Cassidy Orvik NP1 Hillsborough Community College Nursing “D” record Medical Diagnosis: Congestive Heart Failure Congestive

heart failure is a clinical syndrome that is described as the inability of the heart to pump an adequate amount of oxygenated blood to meet the body’s demands (adequate cardiac output). It is a condition that is marked by shortness of breath, edema, and poor tissue perfusion, congestion of the vascular beds, pulmonary edema, jugular vein distention and liver congestion. Abnormal sodium levels and fluid retention (overload) are also often present with congestive heart failure. There are thought to be many causes for the development of congestive heart failure. Common causes either independent or in combination are listed below: Weakened heart muscle, dampened/stenosed heart valves, atherosclerosis, acute MI, toxic exposure (substance abuse with alcohol or cocaine), infection, hypertension, pericardial disease (pericardial effusion), congenital heart disease, and prolonged (serious) arrhythmias. Pathophysiology: When congestive heart failure occurs and there is a drop in cardiac output; the sympathetic nervous system (SNS) is stimulated. Stimulation of the sympathetic nervous system activates the following compensatory changes in an attempt to increase venous return to the heart: Increased heart rate, increased force of contraction, vasoconstriction, increased preload (left end diastolic pressure), increased afterload, and increased systemic vascular resistance. In addition to an increase is SNS, the kidney’s also attempt compensate for the initial decrease in cardiac output by decreasing renal perfusion and activating the renin-angiotensin-aldosterone-system (RAAS). When RAAS is activated the following compensatory process begins: Angiotensin II and Aldosterone are released which lead to sodium retention and vasoconstriction. This release activates the release of increased anti-diuretic hormone (ADH). The release of ADH causes the kidneys to reabsorb more water. The combination of increased sodium and water leads to a further increase preload. In both acute and chronic congestive heart failure these initial compensatory mechanisms eventually become counterproductive. When either the right or left ventricle lose the ability to handle the extra or increased preload there is a backup of fluid. If the left ventricle is involved, the fluid back up reaches the pulmonary bed and causes symptoms such as shortness of breath, dyspnea on exertion, orthopnea and pulmonary edema. If the right ventricle is involved the fluid backs up into the systemic circulation and produces symptoms such as elevated central venous pressure (CVP), elevated jugular venous distention, anorexia and peripheral edema. Significant Diagnostic Tests: In addition to patient history and physical assessment, the following labs, tests and procedures are recommended for diagnosing congestive heart failure

Medical Therapies: Because congestive heart failure is considered to be “syndrome” rather than a disease process. atherosclerosis. An ECHO can also help identify cardiac Tamponade. Imaging Studies: Chest X-ray – Although diagnosis of congestive heart failure may be limited by chest X-ray. Echocardiography (ECHO) – Identifying the regional wall motion abnormalities that are associated with congestive heart failure can be accomplished with an echocardiogram. elevated Aspartate Aminotransferase (AST) or elevated bilirubin are suggestive of congestive hepatomegaly (which is consistent with CHF). it is one of the most useful tools available. the most appropriate treatment regimen is one that focuses on treating the symptoms and processes that present such as ischemia. **Elevated creatinine levels and dilutional hyponatremia may be observed in severe cases of CHF. **A decreased erythrocyte sedimentation rate (ESR) can help to diagnose early mild to moderate CHF.Lab Tests: Beta Natriuretic peptide (BNP) – this laboratory study can help to identify CHF as the origin for unclear dyspnea. When serum levels of BNP are less than 100pg/ml the diagnosis of CHF is unlikely. A pulmonary artery catheter may be placed in order to provide initial and continual monitor of heart pressures and responses to diuretic therapy (this is not a required intervention). inadequate systolic/diastolic function. they are more commonly found on the right side of the chest). Bilateral pleural effusions can be viewed by X-ray (if unilateral. Cardiomegaly can be seen if the cardiothoracic ratio is greater than 50%. ECG can also diagnose dysrhythmias that are caused by left ventricular hypertrophy (which often occurs in left sided failure). Other Tests/Procedures: Electrocardiogram (ECG) – This is a non-specific test that may be useful in diagnosing cardiac ischemia that is caused by congestive heart failure. excessive . chest pain. Cardiac catheterization may be indicated for severe cases of CHF in an attempt to assess and evaluate the progression and prognosis of the syndrome. Serum levels of BNP that range between 100 – 500 pg/ml is probably caused by CHF and BNP levels that are > 500 pg/ml are considered to be definitely consistent with a diagnosis of CHF. Of note: A 12 hour radiographic lag time from onset of symptoms to demonstration on chest X-ray may be present making a diagnosis of congestive heart failure difficult by X-ray alone. pericardial constriction and possible valvular heart disease. **Serum lab values that positively identify pre-renal apothecia: elevated alanine-aminotransferase (ALT).

*Central Venous Pressure (the pressure in the right atrium). Pain relief (Morphine for chest pain). elevated CVP. cyanosis. murmur or mitral insufficiency. the following hemodynamic pressures should be monitored for patients with congestive heart failure. murmur or tricuspid insufficiency. 7. Right Sided Heart Failure: Dependent pitting edema. mental confusion. If a pulmonary artery catheter is placed. breathing. diaphoresis. weight gain. Restrict sodium and fluid intake (strict I&O) 6. basilar crackles or rhonchi. Pharmaceutical therapy often begins with nitrates and diuretics (appropriate medication regimens are the major focus of treatment). Common Symptoms: Left Sided Heart Failure: Capillary refill > 3 seconds. Oxygen therapy as needed (100% non-rebreather mask or intubation with mechanical ventilation may be initially required). *Cardiac Output (the amount of blood ejected from the heart per minute). enlarged right atrium on X-ray. 8. hypoxia (respiratory acidosis). enlarged left ventricle on X-ray. abdominal pain. 2. orthopnea. pulsus alternans (alteration of weak and strong beats). The following medical treatments should be considered for effective treatment of congestive heart failure: 1. fatigue/weakness/lethargy. Bed rest is tolerated (patients may not tolerate bed rest and may wish to sit up with legs dangling off the bed). fatigue/weakness. audible S3 and S4 heart tones. Continuous cardiac/Pulse oximetry monitoring. venous distention. dyspnea on exertion. narrowing pulse pressure. ABC’s (airway. audible S3 and S4 heart tones. elevated pulmonary artery occlusive pressures. circulation). nocturia. cough with frothy sputum (indicative of pulmonary edema). *Cardiac Index (the cardiac output divided by the body surface area). anorexia. weight gain . 3. nocturnal dyspnea. 4. elevated pulmonary artery pressures. 5. hepatojugular reflux. elevated right ventricular pressure. oliguria. enlarged right ventricle of X-ray. enlarged left atrium on X-ray. elevated right atrial pressure. Kussmaul’s sign. tachypnea.preload and renal artery stenosis. narrowing pulse pressure. *Preload (the volume of blood in the ventricle at the end of diastole). arrhythmias. *Afterload/SVR (the amount of work or resistance that the ventricles must overcome to eject) *Pulmonary Artery Pressure (this is the pressure within the pulmonary bed).

source. Assess pain level (degree. rhonchi or pulmonary congestion). Monitor for restless. Anticipated Nursing Diagnosis: Decreased cardiac output Impaired gas exchange Altered tissue perfusion (cardiac) Ineffective breathing pattern Alteration in fluid balance (excess) Fatigue Anxiety Knowledge deficit . Listen to breath sounds (monitor for increased crackles. anxious behavior and promote self-care participation. Evaluate Intake and Output (monitor effects of diuretic therapy and observe for signs and symptoms of either fluid overload or deficit) 1. Evaluate daily weight (a 2. Assess capillary refill (if greater than 3 seconds. quality. Evaluate Digoxin levels (if patient taking Digoxin) 9. Look for the presence of jugular vein distention (jugular vein distention can be a sign of worsening right sided heart failure). 3. onset and relieving factors) 10. 4. Monitor for EKG changes 7. Monitor vital signs/oxygenation/Neuro status (report changes in heart and respiratory rate/patterns 2. assess for signs of peripheral edema). Evaluate electrolyte levels (sodium. Assess bowel function (stool softeners such as Colace should be ordered to prevent constipation). Assess degree of discomfort associated with activity 13.2 kg weight increase over a 1 day period is considered significant). 14. location. potassium and creatinine) 8. 5.Focused Assessments: 1. 6.

" Dynamic Nursing Education.Reference: Hudson. . 2009. Kristi . 22 Feb. 14 Oct.dynamicnursingeducation. "Congestive Heart Failure.>. <www.

°– ¾  f€f ¾fn°nf¾° ¯ f¾ ¾n f¾ °f €  f½¯½f° f f f¯°€– °f   ¯    #¾ ¯f° ¾%f f nf fn½% ¾f n° °f¾¯f  ¾° ¾¾€  f  ¯f f° ½¾¾ ½ €¾° n°– ¾°€  f¾nf ¾ ½¯°f ¯f ©–f ° ¾ °°f°  n°– ¾°  °¯f¾ ¯  ¾ f° €   °°% f %f f¾€ °½ ¾ °n°– ¾  f€f  @  f – ¯f°nf¾ ¾€   ½¯ °€n°– ¾  f€f .

 n ½¾ %¾ ¾f°n f ¾  fnnnf° % °€ n° ½  °¾° ½ nf f ¾ f¾ %½ nf f €€¾°% n°– °f f ¾ f¾ f° ½°– %¾ ¾%f¯f¾  9f½¾– J °n°– ¾  f€f nn¾f°   ¾f ½°nf fn½   ¾¯½f n° ¾¾¾ ¯%-%¾¾¯f ¯f°€ ¾¯½f n° ¾¾¾ ¯ fnf ¾ €°–n¯½ °¾fnf°– ¾°f°f ¯½°n f¾  °¾ °  f  °n f¾  ff °n f¾ €n €n°fn° f¾n°¾n° °n f¾ ½ f % € °  f¾n½ ¾¾ % °n f¾ f€ f f° °n f¾ ¾¾ ¯nf¾nf ¾¾f°n °f °f° °n f¾ ¾-   ° #¾f¾f ¯½n¯½ °¾f € °f n f¾ °nf fn½  n f¾°– °f½ €¾°f° fnf°–  °° f°– °¾° f ¾ ° ¾¾ ¯%% J ° ¾fnf  €°–n¯½ °¾f½n ¾¾ –°¾ °– °¾°f°  ¾ ° f    f¾ n f ¾ ¯  °°f° f¾n°¾n° @¾  f¾ fnf ¾   f¾ € °n f¾ f°  n¯° %% @   f¾ €nf¾ ¾  ° ¾ f ¾ ¯ f   @ n¯ °f°€°n f¾ ¾ ¯f° f  f ¾f€ °n f¾ ½ f  ° fn f° n°nn°– ¾  f€f  ¾ °fn¯½ °¾f¯ nf°¾¯¾  °f n¯ n° ½ n J °   – € °n ¾  f f°    f °n f¾ ½ f   ¾f fn½€€ €  € °n ¾°  €  fn½ fn ¾  ½¯°f f° nf¾ ¾¾¯½¯¾¾nf¾¾° ¾¾€  f  ¾½° f°  ° ½° ff°  ½¯°f ¯f € – °n ¾°  €  fn¾½° ¾¾ ¯nnnf°f°  ½ n ¾¾¯½¯¾¾nf¾  f n °f °¾½ ¾¾ %.¯¯° nf¾ ¾  ° ½ ° °°n¯ °f°f ¾   J f °  f¯¾n  f¯½ ° $¾ °¾  ff ¾ f ¾n ¾¾ fn .

I9%   f ©–f °¾ ¾ °°  f° ff° ½ ½ f ¯f  –°€nf°f–°¾n@ ¾¾ °f °½f °¾f° ½¾nff¾¾ ¾¾¯ °  €°–f ¾   ¾¾f° ½n  ¾f  n¯¯ ° € f–°¾°–n°– ¾  f€f    .

f @ ¾¾  f-f n½ ½ % -9% ¾f f¾ nf° ½ °€.

f¾ –°€°n f ¾½° f J °¾ ¯  ¾€ -9f  ¾¾f°½–$¯  f–°¾¾€.

¾°   ¯  ¾ € -9ff°–   ° ½–$¯¾½ f nf¾  .

f°  -9  ¾ff   ½–$¯f n°¾    €° n°¾¾ °f f–°¾¾€.

  && ¯f f ¾f½¾  °€½  °ff½ nf   f ff°° f¯°f°¾€ f¾  %@%   f ¾½ff ¯°f°¾€ f¾ %@%  f   °f ¾–– ¾ €n°– ¾   ½f¯ –f%n¾n°¾¾ °.

%  && n f¾  n ¾ ¯ °f°f %%nf° ½ f–°¾  f¯ ¯ f .

  && f n f°°   ¾f°  °f½°f ¯f¯f  ¾  °¾   nf¾ ¾€.

  ¯f–°–  ¾  .

 ¾O f – f–°¾¾€n°– ¾  f€f ¯f ¯  n ¾O f ¾° €  ¯¾¾ €¾fff  .

f ¯ –fnf° ¾ °€ nf fnnf¾– f f°  f f½ f €€¾°¾nf°    O f%€°f f  f ¯ n¯¯°€° °  –¾ € n ¾% €° f –f½nf–¯ €¯°¾ €¾¯½¯¾ ¯°¾f°°n ¾O f¯f ½ ¾ °¯f°–f f–°¾¾€n°– ¾  f€f  €€n  O ff°  nnf –f½%.

%  °€°–  –°ff¯°f °¯f ¾ff f¾¾nf  n°– ¾  f€f nf° fnn¯½¾ f° nnf –f¯ °.

nf°f¾ ½ °€ nf fn@f¯½°f ½ nf fn°¾n°f° ½¾¾  ff f ¾ f¾   @ ¾¾$9n  ¾   nnf –f¯%.

% @¾¾f°° ¾½ n€n ¾f¯f ¾ €° f–°¾°–nf fn¾n ¯f f¾nf¾  n°– ¾  f€f .

nf°f¾ f–°¾  ¾¯f¾ff nf¾   €  °nf½ ½%n€ °nn¾° €¾ €f %  .

f fnnf  f°¯f ° nf €¾   nf¾ ¾€.

nf@ f½ ¾   nf¾ n°– ¾  f€f ¾n°¾   #¾° ¯ #f f°f ¾ f¾ ½n ¾¾  ¯¾ f½½½f  f¯ ° –¯ °¾° f€n¾ ¾° f°– ¾¯½¯¾f° ½n ¾¾ ¾f ½ ¾ °¾nf¾¾n ¯f f ¾n ¾¾ °f f ¾¾n$ f¾n€°n° n ¾½f°  n ¾¾  .°f°f ¯½f¾¾ ¾¾f°  ff   ½– ¾¾°f° ½–°¾¾€ ¾° ¯  ½¯°ff nf  ¯f ½fn ° ½ °ff° n°°f¯°€ f ½ ¾¾ ¾f°  ¾½°¾ ¾  n f½%¾¾°f  °  °°%  .

½ f f°  °ff ¾ °¾¾ @ €°–¯ nf f¯ °¾¾  n°¾  € €€ n   f¯ °€n°– ¾  f€f     .

#¾%ff   f°– nnf°%    – ° f½f¾° % °°   f ¯f¾° f°¯ nf°nf  °f°¯f °f  %    .

½° €n ¾½f°%    €f½¯°ff nf  ¾½fn  €°– ¯ °f¯n½ ¾¾ ¾¾   ¯° €½f °¾n°– ¾  f€f  &.°°¾nf fn$9¾ ¯ ¯°°–    9f¯fn nf f½€ ° –°¾°f ¾f°   n¾%f½½½f ¯ nf°  –¯ °¾f  ¯f©€n¾€ f¯ °%     ¾n¾ ¯f° € °f %¾n %    ¾¾ f %½f °¾¯f° f   ¾f° ¯f¾¾½ –¾ f°–°–€€  %    9f°  €%.

f fn½% f¯°€   © n €¯  f½ ¯° %  &.

f fn° % nf fn½      ¾€fn f f%  &.

°fI °¾9 ¾¾ % ½ ¾¾ ° –f¯%  &9 f % ¯ €  °  °n f  ° € f¾ %  &€ f $I% f¯°€ ¾¾f°n f  °n ¾¯¾ n¯  © n% &9¯°f 9 ¾¾ %¾¾ ½ ¾¾ ° ½¯°f %  .

¯¯°¯½¯¾   €  ff  .

f½f € ¾ n° ¾ ½° f  ¾½° f°  ° °n°f ¾½° f n–€ ¾½¯%° nf €½¯°f ¯f% fn½° f  f½ ¾¾  f¾fnfn ¾°n nf°¾¾  ½f% ¾½ffn ¾¾%   f ½¯°ff ½ ¾¾ ¾   f ½¯°ff  nn¾ ½ ¾¾ ¾ f   f°  f° ¾ °nf ¯ °fn°€¾°  ––f°  €f– $ f° ¾¾$ f– ¯¯¯f°¾€€n °n  °f–  € °n °O f  °f–  € f¯°O f °f°–½¾ ½ ¾¾ ½¾¾f °f°¾%f f°€ ff° ¾°– f¾%  –  ff   ½ ° °½°– ¯f  °¾ ¾ °°  ½f©–f € –f f¯f¾   f .

I9   f –ff½ ¾¾   f – °nf½ ¾¾ °f°–½¾ ½ ¾¾ ¾¾¯f#¾ ¾–° ¯¯n¾½ °¾€€n °n f   f°  f° ¾ €f– $ f° ¾¾ f ¯°f ½f° f° f  °f– –f¯°O f  °f– – °n €O f  ––f° .

n¾ ¾¾ ¾¾¯ °¾   .°f¾–°¾$– °f°$- ¾f¾% ½nf°– ¾° ff°  ¾½ff $½f °¾  ff  f –%f – –°n f¾  f f½  ¾n°¾  ¾–°€nf°%   ¾ °  f¾° ¾%¯°€°n f¾ nfn ¾ °n½¯°fn°– ¾°%   ¾¾ ¾¾nf½f €%€– f f°¾ n° ¾ f¾¾ ¾¾€¾–°¾€½ ½ f ¯f%   € ½ ¾ °n €©–f ° ¾ °°%©–f ° ¾ °°nf° f¾–°€¾ °°– –¾  f€f %   .°€ ¾ ¾¾ f°¾ ff° ½¯ ¾ € nf ½fn½f°   ¾¾ ¾¾  €°n°%¾¾€ ° ¾¾nf¾.°€nf°– ¾  ff   n   ¾%¾ ¯ ½f¾¾¯f° n f°° %  ff –°  ¾%€½f °f°––°%  ¾¾ ¾¾½f°  % – f ¾n nf° °¾ f°   °–€fn¾%  ff °f f° ½%¯° €€ n¾€  n f½f°  ¾  €¾–°¾f° ¾¯½¯¾ €  €  f  €n%  ¾¾ ¾¾ – € ¾n¯€f¾¾nf fn  .

fn ¾    ½  °n°¾½f°%  °n½f -¾°–f–°¾¾   n f¾ nf fn½ ¯½f –f¾ nf°–    ¾¾ ½ €¾°%nf fn% ° €€ n   f°–½f °  f°°€  ff°n % n ¾¾% f–  °  ° –  €n  .

 €  °n   ¾° ¾  .

°– ¾  ff °f¯n-¾°– nf° n      °f¯n°¾°– nf° n¯    .