Congestive Heart Failure Case Study

1. Congestive Heart FailureCase Study

2. Congestive Heart Failure

3. Congestive Heart Failure

4. 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

5. Congestive Heart FailureDemographics • 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

6. Congestive Heart FailureRisk Factors • Diabetes Mellitus, cigarette smoking, obesity, high serum cholesterol • Major contributing factor • HYPERTENSION

7. Congestive Heart FailurePathophysiology • 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

8. Congestive Heart Failure

9. Congestive Heart FailurePathophysiology • Mixed Systolic & Diastolic Failure • Poor ejection fraction • High pulmonary pressures • Both ventricles have poor filling and emptying capacity • Acute MI; cardiomyopathy, poorly controlled Hypertension

10. Congestive Heart FailureCommon Causes

11. Congestive Heart FailurePathophysiology • 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

12. Congestive Heart FailureClinical PictureLeft 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

13. Congestive Heart FailurePathophysiology

14. Congestive Heart FailureLeft Sided Ventricular Failure

15. Congestive Heart FailurePathophysiology • 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 • Corpulmonale – ventricular dilation & hypertrophy

16. Congestive Heart FailureClinical PictureRight 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)

17. Right Sided Congestive Heart Failure

18. Congestive Heart FailureDiagnostic 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

19. Congestive Heart Failure

20. CHFRemodeling or Hypertrophy

21. Congestive Heart FailureClassification • 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

22. CHF – Outcome Measures • Use of ß-blockers at dischargeand during admission. • Use of aspirin at discharge and during admission. • Timely and appropriate acutereperfusion (thrombolysis or primaryangioplasty). • The use of angiotensin-convertingenzyme (ACE) inhibitors forpatients with depressed left ventricularsystolic function.Similarly, a minority of patients with AMIare potential candidatesfor this care process, • Theproportionof patients eligible for smoking-cessation counselingis relativelysmall, and ascertainment can be difficult, giventhe variabilityin documentation as well as practice. • Diet andexercise counseling • Cholesterol statusassessment and management.

23. Congestive Heart FailureComplications • Pleural effusion • Dysrhythmias • Left ventricular thrombus • Hepatomegaly – impaired liver function • Acute Pulmonary Edema

24. CHF/ Pulmonary Edema

25. Congestive Heart FailurePulmonary Edema

26. Congestive Heart Failure HemodynamicAssessment

27. Congestive Heart FailureArterial Monitoring

28. Congestive Heart FailureCentral Venous Pressure

29. Congestive Heart FailureHemodynamic MonitoringSwan Ganz Catheter

30. Congestive Heart FailureNursing 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

31. Congestive Heart FailureMedical 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

32. Congestive Heart FailureMedical 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

33. Congestive Heart FailureMedical Treatment Goals • Reducing Anxiety • Sedative action of IV Morphine • Complication: respiratory depression • Determine & Treat Underlying Cause • Systolic or Diastolic failure • Aggressive drug therapy

34. Congestive Heart FailureNursing 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

35. Congestive Heart FailureCase Study