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Heart Failure Chronic

Heart Failure Chronic



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Published by mardsz

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Categories:Types, School Work
Published by: mardsz on Jan 01, 2009
Copyright:Attribution Non-commercial


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Failure of the left and/or right chambers of the heart results in insufficient output to meet tissue needs and causes pulmonary and systemic vascular congestion. This disease condition is termed
heart failure
(HF). Despite diagnosticand therapeutic advances, HF continues to be associated with high morbidity and mortality. (Agency for Health CarePolicy and Research [AHCPR] guidelines [6/94] promote the term
heart failure
[HF] in place of 
congestive heart  failure
[CHF] because many patients with heart failure do not manifest pulmonary or systemic congestion.) The NewYork Heart Association functional classification system for HF includes classes I to IV. Common causes of HF includeventricular dysfunction, cardiomyopathies, hypertension, coronary artery disease, valvular disease, and dysrhythmias.
Although generally managed at the community level, inpatient stay may be required for periodic exacerbation of failure/development of complications.
Myocardial infarctionHypertensionCardiac surgeryDysrhythmiasPsychosocial aspects of care
Patient Assessment Database
May report:
Fatigue/exhaustion progressing throughout the day; exercise intoleranceInsomnia
Chest pain/pressure with activityDyspnea at rest or with exertion
May exhibit:
Restlessness, mental status changes, e.g., anxiety and lethargyVital sign changes with activity
May report:
History of hypertension, recent/acute multiple MIs, previous episodes of HF, valvular heartdisease, cardiac surgery, endocarditis, systemic lupus erythematosus (SLE),anemia, septic shock Swelling of feet, legs, abdomen, “belt too tight” (right-sided heart failure)
May exhibit:
BP may be low (pump failure), normal (mild or chronic HF), or high (fluid overload/increased SVR)Pulse pressure may be narrow, reflecting reduced stroke volumeTachycardia (may be left- or right-sided heart failure)Dysrhythmias, e.g., atrial fibrillation, premature ventricular contractions/tachycardia, heart blocksApical pulse: PMI may be diffuse and displaced inferiorly to the leftHeart sounds: S
(gallop) is diagnostic of congestive failure; S
may occur; S
and S
may be softenedSystolic and diastolic murmurs may indicate the presence of valvular stenosis or insufficiency, both atrial and ventricular.Pulses: Peripheral pulses diminished; central pulses may be bounding, e.g., visible jugular,carotid, abdominal pulsations; alteration in strength of beat may be notedColor ashen, pale, dusky, or even cyanotic Nailbeds pale or cyanotic, with slow capillary refillLiver may be enlarged/palpable, positive hepatojugular reflexBreath sounds: Crackles, rhonchiEdema may be dependent, generalized, or pitting, especially in extremities; JVD may be present
May report:
Anxiety, apprehension, fear Stress related to illness/financial concerns (job/cost of medical care)
May exhibit:
Various behavioral manifestations, e.g., anxiety, anger, fear, irritability
May report:
Decreased voiding, dark urine Night voiding (nocturia)Diarrhea/constipation
May report:
Loss of appetite/anorexia Nausea/vomitingSignificant weight gain (may not respond to diuretic use)Lower extremity swellingTight clothing/shoesDiet high in salt/processed foods, fat, sugar, and caffeineUse of diuretics
May exhibit:
Rapid/continuous weight gainAbdominal distension (ascites); edema (general, dependent, pitting, brawny)Abdominal tenderness (ascites, hepatic engorgement)
May report:
Fatigue/weakness, exhaustion during self-care activities
May exhibit:
Appearance indicative of neglect of personal care
May report:
Weakness, dizziness, fainting episodes
May exhibit:
Lethargy, confusion, disorientationBehavior changes, irritability
May report:
Chest pain, chronic or acute anginaRight upper abdominal pain (right-sided heart failure [RHF])Generalized muscle aches/pains
May exhibit:
 Nervousness, restlessness Narrowed focus (withdrawal)Guarding behavior 
May report:
Dyspnea on exertion, sleeping sitting up or with several pillowsCough with/without sputum production, dry/hacking—especially when recumbentHistory of chronic lung diseaseUse of respiratory aids, e.g., oxygen and/or medications
May exhibit:
Tachypnea; shallow, labored breathing; use of accessory muscles, nasal flaringCough: Dry/hacking/nonproductive or may be gurgling with/without sputum productionSputum may be blood-tinged, pink/frothy (pulmonary edema)Breath sounds may be diminished, with bibasilar crackles and wheezesMentation may be diminished; lethargy, restlessness presentColor: Pallor or cyanosis
May exhibit:
Changes in mentation/confusionLoss of strength/muscle toneSkin excoriations, rashes
May report:
Decreased participation in usual social activities
May report:
Use/misuse of cardiac medications, e.g., beta-blockers, calcium channel blockers
Recent/recurrent hospitalizationsEvidence of failure to improve
Discharge plan
DRG projected mean length of inpatient stay: 5.5 days
Assistance with shopping, transportation, self-care needs, homemaker/maintenance tasksAlteration in medication use/therapyChanges in physical layout of home
Refer to section at end of plan for postdischarge considerations.
Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias,e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent prematureventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRSamplitude may be present.
Chest x-ray:
May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in bloodvessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, maysuggest ventricular aneurysm.
 Sonograms (echocardiogram, Doppler and transesophageal echocardiogram):
May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
 Heart scan (multigated acquisition [MUGA]):
Measures cardiac volume during both systole and diastole, measuresejection fraction, and estimates wall motion.
 Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan):
Determines presenceof myocardial ischemia and wall motion abnormalities.
 Positron emission tomography (PET) scan:
Sensitive test for evaluation of myocardial ischemia/detecting viablemyocardium.
Cardiac catheterization:
Abnormal pressures are indicative and help differentiate right- versus left-sided heart failure,as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into theventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsymay be useful in some patients to determine the underlying disorder, such as myocarditis or amylodosis.
 Liver enzymes:
Elevated in liver congestion/failure.
 Digoxin and other cardiac drug levels:
Determine therapeutic range and correlate with patient response.
 Bleeding and clotting times:
Determine therapeutic range; identify those at risk for excessive clot formation.
May be altered because of fluid shifts/decreased renal function, diuretic therapy.
 Pulse oximetry:
Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
 Arterial blood gases (ABGs):
Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased P
Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine isindicative of renal failure.
 Serum albumin/transferrin:
May be decreased as a result of reduced protein intake or reduced protein synthesis incongested liver.
Complete blood count (CBC):
May reveal anemia, polycythemia, or dilutional changes indicating water retention.Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.
May be elevated, indicating acute inflammatory reaction.
Thyroid studies:
Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.
1. Improve myocardial contractility/systemic perfusion.2. Reduce fluid volume overload.3. Prevent complications.4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

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