Congestive Heart Failure Case Study

Congestive Heart Failure
Case Study
Impaired cardiac pumping
– Ventricular dysfunction
Heart remodeling
– Reduced exercise tolerance

Diminished quality of life
Shortened life expectancy
Associated with CAD and HTN

Demographics
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
Risk Factors
Diabetes Mellitus, cigarette smoking,
obesity, high serum cholesterol
Major contributing factor
HYPERTENSION
Pathophysiology
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
Pathophysiology
Mixed Systolic & Diastolic Failure
– Poor ejection fraction
– High pulmonary pressures

Both ventricles have poor filling and emptying
capacity
– Acute MI; cardiomyopathy, poorly controlled

Hypertension
Common Causes
Chronic Acute
CAD Acute MI
Hypertensive HD Dysrhythmias
Rheumatic Heart Dis Pulmonary emboli
Congenital Heart Dis Thyrotixicosis
Cor pulmonale Hypertensive crisis
Cardiomyopathy Rupture of papillary
Anemia muscle
Bacterial endocarditis VSD
Valvular disorders Myocarditis
Pathophysiology
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
Clinical Picture
Left 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
Pathophysiology
Left Sided Ventricular Failure
Pathophysiology
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
Cor pulmonale – ventricular dilation & hypertrophy
Clinical Picture
Right 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)
Right Sided
Diagnostic 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
CHF
Remodeling or Hypertrophy
Classification
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
CHF – Outcome Measures
Use of ß-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.

Complications
Pleural effusion
Dysrhythmias
Left ventricular thrombus
Hepatomegaly –
impaired liver function
• Acute Pulmonary Edema

CHF/ Pulmonary Edema
Pulmonary Edema
HemodynamicAssessment
Arterial Monitoring
Central Venous Pressure
Hemodynamic Monitoring
Swan Ganz Catheter
Nursing 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
Medical 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
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
Reducing Anxiety
– Sedative action of IV Morphine
Complication: respiratory depression
Determine & Treat Underlying Cause

– Systolic or Diastolic failure
– Aggressive drug therapy
Nursing 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
Case Study

Congestive Heart Failure Case Study

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Congestive Heart Failure

Impaired cardiac pumping

– Reduced exercise tolerance

Associated with CAD and HTN

Most rapidly increasing form of CV

– AHA estimates 450,000 new cases/year

Major contributing factor

– Poor ejection fraction

– High pulmonary pressures

– Acute MI; cardiomyopathy, poorly controlled

– Left ventricular function

Backward flow of blood to right atrium and venous

Primary Cause: left ventricular failure

Chronic pulmonary congestion & hypertension result in right

Class 2 – Slight limitation – fatigue, dyspnea,

Class 3 – marked limitation. Comfortable at

Class 4 – Inability to carry out any physical

Use of aspirin at discharge and during admission.

Timely and appropriate acute reperfusion (thrombolysis or primary

The use of angiotensin-converting enzyme (ACE) inhibitors for patients

The proportion of patients eligible for smoking-cessation counseling is

Diet and exercise counseling

Cholesterol status assessment and management.

Left ventricular thrombus

• Acute Pulmonary Edema

Determine & Treat Underlying Cause

Nsg Action: Administer medications,

Pt/Family Education: Lifestyle

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