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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. Home Previous Next 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. Home Previous Next 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 To return from these tutorials, click the back button on your browser. Home Cardiac Cycle Blood pressure Respiratory System Previous Next Let’s review the basics. Which side of the heart pumps blood to the lungs? – Right – Left Home Previous Next Great Job! The right side of the heart pumps blood to the lungs. Home Click on our friend to move forward. Previous Next Sorry. Remember, the left side of the heart pumps blood to the peripheral circulatory system. Home Click on our friend to try again. Previous Next Which part of the respiratory system is directly responsible for gas exchange? A. Trachea B. Larynx C. Alveoli Home Previous Next Try Again. The trachea is part of the lower airway but is not directly responsible for gas exchange. Click the duck to try again. Home Previous Next 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. Home Previous Next Great Job! The alveoli are thin sacs at the end of the bronchioles which are directly responsible for gas exchange. Home Previous Next 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. Home Previous Next 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. Home Previous Next 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) Home Previous Next What symptoms are caused by right-sided heart failure? Peripheral edema Dyspnea Ascites Hypoxia Anorexia Home Previous Next 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 Home Click here to move forward Previous Next Dyspnea is not a symptom of right-sided heart failure. Click here to return to question Home Previous Next In right sided heart failure, the blood can not move from the peripheral system to the pulmonary system. This does not cause hypoxia. Home Click here to return to question Previous Next 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 Home Click to move forward Previous Next Excellent! Fluid in the abdomen can push on the organs causing nausea and anorexia. Click to return to question Click to move forward Home Previous Next 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) Home Previous Next What symptoms would you observe with left-sided heart failure? Hypoxia Dependent edema Cough with frothy sputum Orthopnea Jugular vein distention Home Previous Next Fabulous!! Hypoxia occurs due to the pulmonary congestion caused by left-sided heart failure. Click here to return to question Home Click here to move forward Previous Next Oops, sorry. Dependent edema occurs when the blood from the peripheral vasculature can not move forward during rightsided heart failure. Click here to return to question Home Previous Next Great job! The cough occurs due to the congestion in the pulmonary vasculature. Click here to return to question Home Click here to move forward Previous Next 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 Home Click here to move forward Previous Next 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 Home Previous Next 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) Home Previous Next How does blood pressure affect heart failure? Home Previous Next 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) Home Previous Next 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) Home Previous Next 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) Home Previous Next 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. Home Previous Next Joe has hypertension. How does Joe develop CHF? Home Previous Next Hypertensio n Click to see how comorbidities might fit together. Vessel Wall Damage Coronar y Artery Disease Atherosclerosi s Myocardial Infarction Ventricular Dysfunction Home CHF Previous Next How bad is Joe’s CHF? There are different classification systems: New York Heart Association American College of Cardiology/ American Heart Association guidelines Home Previous Next 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) Home Previous Next 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) Home Previous Next 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” Home Previous Next Admitted by Dr. Heart Diagnosis: CHF Physician orders: – Chest XRAY – Chemistry panel, BNP, CBC – EKG – Echocardiogram – 2 gram sodium diet – Activity as tolerated Home Previous Next For the next three days you monitor Joe: Daily weight Intake and output Blood sugars Vital signs Activity level Home Previous Next Dr. Heart discharges Joe and tells you to do patient education prior to discharge. What do you teach? Home Previous Next #1 reason for readmission to the hospital is non-compliance with treatment. (Clark & Dunbar, 2003) Home Previous Next What do we teach? Medications and side effects Home Previous Next Which classification of medications promotes the excretion of fluid, reduces preload, and operates at an optimal part of the Frank-Starling curve? Home Diuretics Beta blockers ACE inhibitors Digitalis Previous Next Great Job!! Click here Home Previous Next Sorry, let’s think about that again. Click here Home Previous Next Which group of drugs increase the force and strength of ventricular contraction, decreases heart rate, and increases diastolic filling time? Home Diuretics Beta blockers ACE inhibitors Digitalis Previous Next You are so smart! Click here Home Previous Next You may need to review. Click here Home Previous Next Which group of drugs interferes with the RAA pathway? Home Diuretics Beta blockers ACE inhibitors Digitalis Previous Next Great Job!! Click here Home Previous Next Sorry, let’s think about that again. Click here Home Previous Next Which group of drugs decrease left ventricular dysfunction associated with the sympathetic nervous system? Home Diuretics Beta blockers ACE inhibitors Digitalis Previous Next Very good! Click here Home Previous Next Sorry. Click here Home Previous Next 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 Home Previous Next 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. Home Previous Next Nutrition Low Sodium Diet – Define “What is a low sodium diet?” 2000 milligrams or less per 24 hours – How to read food labels. Home Low sodium means 140mg or less per serving Patients must also monitor their daily fluid intake. Previous Next How does sodium work? Sodium enters the body through the GI tract and is excreted primarily by the kidneys. Water follows sodium. (Porth, 2004) Home Previous Next High sodium foods Canned foods Ham, bacon, sausage Deli meats and hot dogs Prepared mixes, frozen dinners, seasoning packages Salad dressings Fast foods Home Previous Next 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) Home Previous Next 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. Home Previous Next Do you know which foods are rich in potassium? Click on the foods rich in potassium. Home Previous Next VEGETABLES !!! You are correct but did you pick them all? Click our friend to move forward or click the question mark to choose another. Home Previous Next 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. Home Previous Next Turkey, fish, & beef!! Great job! Click on our friend to move forward or click the question mark to return to the question. Home Previous Next Candy?? Did you really mean that? Click our friend to return to the question. Home Previous Next Potato chips?? Did you make a mistake? Click our friend to return to the question. Home Previous Next 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) Home Previous Next Teach patients to observe their urinary output daily. If they notice it decreasing and their weight increasing, they should notify their doctor. Home Previous Next When do I call the doctor? Home Weight gain > 2 lbs. in 24 hours Trouble sleeping Shortness of breath Dry cough Increased swelling in abdomen or extremities Fatigue Previous Next 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. Home Previous Next 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! Home Previous Next 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. Home Previous Next