Congestive Heart Failure Case Study Congestive Heart Failure

Congestive Heart Failure
Case Study
Congestive Heart Failure
Congestive Heart Failure
Congestive Heart Failure
Impaired cardiac pumping
– Ventricular dysfunction
Heart remodeling
– Reduced exercise tolerance
Diminished quality of life
Shortened life expectancy
Associated with CAD and HTN
Congestive Heart Failure
5 million people in US
Most rapidly increasing form of CV
– AHA estimates 450,000 new cases/year
– Increases with age 1 in every 100 adults
– Most common DX in hospitalized adults > 65
– Incidence equal in men and women
Congestive Heart Failure
Risk Factors
Diabetes Mellitus, cigarette smoking,
obesity, high serum cholesterol
Major contributing factor
Congestive Heart Failure
Systolic Failure
– Defect in ventricular contraction
Left Ventricle loses ability to generate enough pressure to
eject blood forward through the high pressure aorta –
Decreased ejection fraction
Afterload – hypertension, cardiomyopathy, and
valvular heart disease
Diastolic Failure
– Impaired ability of ventricles to fill
– Decreased filling = decreased stroke volume
– Pulmonary congestion, pulmonary hypertension,
with normal ejection fraction
Congestive Heart Failure
Congestive Heart Failure
Mixed Systolic & Diastolic Failure
– Poor ejection fraction
– High pulmonary pressures
Both ventricles have poor filling and emptying
– Acute MI; cardiomyopathy, poorly
controlled Hypertension
Congestive Heart Failure
Common Causes
Hypertensive HD
Rheumatic Heart Dis
Congenital Heart Dis
Cor pulmonale
Bacterial endocarditis
Valvular disorders
Acute MI
Pulmonary emboli
Hypertensive crisis
Rupture of papillary
Congestive Heart Failure
Left Venticular Failure – Most Common
– Left ventricular function
– Blood backup – left atrium & pulmonary
– Increased pulmonary pressure
– Fluid extravasation from pulmonary capillary
bed to interstitium & alveoli
– Results: Pulmonary Congestion
Pulmonary Edema
Congestive Heart Failure
Clinical Picture
Left Sided Heart Failure
Decreased Cardiac Output
– Fatigue, weakness, oliguria during the day,
angina, confusion, restlessness, dizziness,
tachycardia, palpitations, pallor, weak
peripheral pulses, cool extremities
Pulmonary Congestion
– Hacking cough, worse at night, dyspnea,
rales, expiratory wheezes, frothy, pink-tinged
sputum, tachypnea, S3/S4 summation gallop
Congestive Heart Failure
Congestive Heart Failure
Left Sided Ventricular Failure
Congestive Heart Failure
Right Ventricular Failure
Backward flow of blood to right atrium and venous
Systemic venous congestion in systemic
Results: peripheral edema, hepatomegaly,
splenomegaly, vascular congestion of the GI tract,
jugular vein distention
Primary Cause: left ventricular failure
Chronic pulmonary congestion & hypertension result in right
ventricular failure
Cor pulmonale – ventricular dilation & hypertrophy
Congestive Heart Failure
Clinical Picture
Right Sided Heart Failure
Jugular vein distention
Enlarged liver & spleen
Anorexia & nausea
Dependent edema (legs & sacrum)
Distended abdomen
Edematous hands and fingers
Polyuria at night
Weight gain
Increased BP (excess volume) OR
Decreased BP (from failure)
Right Sided
Congestive Heart Failure
Congestive Heart Failure
Diagnostic Studies
Goal: Assess the cause & degree of failure
History and Physical Exam
Brain Natriuretic Peptide level (BNP).
– elevated in acute and chronic heart failure
– useful in following the response to treatment of
congestive heart failure.
ABGs, Serum chemistries, LFTs
Chest x-ray
Nuclear imaging studies
Cardiac catheterization
Hemodynamic monitoring
Congestive Heart Failure
Remodeling or Hypertrophy
Congestive Heart Failure
Class 1 – No limitation of physical activity
Class 2 – Slight limitation – fatigue, dyspnea,
Class 3 – marked limitation. Comfortable at
rest; ordinary activities cause symptoms
Class 4 – Inability to carry out any physical
activity without symptoms –
Pain/discomfort at rest
CHF – Outcome Measures
Use of ß-blockers at discharge and during admission.
Use of aspirin at discharge and during admission.
Timely and appropriate acute reperfusion (thrombolysis or primary
The use of angiotensin-converting enzyme (ACE) inhibitors for
patients with depressed left ventricular systolic function. Similarly,
a minority of patients with AMI are potential candidates for this
care process,
The proportion of patients eligible for smoking-cessation
counseling is relatively small, and ascertainment can be difficult,
given the variability in documentation as well as practice.
Diet and exercise counseling
Cholesterol status assessment and management.
Congestive Heart Failure
Pleural effusion
Left ventricular thrombus
Hepatomegaly –
impaired liver function
• Acute Pulmonary Edema
CHF/ Pulmonary Edema
Congestive Heart Failure
Pulmonary Edema
Congestive Heart Failure
Congestive Heart Failure
Arterial Monitoring
Congestive Heart Failure
Central Venous Pressure
Congestive Heart Failure
Hemodynamic Monitoring
Swan Ganz Catheter
Congestive Heart Failure
Nursing Diagnoses
Activity intolerance r/t fatigue
secondary to cardiac insufficiency
Excess fluid volume r/t cardiac
Disturbed sleep pattern r/t nocturnal
Impaired gas exchange r/t increased
preload and afterload
Anxiety r/t dyspnea / fear of death
Knowledge deficit r/t disease process
Congestive Heart Failure
Medical Treatment Goals
Decreasing Intravascular Volume
– Decreasing Venous Return
Decreases preload – decreases the volume to the
left ventricle during diastole
Med: Diuretics – Lasix (furosemide)
Decreasing Afterload
– Decrease systemic vascular resistance
CO increases
Pulmonary congestion decreases
Meds: Nitroglycerine (NTG); Morphine; Calcium
Channel Blockers
Congestive Heart Failure
Medical Treatment Goals
Improving Gas Exchange & Oxygenation
– Supplemental oxygen
– Morphine
Severe cases – intubation / ventilation
Improving Cardiac Function
– Increase cardiac contractility without increasing cardiac oxygen
– Hemodynamic Monitoring:
pulmonary artery pressure; pulmonary artery wedge
pressure (14-18mmg HG)
– Inotropic Meds: Digoxin
Inotropic meds used with hemodynamic monitoring:
– Dobutamine
– Inodilators: (inotropic & vasodilator): Milrinone
Congestive Heart Failure
Medical Treatment Goals
Reducing Anxiety
– Sedative action of IV Morphine
Complication: respiratory depression
Determine & Treat Underlying Cause
– Systolic or Diastolic failure
– Aggressive drug therapy
Congestive Heart Failure
Nursing Process
Assess: Hemodynamic status – VS, PO,
CVP, PAP, PAWP, response to medication
cardiac rhythm, LOC, energy level; labs
Nsg Action: Administer medications,
oxygen, supportive treatment,
community referral & home preparation
Pt/Family Education: Lifestyle
modification, Medication
Congestive Heart Failure
Case Study