Congestive Heart Failure Case Study Congestive Heart Failure
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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 Demographics 5 million people in US Most rapidly increasing form of CV disease – 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 HYPERTENSION Congestive Heart Failure Pathophysiology 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 Pathophysiology Mixed Systolic & Diastolic Failure – Poor ejection fraction – High pulmonary pressures Both ventricles have poor filling and emptying capacity – Acute MI; cardiomyopathy, poorly controlled Hypertension Congestive Heart Failure Common Causes Chronic CAD Hypertensive HD Rheumatic Heart Dis Congenital Heart Dis Cor pulmonale Cardiomyopathy Anemia Bacterial endocarditis Valvular disorders Acute Acute MI Dysrhythmias Pulmonary emboli Thyrotixicosis Hypertensive crisis Rupture of papillary muscle VSD Myocarditis Congestive Heart Failure Pathophysiology Left Venticular Failure – Most Common – Left ventricular function – Blood backup – left atrium & pulmonary veins – 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 Pathophysiology Congestive Heart Failure Left Sided Ventricular Failure Congestive Heart Failure Pathophysiology Right Ventricular Failure Backward flow of blood to right atrium and venous circulation Systemic venous congestion in systemic circulation 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 EKG Echocardiogram Nuclear imaging studies Cardiac catheterization Hemodynamic monitoring Congestive Heart Failure CHF Remodeling or Hypertrophy Congestive Heart Failure Classification Class 1 – No limitation of physical activity Class 2 – Slight limitation – fatigue, dyspnea, palpitations 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 angioplasty). 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 Complications Pleural effusion Dysrhythmias Left ventricular thrombus Hepatomegaly – impaired liver function • Acute Pulmonary Edema CHF/ Pulmonary Edema Congestive Heart Failure Pulmonary Edema Congestive Heart Failure HemodynamicAssessment 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 failure Disturbed sleep pattern r/t nocturnal dyspnea 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 consumption – 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
