CASE STUDYRIGHT SIDE HEART FAILURE

Prepared By:Casambros, Michael Jay PholCastrence, Juan MiguelChavez, KateleneCipriano, Arwin Joseph

Presented To:Charles Bustamante RN

Heart failure (HF) often called congestive heart failure (CHF) is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. Heart failure can cause a number of symptoms including shortness of breath, leg swelling, andexercise intolerance. The condition is diagnosed with echocardiography and blood tests. Treatment commonly consists of lifestyle measures (such as smoking cessation, light exercise including breathing protocols, decreased salt intake and other dietary changes) and medications, and sometimes devices or even surgery.

Signs and SymptomsPhysical examination can reveal pitting

peripheral edema, ascites, and hepatomegaly. Jugular venous pressure is frequently assessed as a marker of fluid status, which can be accentuated by the hepatojugular reflux. If the right ventricular pressure is increased, a parasternal heave may be present, signifying the compensatory increase in contraction strength.

Backward failure of the right ventricle leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body. This causes swelling under the skin (termed peripheral edema or anasarca) and usually affects the dependent parts of the body first (causing foot and ankle swelling in people who are standing up, and sacral edema in people who are predominantly lying down). 

Nocturia (frequent nighttime urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night. In progressively severe cases, ascites (fluid accumulation in the abdominal cavity causing swelling) and hepatomegaly (enlargement of the liver) may develop. Significant liver congestion may result in impaired liver function, and jaundice and even coagulopathy (problems of decreased blood clotting) may occur.

CausesRight-sided heart failure occurs in about 1 in

20 people. Coronary artery disease is the most common cause of heart failure in the United States, but it can be a complication of other conditions.

Heart failure may affect the right side of the heart (right ventricle), the left side (left ventricle), or both sides. In right-sided heart failure, the right ventricle loses its pumping function, and blood may back up into other areas of the body, producing congestion.

Congestion affects the liver, the gastrointestinal tract, and the limbs. In addition, the right ventricle may be unable to pump blood efficiently to the lungs and to the left ventricle.

Causes of right-sided heart failure include failure and lung diseases such as chronic bronchitis and emphysema. Other causes include congenital heart disease, clots in pulmonary arteries, pulmonary, and heart valve disease.

I. PRESENTATION OF THE CASE “I get terribly… out of breath… just walking down the street… and

my ankles are swollen… every night”

History and Physical ExaminationA 58-year-old man comes in to see his family

physician for the first time in 5 years. He complains that he fatigues easily and that each night his ankles swell. He reports that these symptoms have developed slowly over the past 4 months. When asked about other problems, the patient’s states that he often has to get up at night either to urinate or “catch my breath,” and that he has a history of hypertension; his BP was 160/110 at his last visit. He was given prescriptions for antihypertensive medications, but he never complied after the 1st doses, nor followed up for BP monitoring.

ASSESSMENTCues: Interpretation:

EDEMA Some excess fluid may be forced out of the blood vessels into the body’s tissues. It then settles in the feet, ankles, and legs, and sometimes also in the abdomen and liver. 

DYSPNEA Dyspnea, or shortness of breath, resulting from increased pressure, fluid, or both in the lungs, is a common symptom of heart failure.

Cues: Interpretation:ORTHOPNEA Individuals with

orthopnea find that the condition feels worse when they are in a reclining position because the backflow of fluid and buildup in pressure from the heart interferes directly with the free flow of oxygen in the lungs.

HYPERTENSION Heart failure is also associated with untreated hypertension at any age.

PHYSICAL ASSESSMENTFINDINGS INTERPRETATION

SKIN : Cold and Clammy Cold and Clammy, even appearing blue. These latter symptoms indicate a dire (life-threatening) situation requiring immediate attention. This phenomenon is cause of central sleep apnea (cessation of breathing). With this condition the brain fails to send a signal to the muscles to "breathe" during sleep. In more extreme cases the apnea becomes so acute that the patient wakes in the night with a feeling of panic.

FINDINGS INTERPRETATION

Chest: S3 and S4 heart sounds Bibasilar crackles in the lungs with slightly diminished breath sounds. 

An S3 is commonly heard in children and young adults. In older adults and the elderly with heart disease, an S3 often means heart failure.

An abnormal S4 is heard in people with conditions that increase resistance to ventricular filling, such as a weak left ventricle. Bibasilar crackles can also be rales due to fluid accumulation due to heart failure.

FINDINGS INTERPRETATION

Abdomen: Enlarged Liver

Enlarged liver is usually caused by liver disorders related to excessive heart failure. Because heart failure causes the body to fill with excess fluids, the kidneys may not be able to dispose of the extra sodium (a component of salt) and water, a condition known as kidney failure.

FINDINGS INTERPRETATION

Extremities: (1+) pitting bipedal edema

The infiltration of the body with fluid can cause more than breathing problems and sleepless nights. Patients may weigh more, because of the excess water retention, and they may have edema (swelling) of the skin and soft tissues, usually in the feet, ankles, or legs, and sometimes in the lower back. This swelling is characterized by a gradual filling out after the area is depressed with a finger.

FINDINGS INTERPRETATION

Vital signs: PR 89, RR 32, T 37.3c BP 175/120 

Normally, oxygen is easily exchanged through the thin spongy tissue of the lungs. If this tissue becomes waterlogged, as it does in heart failure, less oxygen can be transferred to the blood. If there is not enough oxygen, certain reflexes stimulate faster breathing. Long-standing high blood pressure is another common cause of heart failure. Because there is greater resistance against which the heart must pump, the heart muscle works harder. This results in an enlargement of the heart muscle, especially of the left ventricle, the heart’s main pumping chamber.

Differential Diagnosis: Heart Failure, Renal Failure

Diagnostic Laboratory Tests and StudiesChest Radiograph Interpretation

Cardiomegaly

Chest Radiograph Interpretation

Interstitial edema in the lungs

Chest Radiograph Interpretation

Pleural effusion

ECG:Normal Rate and Rhytm

No evidence of infarction

No evidence of ventricular hypertrophy

Blood Chemistry Normal Interpretation

Sodium: 150 mEq/L

135-148 mEq/L Low blood flow to the kidneys results in sodium retention.

Potassium: 3.1 mEq/L

3.5-5 mEq/L The kidneys usually excrete nearly all the potassium that is taken in. Because you have heart failure, your kidneys are no longer working as well.

Chloride: 101mEq/L

98-106 mEq/L NORMAL

Blood Chemistry Normal InterpretationBUN: 20mg/dL

Creatinine: 1.5mg/dL7-18 mg/dL

0.6-1.2 mg/dL 

In heart failure(a cause of pre-renal azotemia) or any other condition that causes poor perfusion of kidneys, the sluggish flow of glomerular filtrate results in excessive absorption of BUN and elevation of its value in blood. Creatinine, however, is not absorbable and therefore does not rise significantly.

Urinalysis Findings Interpretation

Protein Trace Protein in the urine is a warning sign. It may indicate kidney damage or disease or it may be a transient elevation due to an infection, medication, vigorous exercise, or it’s a sign of congestive heart failure.

II. ANATOMY AND PHYSIOLOGY

Renin-Angiotensin-Aldosterone System

III. PATHOPHYSIOLOGY

IV. GOALS OF TREATMENT

MEDICATIONS: Digitalis Therapy Diuretic Therapy Vasodilators

Treatment

•Diet: sodium-restricted diet to prevent fluid excess

•Activity: balanced program of activity and rest

•Oxygen Therapy: to increase oxygen supply

SURGICAL MANAGEMENT

Coronary Artery Bypass Graft Surgery

is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the leg, arm, or chest.

Ventricular Assist Device

A ventricular assist device (VAD) is a battery-operated mechanical system consisting of a blood pump and a control unit used for temporary support of blood circulation. The VAD decreases the workload of the heart while maintaining adequate blood flow and blood pressure.

Heart Transplantation

Heart transplantation, also called cardiac transplantation, is the replacement of a patient's diseased or injured heart with a healthy donor heart.

NURSING MANAGEMENTProviding OxygenationPromoting Rest and ActivityDecreasing AnxietyFacilitating Fluid BalanceProviding Skin CarePromoting NutritionPromoting EliminationFacilitating Learning

V. LIST OF NURSING DIAGNOSIS

• Ineffective tissue perfusion related to impaired transport of O2 across alveolar and or capillary membrane AEB dyspnea, body weakness and tachypnea

• Ineffective breathing pattern related to respiratory muscle fatigue secondary to pleural effusion

•Decrease cardiac output related to altered after load and contractility of the heart secondary to heart failure.

•Activity Intolerance related to Imbalance between O2 Supply and Demand AEB Verbal Report of Fatigue and Weakness

•Disturbance of sleep pattern related to illness resulting in interrupted sleep caused by nocturnal dyspnea.

VI. NURSING CARE PLAN