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Congestive Heart FailureCongestive Heart FailureCase StudyCase Study
Congestive Heart FailureCongestive Heart Failure
Congestive Heart FailureCongestive Heart Failure
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
Congestive Heart FailureCongestive Heart Failure
Congestive Heart FailureCongestive Heart FailurePathophysiologyPathophysiology
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
Congestive Heart FailureCongestive Heart FailurePathophysiologyPathophysiology
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 FailurePathophysiologyPathophysiology
Congestive Heart FailureCongestive Heart FailureLeft Sided Ventricular FailureLeft Sided Ventricular Failure
Congestive Heart FailureCongestive Heart FailurePathophysiologyPathophysiology
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
Congestive Heart FailureCongestive Heart Failure
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
Congestive Heart FailureCongestive Heart FailureMedical Treatment GoalsMedical Treatment Goals
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
Congestive Heart FailureCongestive Heart FailureMedical Treatment GoalsMedical Treatment Goals
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