Congestive Heart Failure: What your patients need to know.

1
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

2
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.

3
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.

4
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.

5
Lets review the basics.

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

6
Great Job!

• The right side of the heart pumps blood to the
  lungs.
• Click on our friend to move forward.

7
Sorry.

• Remember, the left side of the heart pumps blood
  to the peripheral circulatory system.
• Click on our friend to try again.

8
Which part of the respiratory system is directly
responsible for gas exchange?

• A. Trachea
• B. Larynx
• C. Alveoli

9
Try Again.

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

10
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.

11
Great Job!

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

12
Now that weve reviewed the basics, lets 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.

13
Lets 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.

14
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)

15
What symptoms are caused by right-sided heart
failure?

• Peripheral edema
• Dyspnea
• Ascites
• Hypoxia
• Anorexia

16
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

17
Dyspnea is not a symptom of right-sided heart
failure.

• Click here to return to question

18
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
  

19
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

20
Excellent!Fluid in the abdomen can push on the
organs causing nausea and anorexia.

• Click to return to
  question
• Click to move
  forward

21
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)

22
What symptoms would you observe with left-sided
heart failure?

• Hypoxia
• Dependent edema
• Cough with frothy sputum
• Orthopnea
• Jugular vein distention

23
Fabulous!!

• Hypoxia occurs due to the pulmonary congestion
  caused by left-sided heart failure.
• Click here to return to question
  Click here to move forward

24
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

25
Great job!

• The cough occurs due to the congestion in the
  pulmonary vasculature.
• Click here to return to question Click
  here to move forward

26
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

27
Lets 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

28
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)

29
How does blood pressure affect heart failure?
30
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)

31

• 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)

32

• 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)

33
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.

34
Joe has hypertension. How does Joe develop CHF?

35
Hypertension
Click to see how comorbidities might fit
together.
Vessel Wall Damage
Coronary Artery Disease
Atherosclerosis
Myocardial Infarction
Ventricular Dysfunction
CHF
36
How bad is Joes CHF?

• There are different classification systems
• New York Heart Association
• American College of Cardiology/ American
  Heart Association guidelines

37
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)

38
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)

39
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

40
Admitted by Dr. Heart

• Diagnosis CHF
• Physician orders
• Chest XRAY
• Chemistry panel, BNP, CBC
• EKG
• Echocardiogram
• 2 gram sodium diet
• Activity as tolerated

41
For the next three days you monitor Joe
Daily weight Intake and output Blood
sugars Vital signs Activity level
42
Dr. Heart discharges Joe and tells you to do
patient education prior to discharge.

• What do you teach?

43

• 1 reason for readmission to the hospital is
  non-compliance with treatment.
• (Clark Dunbar, 2003)

44
What do we teach?

• Medications and side effects

45
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
ACE inhibitors
46
Great Job!!

• Click here

47
Sorry, lets think about that again.

• Click here

48
Which group of drugs increase the force and
strength of ventricular contraction, decreases
heart rate, and increases diastolic filling time?
Diuretics
Beta blockers
Digitalis
ACE inhibitors
49
You are so smart!

• Click here

50
You may need to review.

• Click here

51
Which group of drugs interferes with the RAA
pathway?
Diuretics
Beta blockers
Digitalis
ACE inhibitors
52
Great Job!!

• Click here

53
Sorry, lets think about that again.

• Click here

54
Which group of drugs decrease left ventricular
dysfunction associated with the sympathetic
nervous system?
Diuretics
Beta blockers
Digitalis
ACE inhibitors
55
Very good!

• Click here

56
Sorry.

• Click here

57
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

58

• 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.

59
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.

60
How does sodium work?

• Sodium enters the body through the GI tract and
  is excreted primarily by the kidneys. Water
  follows sodium.
• (Porth, 2004)

61
High sodium foods

• Canned foods
• Ham, bacon, sausage
• Deli meats and hot dogs
• Prepared mixes, frozen dinners, seasoning
  packages
• Salad dressings
• Fast foods

62
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)

63
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.

64
Do you know which foods are rich in potassium?

• Click on the foods rich in potassium.

65
VEGETABLES !!!

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

66
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.

67
Turkey, fish, beef!!

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

68
Candy??

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

69
Potato chips??

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

70
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)

71

• Teach patients to observe their urinary output
  daily. If they notice it decreasing and their
  weight
• increasing, they should
• notify their doctor.

72
When do I call the doctor?

• Weight gain gt 2 lbs. in 24 hours
• Trouble sleeping
• Shortness of breath
• Dry cough
• Increased swelling in abdomen or extremities
• Fatigue

73
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.
74
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!

75
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/guidelin
  es/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.alver
  no.edu/bowneps/pathofbloodflow/pathmap.htm.
• Bowne, P., 2004-2006. PATHO Interactive
  Physiology Tutorials. Retrieved May 11, 2007 from
  http// faculty.alverno.edu/bowneps/cardiaccycle/c
  ardiaccycle1map.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.co
  m/ap/respiratorysystem/menu/menu.html.