Concept Mapping CHF:

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Mr. Hill, 80 y/o African American male, is admitted to you Cardiac unit for exacerbation of his CHF. On admission he is confused, weak, and appears flushed. He is short of breath, taking deep, rapid breaths and refuses to lie down. He is also complaining of a head ache and chest pain.

His Vitals are: BP=164/94, HR= 84, Temp= 101, RR= 30. On exam he is found to have 4+ pitting edema in both legs, bilateral jugular vein distention (JVD), and a bounding heartbeat. The pt now weighs 175 lbs, when his usual weight is 150 lbs.

EKG does not indicate an active MI, but reveals flattened T waves and ST depression. Chest X-Ray (CXR) reveals consolidation in Rt. Lower lobe of the lung, and hypertrophy of left ventricle of the heart. Labs are: pCO2= 48, pH=7.31, Hgb= 9.0, Hct= 30.0, WBC= 17,000, Na= 155, K= 3.3, BUN=52, Crt=16.

History reveals a history of Diabetes II, hypertension, smoking x 20 yrs, and arthrosclerosis. Pt takes Lisinopril and Metoprolol for HTN. Pt has been able to control glucose by diet and exercise. The Pt has been trying to quit smoking. He is using a nicotine patch. However, he states that he “cheated” and was smoking also.

Upon admission, Mr. Hill was put on 4L of O2 via mask. An IV was started and 10 M Eq KCL, Normal saline was administered. Pt was started on a course of IV Ceftriaxone and Azythromyacin. He was also given Lasix and Lisinopril IV Push and ordered IV Morphine as needed for pain. Metoprolol was discontinued.

On the second day, his Urine output dropped to 15 cc/hr and his labs jumped to BUN=150 and Crt=118. Hemodialysis was ordered.

How would you concept map Mr. Hill’s case?

There is a lot of info in this case study. Lets start by separating out into manageable categories:

S/SxHeadacheChest PainWeaknessConfusionOrthopneaSOBFlushingWeight gainPitting edemaJVDBounding HeartBeatBP=164/94HR= 84Temp= 101 RR= 30UO= 15 cc/hr

Labs/DiagpCO2= 48pH=7.31Hgb= 9.0Hct= 30.0, WBC= 17,000Na= 155K= 3.3BUN= 150 Crt= 180

CXR= ConsolidationLV hypertrophy

EKG= Flat T waves and ST depression.

RiskArthrosclerosisDM IISmokingHTNAgeRaceMetoprolol

Meds/TXCeftriaxoneAzythromyacinLasix LisinoprilMorphineO2

KClHemodialysis

That’s great but…

• It still looks like a list of stuff. We don’t know what is going on with Mr. Hill. We need to know more.

• Since we know that CHF is the problem, we can start by looking it up in the book, on the internet, or other resources until we feel we have a good idea about the CHF disease process.

CHF Basics• Although it says Coronary, CHF effect also involves the

lungs and can effect the kidneys.• Basically, the pressure in the blood vessels increases

making it hard for the left ventricle to pump out the blood.

• The blood backs up into the lungs causing problems there. This leads to accumulation of CO2 which can lead to Resp. Acidosis. It can also lead to Bacterial growth and Pnuemonia.

• As the heart fails to keep up, the kidneys’ blood supply is cut. The Kidneys and the ANS will attempt to compensate by raising the blood pressure (to squeeze blood into the kidneys). After a while, the kidneys fails which leads to a whole set of problems (remember that the kidneys control RBC production and HCO3 to neutralize acid).

Now we are ready to start mapping

Divide your paper into three areas

Kidney Heart Lungs

We place the heart in the middle because we know

that it is the central organ here and that the

damage of the other organs stems from it

↑Systemic Vascular Resistance

↑Afterload

↑LV contraction

↑O2 Requirement

Hypoxia of Cardiac tissue

↓LV contraction force

Arthrosclerosis, DM II, race,

Smoking, HTN, Age

BP=164/94

Metoprolol

Increased Nicotine intake

Start in the middle top of your paper.

Remodeling CXR= LV Hypertrophy

↑LV End Diastolic Volume

Blood back up in lungs

Pulmonary Edema

↑ Pulm. Vascular resistance

Blood backs up to Rt. Side of heart

↑RV preload

Heart Failure

Pulmonary Edema

↓Oxygenation of alveoli

↑CO2

↓pH

Respiratory Acidosis

Respiratory Failure

SOBOrthopnea

RR=30↑pCO2= 48

↓pH=7.31

O2 mask

HA, Weakness, Confusion

Flushed

“Pulmonary Edema” leads us to the first lung problem: The inablility to

Oxygenate the blood

↑Bacterial Growth

Inflammatory response

Vasodilatation, Immune response, and clotting

PNA

Temp=101°Pain

↑WBC=17,000CXR=Consolidation

CeftriaxoneAzythromycin

Morphine

Pulmonary Edema

“Pulmonary Edema” can also lead to Pnumonia

↓LV contraction force↓Systemic BP

↓Renal Blood flow

Renin Release

Angiotesin 1+2 release

Aldosterone release

↑H2O and Na retention

Fluid volume excess

Weight gain= 25 lbsPitting Edema

Bounding Heart beatJVD

↓Hgb=9.0↓Hct= 30.0

ADH release

↓K

Lasix

Arrhythmia MI

Lisinopril

↓K= 3.3

EKG= Flat T waves and ST depression

KCl

↑Na=155

If we go back to the heart column, we will be

able to trace how the kidney is effected and trys to compensate.

Starts at the “↓LV contraction force.”

↓Systemic BP

↓Renal Blood flow

↑Systemic Vascular Resistance

↓GFR

Renal Failure

↓Erythropoetin↓HCO3

↓RBC synthesisMetabolic Acidosis

↓Hgb=9.0↓Hct= 30.0

↓Urine output

UO=15cc/hr

↑Peripheral arteries constriction

↑Epinephrine

HA, weakConfusion

RR=30

↓pH=7.31

HD

↑BUN= 150↑Crt= 118

However, if the kidney cannot compensate… “↓Systemic BP” also triggers the ANS to respond

↑Systemic Vascular Resistance

↑LV contraction

↑O2 Requirement

Hypoxia of Cardiac tissue

↑LV End Diastolic Volume

Blood back up in lungs

Pulmonary Edema

↑ Pulm. Vascular resistance

Blood backs up to Rt. Side of heart

↑RV preload

Heart Failure

↓Oxygenation of alveoli

↑CO2

↓pH

Respiratory Acidosis

Respiratory Failure

↓LV contraction force

SOBOrthopnea

RR=30↑pCO2= 48

↓pH=7.31

↑Bacterial Growth

Inflammatory response

Vasodilatation, Immune response, and clotting

PNA

O2 mask

Temp=101°Pain

↑WBC=17,000CXR=Consolidation

↓Systemic BP

↓Renal Blood flow

Renin Release

Angiotesin 1+2 release

Aldosterone release

↑H2O and Na retention

Fluid volume excess

Weight gain= 25 lbsPitting Edema

Bounding Heart beatJVD

↓Hgb=9.0↓Hct= 30.0

ADH release

↓K

Lasix

↓GFR

Renal Failure

↓Erythropoetin↓HCO3

↓RBC synthesisMetabolic Acidosis

↓pH=7.31

↓Hgb=9.0↓Hct= 30.0

↓Urine output

Arthrosclerosis, DM II, race smoking, HTN, age

UO=15cc/hr

Arrhythmia MI

↑Peripheral arteries constriction

↑Epinephrine

LisinoprilKCl

CeftriaxoneAzythromycin

Morphine

PathoS/SxLabs/diagRisk Meds/TxSequelae

Congestive Heart Failure

Kidney Heart Lungs

HA, weakConfusion

RR=30

HA, Weakness, Confusion

Flushed

↑Afterload

↓K= 3.3

EKG= Flat T waves and ST depression

HD

↑BUN= 150↑Crt= 118

BP=164/94

Metoprolol

↑Na=155

Increased Nicotine intake

Which returns us to where we

started

We can now make additional

connections

Remodeling CXR= LV Hypertrophy

Congratulations!!!

You have completed the CHF map with Lung and Kidney involvement.

Many of the concepts in it are probably new to you. Don’t panic about understanding every detail of the pathway. You will probably cover them in future units.