congestive heart failure case study. congestive heart failure

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  • Congestive Heart FailureCase Study

  • Congestive Heart Failure

  • Congestive Heart Failure

  • Congestive Heart FailureImpaired cardiac pumping

    Ventricular dysfunctionHeart remodeling

    Reduced exercise toleranceDiminished quality of lifeShortened life expectancy

    Associated with CAD and HTN

  • Congestive Heart FailureDemographics

    5 million people in US

    Most rapidly increasing form of CV disease

    AHA estimates 450,000 new cases/yearIncreases with age 1 in every 100 adultsMost common DX in hospitalized adults > 65Incidence equal in men and women

  • Congestive Heart FailureRisk FactorsDiabetes Mellitus, cigarette smoking, obesity, high serum cholesterol

    Major contributing factor


  • Congestive Heart FailurePathophysiologySystolic FailureDefect in ventricular contractionLeft Ventricle loses ability to generate enough pressure to eject blood forward through the high pressure aorta Decreased ejection fractionAfterload hypertension, cardiomyopathy, and valvular heart disease

    Diastolic FailureImpaired ability of ventricles to fill Decreased filling = decreased stroke volumePulmonary congestion, pulmonary hypertension, with normal ejection fraction

  • Congestive Heart Failure

  • Congestive Heart FailurePathophysiologyMixed Systolic & Diastolic Failure

    Poor ejection fraction

    High pulmonary pressuresBoth ventricles have poor filling and emptying capacity

    Acute MI; cardiomyopathy, poorly controlled Hypertension

  • Congestive Heart FailureCommon Causes

    ChronicAcuteCADHypertensive HDRheumatic Heart DisCongenital Heart DisCor pulmonaleCardiomyopathyAnemiaBacterial endocarditisValvular disordersAcute MIDysrhythmiasPulmonary emboliThyrotixicosisHypertensive crisisRupture of papillary muscleVSDMyocarditis

  • Congestive Heart FailurePathophysiologyLeft Venticular Failure Most Common

    Left ventricular functionBlood backup left atrium & pulmonary veinsIncreased pulmonary pressureFluid extravasation from pulmonary capillary bed to interstitium & alveoliResults: Pulmonary Congestion Pulmonary Edema

  • Congestive Heart FailureClinical PictureLeft Sided Heart FailureDecreased Cardiac OutputFatigue, weakness, oliguria during the day, angina, confusion, restlessness, dizziness, tachycardia, palpitations, pallor, weak peripheral pulses, cool extremitiesPulmonary CongestionHacking cough, worse at night, dyspnea, rales, expiratory wheezes, frothy, pink-tinged sputum, tachypnea, S3/S4 summation gallop

  • Congestive Heart FailurePathophysiology

  • Congestive Heart FailureLeft Sided Ventricular Failure

  • Congestive Heart FailurePathophysiologyRight Ventricular Failure

    Backward flow of blood to right atrium and venous circulationSystemic venous congestion in systemic circulationResults: 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 failureCor pulmonale ventricular dilation & hypertrophy

  • Congestive Heart FailureClinical PictureRight Sided Heart FailureJugular vein distentionEnlarged liver & spleenAnorexia & nauseaDependent edema (legs & sacrum)Distended abdomenEdematous hands and fingersPolyuria at nightWeight gainIncreased BP (excess volume) ORDecreased BP (from failure)

  • Right Sided Congestive Heart Failure

  • Congestive Heart FailureDiagnostic StudiesGoal: Assess the cause & degree of failureHistory and Physical ExamBrain 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, LFTsChest x-rayEKGEchocardiogramNuclear imaging studiesCardiac catheterizationHemodynamic monitoring

  • Congestive Heart Failure

  • CHFRemodeling or Hypertrophy

  • Congestive Heart FailureClassificationClass 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 MeasuresUse of -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 FailureComplicationsPleural effusion


    Left ventricular thrombus

    Hepatomegaly impaired liver function

    Acute Pulmonary Edema

  • CHF/ Pulmonary Edema

  • Congestive Heart FailurePulmonary Edema

  • Congestive Heart Failure HemodynamicAssessment

  • Congestive Heart FailureArterial Monitoring

  • Congestive Heart FailureCentral Venous Pressure

  • Congestive Heart FailureHemodynamic MonitoringSwan Ganz Catheter

  • Congestive Heart FailureNursing DiagnosesActivity intolerance r/t fatigue secondary to cardiac insufficiencyExcess fluid volume r/t cardiac failureDisturbed sleep pattern r/t nocturnal dyspnea Impaired gas exchange r/t increased preload and afterloadAnxiety r/t dyspnea / fear of deathKnowledge deficit r/t disease process

  • Congestive Heart FailureMedical Treatment GoalsDecreasing Intravascular VolumeDecreasing Venous Return Decreases preload decreases the volume to the left ventricle during diastoleMed: Diuretics Lasix (furosemide)

    Decreasing AfterloadDecrease systemic vascular resistanceCO increases Pulmonary congestion decreasesMeds: Nitroglycerine (NTG); Morphine; Calcium Channel Blockers

  • Congestive Heart FailureMedical Treatment GoalsImproving Gas Exchange & OxygenationSupplemental oxygenMorphineSevere cases intubation / ventilationImproving Cardiac FunctionIncrease cardiac contractility without increasing cardiac oxygen consumptionHemodynamic Monitoring: pulmonary artery pressure; pulmonary artery wedge pressure (14-18mmg HG)Inotropic Meds: DigoxinInotropic meds used with hemodynamic monitoring:DobutamineInodilators: (inotropic & vasodilator): Milrinone

  • Congestive Heart FailureMedical Treatment GoalsReducing AnxietySedative action of IV MorphineComplication: respiratory depression

    Determine & Treat Underlying CauseSystolic or Diastolic failureAggressive drug therapy

  • Congestive Heart FailureNursing ProcessAssess: 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 FailureCase Study