Congestive heart failure what your patients need to know
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Congestive Heart Failure : What your patients need to know. Lisa M. Kappers, RN, BSN Alverno College MSN Program Patient Care Coordinator – Infusion Therapy Center, WFSI – All Saints. Tutorial Instructions.

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Congestive Heart Failure: What your patients need to know.

Lisa M. Kappers, RN, BSN

Alverno College MSN Program

Patient Care Coordinator – Infusion Therapy Center, WFSI – All Saints


Tutorial Instructions

  • Use the buttons at the bottom of each slide to navigate through the tutorial or follow the special instructions on certain slides.

  • The “Home” button will bring you back to the beginning.


Tutorial Outcomes

  • At the end of this tutorial you will be able to:

    • Teach your patients about the pathophysiology of CHF.

    • Teach your patients about the importance of a low sodium diet.

    • Teach your patients how to “live” with CHF.


In order to complete this tutorial:

  • You should know the basic pathophysiology of normal cardiac function and normal respiratory function. If you need to review, the links below will take you to tutorials on:

  • Path of blood flow Cardiac Cycle Blood pressure Respiratory System

  • To return from these tutorials, click the back button on your browser.


Let’s review the basics.

  • Which side of the heart pumps blood to the lungs?

    • Right

    • Left


Great Job!

  • The right side of the heart pumps blood to the lungs.

  • Click on our friend to move forward.


Sorry.

  • Remember, the left side of the heart pumps blood to the peripheral circulatory system.

  • Click on our friend to try again.


Which part of the respiratory system is directly responsible for gas exchange?

  • A. Trachea

  • B. Larynx

  • C. Alveoli


Try Again.

  • The trachea is part of the lower airway but is not directly responsible for gas exchange. Click the duck to try again.


Try Again.

  • The larynx is responsible for air flow in and out of the lungs as it is a part of the upper airway. It is not responsible for gas exchange.

  • Click the gator to try again.


Great Job!

  • The alveoli are thin sacs at the end of the bronchioles which are directly responsible for gas exchange.


Now that we’ve reviewed the basics, let’s talk about CHF.

  • Remember, the basics are essential in order to complete this tutorial. If you need to review, return to the provided links at the beginning of the tutorial.


Let’s define congestive heart failure.

  • Heart failure is defined by the ACC/AHA as a disorder where the ventricle is prohibited from filling with or ejecting blood (2005). There are many different clinical signs of heart failure.


Right-Sided Heart Failure

  • Right sided heart failure occurs when the heart can not move the blood from the periphery into the pulmonary system. This causes blood to back up into the peripheral venous system.

  • (Porth, 2004)


What symptoms are caused by right-sided heart failure?

  • Peripheral edema

  • Dyspnea

  • Ascites

  • Hypoxia

  • Anorexia


You are correct!When the right side of the heart can not move blood from the peripheral system to the pulmonary system, peripheral edema occurs.

  • Click here to pick another symptom Click here to move forward


Dyspnea is not a symptom of right-sided heart failure.

Click here to return to question


In right sided heart failure, the blood can not move from the peripheral system to the pulmonary system. This does not cause hypoxia.

  • Click here to return to question


Good job!When blood can not be moved from the peripheral system to the pulmonary system, fluid builds up in the abdominal cavity causing ascites.

  • Click to return to question Click to move forward


Excellent!Fluid in the abdomen can push on the organs causing nausea and anorexia.

  • Click to return to question

  • Click to move forward


Left-Sided Heart Failure

  • Left-sided heart failure occurs when the blood from the pulmonary system can not be pumped into the peripheral system. This causes the blood to back up into the pulmonary vasculature.

  • (Porth, 2004)


What symptoms would you observe with left-sided heart failure?

  • Hypoxia

  • Dependent edema

  • Cough with frothy sputum

  • Orthopnea

  • Jugular vein distention


Fabulous!!

  • Hypoxia occurs due to the pulmonary congestion caused by left-sided heart failure.

    Click here to return to questionClick here to move forward


Oops, sorry.

  • Dependent edema occurs when the blood from the peripheral vasculature can not move forward during right-sided heart failure.

    Click here to return to question


Great job!

  • The cough occurs due to the congestion in the pulmonary vasculature.

    Click here to return to question Click here to move forward


Great thinking!

  • Orthopnea occurs when the patient is reclined and the blood from the peripheral vasculature settles in the pulmonary system.

    Click here to return to question Click here to move forward


Let’s think about this.

  • Jugular vein distention occurs when blood backs up in the peripheral vasculature. This happens during severe right-sided heart failure.

    Click here to return to the question


Chronic Heart Failure

  • Chronic heart failure is a combination of right and left heart failure. The right and left ventricles must maintain an equal output. Persistent left sided failure can lead to right sided failure. (Porth, 2004)


How does blood pressure affect heart failure?


Hypertension

  • There are two types of hypertension: primary and secondary.

  • Primary hypertension accounts for 90 – 95% of all cases and does not result from another disease process.

  • Secondary hypertension is the direct cause of a primary disease process such as renal disease.

  • (Porth, 2004)


  • Uncontrolled hypertension increases the workload of the left ventricle by increasing the pressure against which the heart must pump. The left ventricle hypertrophies or thickens, decreasing ejection fraction and putting the patient at risk for CHF.

  • (Porth, 2004)


  • Hypertension is a risk factor for all major cardiovascular disorders such as atherosclerosis, stroke, heart failure, coronary artery disease, and peripheral artery disease.

  • (Porth, 2004)


Atherosclerosis and Coronary Artery Disease

  • Atherosclerosis is defined as fatty lesions developing in the intimal lining of the aorta, coronary arteries, and the large arteries that supply blood to the brain.


Joe has hypertension. How does Joe develop CHF?


Hypertension

Click to see how comorbidities

might fit together.

Vessel Wall

Damage

Coronary

Artery

Disease

Atherosclerosis

Myocardial

Infarction

Ventricular

Dysfunction

CHF


How bad is Joe’s CHF?

  • There are different classification systems:

  • New York Heart Association

  • American College of Cardiology/ American Heart Association guidelines


New York Heart Association classification

  • Based on the ability to function

  • Level I – No symptoms, no activity limits

  • Level II – Mild symptoms, slight limits, comfortable at rest

  • Level III – Moderate limited activity, comfortable only at rest

  • Level IV – Severe restrictions, symptomatic at rest

  • (Porth, 2004)


ACC/AHA Heart Failure Guidelines

  • Based on risk factors, ventricular remodeling, and progressive symptoms

  • Stage A - High risk for HF, no structural heart disease, no symptoms

  • Stage B – Structural heart disease, no symptoms

  • Stage C – Structural heart disease with prior or current symptoms

  • Stage D – Refractory HF

  • (Hunt et al, 2005)


Joe becomes very short of breath and presents to the emergency room:

  • 56 YEAR OLD MALE

  • Hx: diabetes, CAD, HTN

  • C/O SOB, “light headed”


Admitted by Dr. Heart

  • Diagnosis: CHF

  • Physician orders:

    • Chest XRAY

    • Chemistry panel, BNP, CBC

    • EKG

    • Echocardiogram

    • 2 gram sodium diet

    • Activity as tolerated


For the next three days you monitor Joe:

Daily weight

Intake and output

Blood sugars

Vital signs

Activity level


Dr. Heart discharges Joe and tells you to do patient education prior to discharge.

What do you teach?


  • #1 reason for readmission to the hospital is non-compliance with treatment.

  • (Clark & Dunbar, 2003)


What do we teach?

Medications and side effects


Which classification of medications promotes the excretion of fluid, reduces preload, and operates at an optimal part of the Frank-Starling curve?

Diuretics

Beta blockers

Digitalis

ACEinhibitors


Great Job!!

Click here


Sorry, let’s think about that again.

Click here


Which group of drugs increase the force and strength of ventricular contraction, decreases heart rate, and increases diastolic filling time?

Diuretics

Beta blockers

Digitalis

ACEinhibitors


You are so smart!

Click here


You may need to review.

Click here


Which group of drugs interferes with the RAA pathway?

Diuretics

Beta blockers

Digitalis

ACEinhibitors


Great Job!!

Click here


Sorry, let’s think about that again.

Click here


Which group of drugs decrease left ventricular dysfunction associated with the sympathetic nervous system?

Diuretics

Beta blockers

Digitalis

ACEinhibitors


Very good!

Click here


Sorry.

Click here


Common side effects that your patient should be aware of:

  • Diuretics: excessive urination, hypotension & dizziness, hypokalemia

  • Beta Blockers: fatigue, impotence, bradycardia, dizziness & hypotension

  • ACE Inhibitors: Excessive urination, angioedema, electrolyte imbalance, dizziness & hypotension

  • Digitalis: bradycardia, toxicity


Medications such as diuretics can alter the levels of electrolytes such as potassium within the blood. Nutrition can be an important factor in maintaining a balance for the patient with CHF.


Nutrition

  • Low Sodium Diet

    • Define “What is a low sodium diet?”

      • 2000 milligrams or less per 24 hours

    • How to read food labels.

      • Low sodium means 140mg or less per serving

        Patients must also monitor their daily fluid intake.


How does sodium work?

  • Sodium enters the body through the GI tract and is excreted primarily by the kidneys. Water follows sodium.

  • (Porth, 2004)


High sodium foods

  • Canned foods

  • Ham, bacon, sausage

  • Deli meats and hot dogs

  • Prepared mixes, frozen dinners, seasoning packages

  • Salad dressings

  • Fast foods


How does potassium work?

  • Potassium regulates the electrical membrane potentials controlling the contractility of skeletal, cardiac, and smooth muscles. Hypokalemia causes EKG changes and ventricular arrythmias. Hyperkalemia can cause ventricular fibrillation and cardiac arrest.

  • (Porth, 2004)


What about potassium?

  • Some diuretics cause potassium loss.

    • Loop diuretics

    • Thiazide diuretics

    • Thiazide-like diuretics

      Also, excessive vomiting/diarrhea.

      Potassium excess is typically caused by renal insufficiency or failure.


Do you know which foods are rich in potassium?

  • Click on the foods rich in potassium.


VEGETABLES !!!

  • You are correct but did you pick them all? Click our friend to move forward or click the question mark to choose another.


FRUIT!!

  • Great job but did you get them all? Click on our friend to move forward or click the question mark to return to the question.


Turkey, fish, & beef!!

  • Great job! Click on our friend to move forward or click the question mark to return to the question.


Candy??

  • Did you really mean that? Click our friend to return to the question.


Potato chips??

Did you make a mistake? Click our friend to return to the question.


The kidneys regulate electrolytes.

  • The function of the kidneys

    are to filter the blood and

    maintain fluid and

    electrolyte balance. The

    kidneys produce 1.5 liters

    of urine per day. (Porth, 2004)


  • Teach patients to observe their urinary output daily. If they notice it decreasing and their weight

    increasing, they should

    notify their doctor.


When do I call the doctor?

  • Weight gain > 2 lbs. in 24 hours

  • Trouble sleeping

  • Shortness of breath

  • Dry cough

  • Increased swelling in abdomen or extremities

  • Fatigue


Congestive heart failure affects and is affected by multiple body systems. With your increased understanding comes an improved foundation for patient education and improved patient outcomes.


THANK YOU!

Thank you for completing this tutorial. I hope it has provided you with information to use when educating your CHF patients.

Good Luck!


References

  • Hunt, S.A., Abraham, W.T., Chin, M.H., Feldman, A.M., Francis, G.S., Ganiats, T.G., Jessup, M., Konstam, M.A., Mancini, D.M., Michl, K., Oates, j.A., Rahko, P.S., Silver, M.A., Stevenson, L.W., & Yancy, C.W. (2005). ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American College of Cardiology Web Site. Available at: http://www.acc.org/clinical/guidelines/failure//index.pdf.

  • Porth, C.M. (2004). Essentials of pathophysiology: Concepts of altered health states. Philadelphia, PA: Lippincott Williams & Wilkins.

  • Clark, P.C., & Dunbar, S.B. (2003). Family partnership intervention: A guide for a family approach to care of patients with heart failure. AACN Clinical Issues: Advanced Practice in Acute Critical Care, 14(4), 467-476.

  • Images retrieved from Microsoft Office Clip Art.

  • Bowne, P. S., 2004. Path of Blood Flow Tutorial. Retrieved April 27, 2007 from http://faculty.alverno.edu/bowneps/pathofbloodflow/pathmap.htm.

  • Bowne, P., 2004-2006. PATHO Interactive Physiology Tutorials. Retrieved May 11, 2007 from http:// faculty.alverno.edu/bowneps/cardiaccycle/cardiaccycle1map.htm.

  • Bowne, P., 2004-2006. PATHO Interactive Physiology Tutorials. Retrieved May 11, 2007 from http://faculty.alverno.edu/bowneps/bp/bpindex.htm.

  • Sheffield, S., (2007). Get Body Smart-The respiratory system – Anatomy & physiology. Retrieved May 11, 2007 from http://getbodysmart.com/ap/respiratorysystem/menu/menu.html.


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