Congestive Heart Failure
Download
Report
Transcript Congestive Heart Failure
Heart Failure (CHF)
Brunner, ch. 30, pp. 824-840
Chronic Heart Failure
Has exacerbations and remissions. Acute phase is
called acute decompensated heart failure.
Most common hospital admission in pts over 65
Second most common office visit
ER visits and readmissions are common.
Prevention and early intervention are important
health initiatives.
Pathophysiology
Impairment of ventricles from damage or
overstretching (Starling’s Law) makes them
unable to fill with and effectively pump blood.
As a result, cardiac output falls (decreased ejection
fraction), leading to decreased tissue perfusion,
making the heart unable to meet the metabolic
demands of the body.
Physiologic Compensatory
Mechanisms
Decreased CO stimulates SNS to release
catecholamines
This increases HR, BP, peripheral resistance, and
venous return
This decreases ventricular filling time and
decreases CO leading to decreased organ
perfusion
Results in increased myocardial workload and O2
demand.
Compensatory Mechanisms cont’d
Decreased CO and renal perfusion stimulates the
Renin-Angiotensin-Aldosterone System creating a
rock-slide effect (RAAS cascade)
Angiotensin stimulates aldosterone
Antidiuretic hormone is released
leading to……………………..
Compensatory Mechanisms
cont’d
Vasoconstriction
Increased BP
Salt and water retention
Increased vascular volume
Causing atrial natriuretic and b-type natriuretic
peptides (ANP & BNP, heart hormones) and nitric
oxide to kick in resulting in vasodilation and
diuresis…….
Compensation successful!
Pathophysiology:
Decompensation—ADHF
Occurs when these mechanisms become exhausted
and fail to maintain the CO needed for adequate
tissue perfusion.
Alveoli become filled with serosanguineous fluid
from congestion and the fluid leaks into interstitial
spaces. Lung tissue becomes less compliant and
airways constrict (AKA: Pulmonary Edema)
S/S of ADHF; AKA: Pulmonary
Edema
Severe dyspnea, tachypnea, orthopnea
Dry hacking cough, audible wheezing and moist
sounds, hemoptysis,
Lungs with crackles, wheezes, rhonchi
<SBP, >DBP, <PP, tachy, S3 gallop rhythm
Anxious, pale, cyanotic, dropping O2 sat
Cold, clammy skin
S/S of Chronic Heart Failure
Wt gain, edema
JVD
Hepatomegaly
Oliguria, nocturia
DOE, PND, orthopnea
Fatigue, anorexia
Restlessness, confusion, decreased attn span
Skin changes in extremities
Etiology of Heart Failure
Long standing CAD—creates prolonged ischemia
Previous MI—weakens muscle
HTN—increases afterload in great vessels, causes
LV hypertrophy
Hx of pericarditis—scar tissue causes constriction
Dysrhythmias—affect pump action
Etiology cont’d
Anemia—increases HR
Thyroid disease—increases HR and BP
Lyte imbalances—affects regularity, contractility
COPD—increases afterload in PA
Diabetes—constricts small arteries
Valvular disorders—causes leakage
Classifications of Heart Failure:
Right and Left
Right-sided
Congestion in right
chambers
Increase in CVP
Increase in size of RV
Backflow to vena cava
Congestion in jugular
veins, liver, lower
extremities
Left-sided
Congestion in left
chambers
Increase in size of LV
Backflow to
pulmonary veins
Congestion in lungs
Classifications: Forward and
Backward
Systolic Failure (Forward Failure)—poor cardiac
contraction results in poor CO and decreased EF. Kidneys
suffer the most.
Diastolic Failure (Backward Failure)—ventricles are
stiff and thick and will not relax enough during the resting
phase to receive adequate amount of blood to maintain
good CO. Also causes backflow into lungs and systemic
circulation.
Classifications: Functional
According to activity
tolerance:
1: no limitations
2: slight limitations
3: marked limitation
4: inability to tolerate
without discomfort
According to risk and
symptoms (826):
A: risk but no sx
B: HD but no sx
C: HD with sx of CHF
D: Advanced HD with
severe sx
Classifications: Wet/Dry;
Warm/Cold
Wet means the patient has fluid overload
Dry means the patient does not.
Warm means the patient has good perfusion
Cold means the patient does not.
Diagnostic Assessment
CXR—fluid and heart enlargement
ECG—can reveal hx of heart problems
Echo or TEE—enlargement, valvular function,
condition of great vessels, ejection fraction
ABGs, O2 sat, cardiac markers, BMP
Liver functions, thyroid functions, BUN,
creatinine, BNP
Stress testing
Collaborative Management: Core
Measures
Discharge Instructions (see Pt Ed slide)
Evaluation of Left Ventricular Systolic (LVS)
Function (ejection fraction). Must be documented
on the chart.
ACEI or ARB for LVSD (ejection fraction less
than 40%).
Adult Smoking Cessation Advice
Admission Criteria
Left-sided
O2 sat < 89
BUN or creatinine 1½ times
upper limits of normal
Change in mental status
Failed OP tx (2 vs/7d)
Sustained HR 100-120
Right-sided
O2 sat < 89
Weight gain > 3 lb/2d
Edema of extremities
Management of ADHF
Hi-Fowlers
O2 mask or BiPAP. Intubation and mechanical ventilation
is possible if needed
VS, Pulse ox, UOP hourly
Telemetry
Daily wt
Meds: diuretics (Lasix), vasodilators (NTG), inotropics
(dobutamine), morphine, (brain (B-type) natriuretic
peptide) Natrecor
Hemodynamic monitoring—CVP, PAWP
Circulatory assistive devices—VAD, IABP
Management of Chronic HF
Meds:
Digoxin
Lasix
ACEIs (Vasotec)
ARBs (Cozaar)
Renin inhibitor (Tekturna)
Beta-blockers (Lopressor)
Nitrates (isosorbide initrate)
Be mindful of potential dangerous side effects (837)
Management cont’d
6 small meals of NAS diet with >calories, protein
Fowler’s position
O2 by NC 3-6 L/min
Rest-activity schedule, stress reduction
I&O, daily wts, possible fluid restriction
Circulatory assistive device
Long-term: cardiac transplantation
Complications
Pleural effusion from pulmonary congestion
Dysrhythmias caused by stretching of the
chambers particularly the atria (a-fib) and
especially if EF < 35%
LV thrombus from atrial fib and poor ventricular
function. Need anticoagulant therapy.
Liver dysfunction—can result in cirrhosis
Renal failure from poor renal perfusion
Patient Education
Disease process
Meds—indications, SEs
Balancing rest and activity
Low Na diet; fluid restriction if indicated
Monitoring of fluid status—daily wt—same time, same
clothes
S&S to report—chest pain, palpitations, DOE, PND,
orthopnea, hemoptysis, wt gain (>3 lb/2d or >5 lb/wk),
increase in edema, fatigue, cough, anorexia
Emotional support—high level of anxiety and
depression
Keep appts