and filling with blood. EPIDEMIOLOGY: Congestive Heart failure is one of the primary causes of hospitalization in age 65 and above. Gender, age and race are variables which differ in prevalence of congestive heart disease globally. Both men and women have almost same incidence rate of heart failure, however several differences are observed as women tend to develop heart failure after menopause, have more distinct signs and symptoms and have an elevated survival rate than men. The incident rate of heart failure increases as the age progresses. The frequency of disease is 1-2% in population of 55 and below while increases dramatically to 10% for 55 and above. The occurrence of congestive heart failure is more pronounced in Americans, Hispanics, and Africans. Dumitru, I., Baker, M. (2010). CAUSES OF RIGHT-SIDED CONGESTIVE HEART FAILURE: There are numerous intrinsic and extrinsic causes for congestive heart failure which include myocardial infarction, congenital heart diseases, valvular defects, cardiomyopathy, systemic hypertension, chronic obstructive pulmonary disease, pulmonary embolism, blood volume excess, metabolic respiratory acidosis, cardiac dysrhythmias etc,. However several specific causes have been identified for right sided congestive heart failures which are listed below: Left ventricular failure Coronary artery disease (ischemia) Pulmonary valve stenosis Pulmonary embolism Neuromuscular disease Chronic pulmonary disease Pulmonary hypertension (Dumitru, I., Baker, M. 2010). SIGNS AND SYMPTOMS: Heart failure symptoms which are widely used in clinical studies and diagnosis can be cardiac or non-cardiac. General cardiac symptoms include breathlessness, chest pain, palpitations, exertional dyspnea, orthopnea, dyspnea at rest and pulmonary edema to name a few. Other non-cardiac symptoms include anorexia, nausea, weight-loss, fatigue, bloating, nocturia, weakness etc. (Swierzewski, S., J. 2000). Predominantly heart failure symptoms are arbitrarily classified into right sided or left sided however heart failure is usually not only left sided or right sided but usually one following the other or both occurring simultaneously. Right sided failure is the result of backward failure of right ventricle which leads to congestion of systemic capillaries. This causes excessive fluid accumulation in the body and results in edema. Also increased fluid accumulation may result in enlarged abdominal girth, epigastric and right upper quadrant abdominal pain. Along with that nocturia occurs when this fluid from the legs return to main blood stream when patient is in lying position. In more severe cases, ascites, hepatomegaly(enlargement of liver) and impaired liver function may develop. Diagnosis of right sided heart failure is often confused with hepatic failure. ( Dumitru, I., Baker, M. 2010). Another symptom associated with congestive heart failure Dyspnea is more prominent in left ventricle failure as compared to right sided ones; however when cardiac output is decreased in patients with right-sided heart failure severe dyspnea may occur as a direct consequence of lowered cardiac output, metabolic acidosis, poor perfusion of respiratory muscles, hypoxemia. Physical examination of such patients may reveal peripheral edema, hepatomegaly and ascites. Jugular venous pressure is commonly assessed as a fluid status marker of the patient. MANAGEMENT: Management of the patient may be approached by following ways: 1. TREATMENT: Treatment of congestive heart failure patients include oxygen therapy which aims to provide increased oxygen supply to the patient. Along with that sodium restricted diet to avoid excessive fluid accumulation. Moreover, proper exercise and a balance between work activities and rest to avoid hypertension. NURSING PRACTISE MANAGEMENT: Providing oxygenation is one of the most primary responsibilities by the nursing staff. This may be done by administering oxygen therapy per nasal cannula. Propping up the patient in semi-Fowler’s or high Fowler’s position to support greater lung expansion. Bed rest and limited activity may be vital for congestive heart failure patient. Providing extra pillows for the added support in high Fowler’ position may help the patient. Administering valium as per prescription of the doctor may assist in relaxation and better sleep patterns. However, gradual activities like dangling from the bed, sitting up in chair, walking close distances with assistance will prevent venous thrombosis and embolism encountered by prolonged bed rest. Decreasing anxiety by sharing of feelings, strengthening will power can be fundamental for the recovery of the patient as increased anxiety caused higher blood pressures and breathlessness. Maintaining the fluid balance of the patient by sodium restricted diet, monitoring weight and blood pressure and also administering digitalis or diuretics as prescribed is helpful in management of the patient. One of the nursing responsibilities in congestive heart failure patients includes skin care as the edematous skin of the patient is susceptible to pressure sores regularly change positions of patient on bed. Also use protective devices to prevent pressure sores and often assess sacral area. Encouraging nutrition and promoting elimination of wastes of the patient is important for the recovery of congestive heart patient. Nutrition provided must be low calorie, rich in vitamins and minerals with reduced salt content and in small portions to minimize exertion on gastrointestinal blood requirements. Avoid processed food at all costs. On the other hand, advise the patient to avoid straining during defecation. Administer laxative as required and promote use of bed side commodes. If acute pulmonary edema occurs in a patient following steps should be followed for appropriate management: High Fowler’s position Oxygen therapy by nasal mask or cannula Rapid digitalization Diuretic therapy Administration Morphine sulphate as prescribed Administration of Aminophylline IV for relief of bronchospasm and increased cardiac output 2. MEDICATIONS: Digitalis Therapy: It is one of the major therapies for congestive heart failure and has a positive inotropic effect (reinforces cardiac contractility) and negative chronotropic effects (decreases heart rate). Most commonly used medicine in this type of therapy is DOC (Lanoxin/digoxin). Antidote for toxicity is Digiband. Nursing responsibilities in this type of therapy include: Evaluating the heart rate before administration if it is below 60 or above 120 hold back the drug. Monitor serum potassium Evaluate signs of Digitalis Toxicity which include bradycardia, nausea, vomiting, diarrhea, dysrhthmias, misrepresented visual perceptions etc. Diuretic Therapy: The aim of this therapy is to lower the circulating volume thereby reducing the cardiac workload. Most commonly diuretic drugs used are Thiazides, Loop diuretics, potassium-sparing. Nursing responsibilities for this type of therapy include: Administer drugs in early afternoon or early morning to prevent from the symptoms of nocturia. Assess for the signs of hypokalemia. Supplement diet with potassium rich food. Vasodilators: This therapy focuses on decreasing after load by lowering the resistance to ventricular emptying. Commonly used vasodilators include Nitroprusside, Hydrazaline, and Captopril etc. NATRIURETIC PEPTIDES: The natriuretic peptide system comprises of four structurally peptides responsible for adjusting pressure and volume by promoting the removal of Na ions from the blood. The most important of these active peptides serving as hormones are atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). These hormones are primarily responsible for playing a regulatory role in cardiovascular diseases. One of the first natriuretic peptide to be identified was atrial natriuretic peptide (ANP) in 1960’s: a 28-amino acid hormone found in the atrium of heart. .(Mair, J., Friedl. W., and others., 1999) Brain natriuretic peptide (BNP) or B-type is a 32-amino acid hormone secreted from cardiac myocytes and is released in reaction to ventricular stretch and volume overload.(Mair, J., Friedl. W., and others., 1999). It plays an important role in maintaining electrolyte-fluid homeostasis and its level increases exponentially as the ventricles fail to pump blood.(Doyama, K., Fukumoto, M., Takemura, G., Tanaka, M., Oda, T., Hasegawa, K., Inada, T., and others., 1998) BNP is considered one of significant markers in assessing the cardiovascular status of the patient as its levels are elevated in congestive heart failure patients. PATHOPYSIOLOGY OF RIGHT-SIDED CONGESTIVE HEART FAILURE: Congestive heart failure is described the disturbance in body fluid balance and structural and functional injury of myocardium. A number of neuro-hormones play role in congestive heart disease which includes vasoconstrictors, anti-natriuretic systems and the renin–angiotensin–aldosterone system. (Bialik, G, M., Abassi. Z. A., Hammel, I., Winaver, J., Lewinson, D. 2001). In their studies, Mukoyama et al. (1991) have found that BNP levels found in the atrium are proportionally related to the severity of the disease and BNP levels increase in response to high atrial pressure. In contrast Moe et al.1996 demonstrated that both ANP and BNP are released during heart failure and later research has revealed that plasma level of these two peptides increase dramatically during heart failure. ANP and BNP both are released from atria and ventricles respectively and both the hormones are involved in increase in natriuresis and vasodilation. BNP in particular restrain sodium reabsorption in proximal convoluted tubule in kidney and also inhibits rennin, aldosterone release. (Bialik, G, M., Abassi. Z. A., Hammel, I., Winaver, J., Lewinson, D. 2001). The BNP levels in the blood are linked positively with the cardiac filling pressure volumes and it is inversely related to left ventricular discharge. The neuro-hormonal imbalance between the natriuretic peptide system and rennin-angiotensin-aldosterone system is the major cause of congestive heart failure. Therefore BNP is considered one of the most important markers in heart failure and monitoring of increase in this hormone may help in early prediction of the disease. Alteration in BNP pressure over a passage of time is associated with changes in ventricular volume thereby appearance of clinical symptoms are noticed in the patients. However due to intra-individual differences and large number of factors affecting BNP levels it is not yet possible to interpret precisely the nature and magnitude of BNP level variations. (Ahn, M., Yoo, B., 2007). CONCLUSION: Right sided congestive heart failure is a condition characterized by failure of right ventricle to pump sufficient blood into the body leading to myocardial dysfunction. About 22 million people worldwide suffer from congestive heart diseases and it is a major cause of hospitalization in several countries. Symptoms of this disease may include chest pain, pulmonary edema, dyspnea, orthopnea, nausea; bloating etc. Two active peptides serving as hormones i.e. ANP and BNP released from atria and ventricles respectively are involved in natriuressis and vasodilation and levels of these hormones are very important in maintain a regulation during cardiovascular diseases. Research has indicated that timely and accurate measuring of BNP levels can prove to be a breakthrough in early diagnosis of right sided congestive heart failure. And with appropriate management and medication, recovery and survival rate of congestive heart failure patients can be increased. Treatment of such patients can be approached either by management practices which comprises of providing high oxygen concentration, sodium restricted diet; bed rest etc. Medications may include either digitalis therapy or diuretic therapy. Also vasodilators are used in treating congestive heart failure patients. References Ahn, M., Yoo, B. (2007). Serial Monitoring of B-Type Natriuretic Peptide in Heart Failure Patients. Korean Circulation J ;37:393-398 Bialik, G, M., Abassi. Z. A., Hammel, I., Winaver, J., Lewinson, D. (2001). Evaluation of atrial natriuretic peptide in atrial granules of rats with experimental congestive heart failures. Journal of Histochemistry and Cytochemistry, Vol. 49, 1293-1300. Dumitru, I., Baker, M. (2010). Heart failure. http://emedicine.medscape.com/specialties Doyama, K., Fukumoto, M., Takemura, G., Tanaka, M., Oda, T., Hasegawa, K., Inada, T., and others. (1998). Expression and distribution of brain natriuretic peptide in human right atria. Journal of the American college of Cardiology; Vol 32, 1832-1838. Faubion, D. A. (2004). B-Type natriuretic peptide and congestive heart failure, Clinical Laboratory Science. Mair, J., Friedl. W., and others. (1999)Natriuretic peptides in assessment of left ventricular dysfunction. Scand J Clin Lab Invest 59:(Suppl 230)132-42. McMurray, J., Pfeffer, M.,A., (2005). "Heart failure". Lancet 365 (9474): 1877–89. doi:10.1016/S0140-6736(05)66621-4. PMID 15924986 Moe, G.W., Grima, E.A., Wong, N.L.M., Howard, R.J., Armstrong, P.W., (1996) Plasma and cardiac tissue atrial and brain natriuretic peptides in experimental heart failure. J. Am Coll Cardiol 27:720-727 Mukoyama, M., Nakao, K., Hosoda, K., Suga, S., Saito, Y., Ogawa, Y., Shirakami, G., Jougasaki, M., Obata, K., Yasue, H., Kambayashi, Y., Inouye, K., Imura, H. (1991) Brain natriuretic peptide as a novel cardiac hormone in humans. Evidence for an exquisite dual natriuretic peptide system, atrial natriuretic peptide and brain natriuretic peptide. J. Clin Invest 87:1402-1412 Nakamura, S., Naruse, M., Naruse, K., Kawana, M., Nishikawa, T., Hosoda, S., Tanaka, I., Yoshimi, T., Yoshihara, I., Inagami, T. (1991). Atrial natriuretic peptide and brain natriuretic peptide coexist in the secretory granules of human cardiac myocytes. Am J Hypertens 4:909-912 Swierzewski, S., J. (2000). Congestive heart failure. http://www.cardiologychannel.com/chf/symptoms.shtml Prevention of Cardiovascular Disease Guidelines for assessment and management of cardiovascular risk, Geneva, 2005 Read More