congestive heart failure case study. congestive heart failure

Congestive Heart FailureCongestive Heart FailureCase StudyCase Study

Congestive Heart FailureCongestive Heart Failure


Impaired cardiac pumpingImpaired cardiac pumping

– Ventricular dysfunctionHeart remodelingHeart remodeling

– Reduced exercise toleranceReduced exercise toleranceDiminished quality of lifeDiminished quality of life

Shortened life expectancyShortened life expectancy

Associated with CAD and HTNAssociated with CAD and HTN

Congestive Heart FailureCongestive Heart FailureDemographicsDemographics

5 million people in US 5 million people in US

Most rapidly increasing form of CV Most rapidly increasing form of CV diseasedisease

– AHA estimates 450,000 new cases/yearAHA estimates 450,000 new cases/year– Increases with age 1 in every 100 adultsIncreases with age 1 in every 100 adults– Most common DX in hospitalized adults > 65Most common DX in hospitalized adults > 65– Incidence equal in men and womenIncidence equal in men and women

Congestive Heart FailureCongestive Heart FailureRisk FactorsRisk Factors

Diabetes Mellitus, cigarette smoking, Diabetes Mellitus, cigarette smoking, obesity, high serum cholesterolobesity, high serum cholesterol

Major contributing factorMajor contributing factor

HYPERTENSIONHYPERTENSION

Congestive Heart FailureCongestive Heart FailurePathophysiologyPathophysiology

Systolic FailureSystolic Failure– Defect in ventricular contractionDefect in ventricular contraction

Left Ventricle loses ability to generate enough pressure to Left Ventricle loses ability to generate enough pressure to eject blood forward through the high pressure aorta – eject blood forward through the high pressure aorta – Decreased ejection fractionDecreased ejection fraction

Afterload Afterload – hypertension, cardiomyopathy, and – hypertension, cardiomyopathy, and valvular heart diseasevalvular heart disease

Diastolic FailureDiastolic Failure– Impaired ability of ventricles to fill Impaired ability of ventricles to fill – Decreased filling = Decreased filling = decreased stroke volumedecreased stroke volume– Pulmonary congestion, pulmonary hypertension, with Pulmonary congestion, pulmonary hypertension, with

normal ejection fractionnormal ejection fraction


Mixed Systolic & Diastolic FailureMixed Systolic & Diastolic Failure

– Poor ejection fractionPoor ejection fraction

– High pulmonary pressuresHigh pulmonary pressuresBoth ventricles have poor filling and emptying Both ventricles have poor filling and emptying capacitycapacity

– Acute MI; cardiomyopathy, poorly controlled Acute MI; cardiomyopathy, poorly controlled HypertensionHypertension

Congestive Heart FailureCongestive Heart FailureCommon CausesCommon Causes

ChronicChronic AcuteAcute

CADCAD

Hypertensive HDHypertensive HD

Rheumatic Heart DisRheumatic Heart Dis

Congenital Heart DisCongenital Heart Dis

Cor pulmonaleCor pulmonale

CardiomyopathyCardiomyopathy

AnemiaAnemia

Bacterial endocarditisBacterial endocarditis

Valvular disordersValvular disorders

Acute MIAcute MI

DysrhythmiasDysrhythmias

Pulmonary emboliPulmonary emboli

ThyrotixicosisThyrotixicosis

Hypertensive crisisHypertensive crisis

Rupture of papillary Rupture of papillary musclemuscle

VSDVSD

MyocarditisMyocarditis


Left Venticular Failure Left Venticular Failure – – Most CommonMost Common

– Left ventricular functionLeft ventricular function– Blood backup – left atrium & pulmonary veinsBlood backup – left atrium & pulmonary veins– Increased pulmonary pressureIncreased pulmonary pressure– Fluid extravasation from pulmonary capillary Fluid extravasation from pulmonary capillary

bed to interstitium & alveolibed to interstitium & alveoli– Results: Pulmonary Congestion Results: Pulmonary Congestion

Pulmonary Edema Pulmonary Edema

Congestive Heart FailureCongestive Heart FailureClinical PictureClinical Picture

Left Sided Heart FailureLeft Sided Heart Failure

Decreased Cardiac OutputDecreased Cardiac Output– Fatigue, weakness, oliguria during the day, Fatigue, weakness, oliguria during the day,

angina, confusion, restlessness, dizziness, angina, confusion, restlessness, dizziness, tachycardia, palpitations, pallor, weak tachycardia, palpitations, pallor, weak peripheral pulses, cool extremitiesperipheral pulses, cool extremities

Pulmonary CongestionPulmonary Congestion– Hacking cough, worse at night, dyspnea, Hacking cough, worse at night, dyspnea,

rales, expiratory wheezes, frothy, pink-tinged rales, expiratory wheezes, frothy, pink-tinged sputum, tachypnea, S3/S4 summation gallopsputum, tachypnea, S3/S4 summation gallop

Congestive Heart FailureCongestive Heart FailureLeft Sided Ventricular FailureLeft Sided Ventricular Failure


Right Ventricular FailureRight Ventricular Failure

Backward flow of blood to right atrium and venous Backward flow of blood to right atrium and venous circulationcirculationSystemic venous congestion in systemic Systemic venous congestion in systemic circulationcirculationResults: peripheral edema, hepatomegaly, Results: peripheral edema, hepatomegaly, splenomegaly, vascular congestion of the GI tract, splenomegaly, vascular congestion of the GI tract, jugular vein distentionjugular vein distention

Primary CausePrimary Cause: : left ventricular failureleft ventricular failure

Chronic pulmonary congestion & hypertension result in right Chronic pulmonary congestion & hypertension result in right ventricular failureventricular failureCor pulmonaleCor pulmonale – ventricular dilation & hypertrophy – ventricular dilation & hypertrophy

Congestive Heart FailureCongestive Heart FailureClinical PictureClinical Picture

Right Sided Heart FailureRight Sided Heart FailureJugular vein distentionJugular vein distentionEnlarged liver & spleenEnlarged liver & spleenAnorexia & nauseaAnorexia & nauseaDependent edema (legs & sacrum)Dependent edema (legs & sacrum)Distended abdomenDistended abdomenEdematous hands and fingersEdematous hands and fingersPolyuria at nightPolyuria at nightWeight gainWeight gainIncreased BP (excess volume) ORIncreased BP (excess volume) ORDecreased BP (from failure)Decreased BP (from failure)

Right Sided Right Sided Congestive Heart FailureCongestive Heart Failure

Congestive Heart FailureCongestive Heart FailureDiagnostic StudiesDiagnostic Studies

Goal: Assess the cause & degree of failureGoal: Assess the cause & degree of failure

History and Physical ExamHistory and Physical Exam

Brain Natriuretic Peptide level (BNP). Brain Natriuretic Peptide level (BNP). – elevated in acute and chronic heart failure elevated in acute and chronic heart failure – useful in following the response to treatment of useful in following the response to treatment of

congestive heart failure.congestive heart failure.

ABGs, Serum chemistries, LFTsABGs, Serum chemistries, LFTs

Chest x-rayChest x-ray

EKGEKG

EchocardiogramEchocardiogram

Nuclear imaging studiesNuclear imaging studies

Cardiac catheterizationCardiac catheterization

Hemodynamic monitoringHemodynamic monitoring

CHFCHFRemodeling or HypertrophyRemodeling or Hypertrophy

Congestive Heart FailureCongestive Heart FailureClassificationClassification

Class 1Class 1 – No limitation of physical activity – No limitation of physical activity

Class 2Class 2 – Slight limitation – fatigue, dyspnea, – Slight limitation – fatigue, dyspnea, palpitationspalpitations

Class 3Class 3 – marked limitation. Comfortable at – marked limitation. Comfortable at rest; ordinary activities cause symptomsrest; ordinary activities cause symptoms

Class 4Class 4 – Inability to carry out any physical – Inability to carry out any physical activity without symptoms – activity without symptoms –

Pain/discomfort at restPain/discomfort at rest

CHF – Outcome MeasuresCHF – Outcome MeasuresUse of ß-blockers at dischargeUse of ß-blockers at discharge and during admission. and during admission.

Use of aspirin at discharge and during admissionUse of aspirin at discharge and during admission..

Timely and appropriate acuteTimely and appropriate acute reperfusion (thrombolysis or primaryreperfusion (thrombolysis or primary

angioplasty).angioplasty).

The use of angiotensin-convertingThe use of angiotensin-converting enzyme (ACE) inhibitors forenzyme (ACE) inhibitors for

patients with depressed left ventricularpatients with depressed left ventricular systolic function.systolic function. Similarly, a Similarly, a minority of patients with AMIminority of patients with AMI are potential candidatesare potential candidates for this care for this care process,process,

TheThe proportionproportion of patients eligible for smoking-cessation counselingof patients eligible for smoking-cessation counseling

is relativelyis relatively small, and ascertainment can be difficult, givensmall, and ascertainment can be difficult, given the the variabilityvariability in documentation as well as practice. in documentation as well as practice.

Diet andDiet and exercise counselingexercise counseling

Cholesterol statusCholesterol status assessment and management. assessment and management.

Congestive Heart FailureCongestive Heart FailureComplicationsComplications

Pleural effusionPleural effusion

DysrhythmiasDysrhythmias

Left ventricular thrombusLeft ventricular thrombus

Hepatomegaly – Hepatomegaly –

impaired liver functionimpaired liver function

• Acute Pulmonary EdemaAcute Pulmonary Edema

CHF/ Pulmonary EdemaCHF/ Pulmonary Edema

Congestive Heart FailureCongestive Heart FailurePulmonary EdemaPulmonary Edema

Congestive Heart Failure Congestive Heart Failure HemodynamicAssessmentHemodynamicAssessment

Congestive Heart FailureCongestive Heart FailureArterial MonitoringArterial Monitoring

Congestive Heart FailureCongestive Heart FailureCentral Venous PressureCentral Venous Pressure

Congestive Heart FailureCongestive Heart FailureHemodynamic MonitoringHemodynamic Monitoring

Swan Ganz CatheterSwan Ganz Catheter

Congestive Heart FailureCongestive Heart FailureNursing DiagnosesNursing Diagnoses

Activity intolerance r/t fatigue Activity intolerance r/t fatigue secondary to cardiac insufficiencysecondary to cardiac insufficiencyExcess fluid volume r/t cardiac failureExcess fluid volume r/t cardiac failureDisturbed sleep pattern r/t nocturnal Disturbed sleep pattern r/t nocturnal dyspnea dyspnea Impaired gas exchange r/t increased Impaired gas exchange r/t increased preload and afterloadpreload and afterloadAnxiety r/t dyspnea / fear of deathAnxiety r/t dyspnea / fear of deathKnowledge deficit r/t disease processKnowledge deficit r/t disease process

Congestive Heart FailureCongestive Heart FailureMedical Treatment GoalsMedical Treatment Goals

Decreasing Intravascular VolumeDecreasing Intravascular Volume– Decreasing Venous ReturnDecreasing Venous Return

Decreases preload – decreases the volume to the Decreases preload – decreases the volume to the left ventricle during diastoleleft ventricle during diastoleMed: Diuretics – Lasix (furosemide)Med: Diuretics – Lasix (furosemide)

Decreasing AfterloadDecreasing Afterload– Decrease systemic vascular resistanceDecrease systemic vascular resistance

CO increases CO increases Pulmonary congestion decreasesPulmonary congestion decreasesMeds: Nitroglycerine (NTG); Morphine; Calcium Meds: Nitroglycerine (NTG); Morphine; Calcium Channel BlockersChannel Blockers


Improving Gas Exchange & OxygenationImproving Gas Exchange & Oxygenation– Supplemental oxygenSupplemental oxygen– MorphineMorphine

Severe cases – intubation / ventilationSevere cases – intubation / ventilation

Improving Cardiac FunctionImproving Cardiac Function– Increase cardiac contractility without increasing cardiac oxygen Increase cardiac contractility without increasing cardiac oxygen

consumptionconsumption– Hemodynamic Monitoring: Hemodynamic Monitoring:

pulmonary artery pressure; pulmonary artery wedge pulmonary artery pressure; pulmonary artery wedge pressure (14-18mmg HG)pressure (14-18mmg HG)

– Inotropic MedsInotropic Meds: Digoxin: DigoxinInotropic meds used with hemodynamic monitoring:Inotropic meds used with hemodynamic monitoring:

– DobutamineDobutamine– InodilatorsInodilators: : (inotropic & vasodilator): Milrinone


Reducing AnxietyReducing Anxiety– Sedative action of IV MorphineSedative action of IV Morphine

Complication: respiratory depressionComplication: respiratory depression

Determine & Treat Underlying CauseDetermine & Treat Underlying Cause– Systolic or Diastolic failureSystolic or Diastolic failure– Aggressive drug therapyAggressive drug therapy

Congestive Heart FailureCongestive Heart FailureNursing ProcessNursing Process

AssessAssess: : Hemodynamic status – VS, PO, Hemodynamic status – VS, PO, CVP, PAP, PAWP, response to medicationCVP, PAP, PAWP, response to medication

cardiac rhythm, LOC, energy level; labs cardiac rhythm, LOC, energy level; labs

Nsg ActionNsg Action: : Administer medications, Administer medications, oxygen, supportive treatment, oxygen, supportive treatment, community referral & home preparationcommunity referral & home preparation

Pt/Family EducationPt/Family Education: Lifestyle : Lifestyle modification, Medicationmodification, Medication

Congestive Heart FailureCongestive Heart FailureCase StudyCase Study

congestive heart failure case study. congestive heart failure

Documents

pulmonary hypertension

pulmonary capillary

vascular congestion

decreased filling

peripheral edema

right atrium

high pressure aorta

poor filling