Congestive Heart Congestive Heart FailureFailure: : What your patients What your patients need to know.need to know.

Lisa M. Kappers, RN, BSNLisa M. Kappers, RN, BSN

Alverno College MSN ProgramAlverno College MSN ProgramPatient Care Coordinator – Infusion Therapy Patient Care Coordinator – Infusion Therapy Center, WFSI – All SaintsCenter, WFSI – All Saints

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Tutorial InstructionsTutorial Instructions

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

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

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Tutorial OutcomesTutorial Outcomes

At the end of this tutorial you will be able to:At the end of this tutorial you will be able to:– Teach your patients about the pathophysiology of Teach your patients about the pathophysiology of

CHF.CHF.– Teach your patients about the importance of a low Teach your patients about the importance of a low

sodium diet.sodium diet.– Teach your patients how to “live” with CHF.Teach your patients how to “live” with CHF.

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In order to complete this In order to complete this tutorial:tutorial:

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

Path of blood flow Cardiac Cycle Blood pressure Respiratory SystemPath of blood flow Cardiac Cycle Blood pressure Respiratory System

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

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Let’s review the Let’s review the basics.basics.

Which side of the heart pumps Which side of the heart pumps blood to the lungs?blood to the lungs?– RightRight– LeftLeft

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Great Job!Great Job!

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

Click on our friend to move forward.Click on our friend to move forward.

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Sorry.Sorry. Remember, the left side of the Remember, the left side of the

heart pumps blood to the heart pumps blood to the peripheral circulatory system.peripheral circulatory system.

Click on our friend to try again.Click on our friend to try again.

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Which part of the Which part of the respiratory system is respiratory system is

directly responsible for gas directly responsible for gas exchange?exchange?

A. TracheaA. Trachea B. LarynxB. Larynx C. AlveoliC. Alveoli

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Try Again.Try Again.

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

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Try Again.Try Again.

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

Click the gator to try again.Click the gator to try again.

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Great Job!Great Job!

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

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

CHF.CHF. Remember, the basics are Remember, the basics are

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

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Let’s define congestive Let’s define congestive heart failure.heart failure.

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

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Right-Sided Heart Right-Sided Heart FailureFailure

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

(Porth, 2004)(Porth, 2004)

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What symptoms are What symptoms are caused by right-sided caused by right-sided

heart failure?heart failure? Peripheral edemaPeripheral edema DyspneaDyspnea AscitesAscites HypoxiaHypoxia AnorexiaAnorexia

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

peripheral edema occurs.peripheral edema occurs.

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

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Dyspnea is not a Dyspnea is not a symptom of right-sided symptom of right-sided

heart failure.heart failure.Click here to return to questionClick here to return to question

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In right sided heart failure, the In right sided heart failure, the blood can not move from the blood can not move from the

peripheral system to the pulmonary peripheral system to the pulmonary system. This does not cause system. This does not cause

hypoxia.hypoxia. Click here to return to question Click here to return to question

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Good job!Good job!When blood can not be moved from When blood can not be moved from

the peripheral system to the the peripheral system to the pulmonary system, fluid builds up in pulmonary system, fluid builds up in

the abdominal cavity causing the abdominal cavity causing ascites.ascites.

Click to return to question Click to move Click to return to question Click to move forwardforward

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Excellent!Excellent!Fluid in the abdomen can push on Fluid in the abdomen can push on

the organs causing nausea and the organs causing nausea and anorexia.anorexia.

Click to return to questionClick to return to question

Click to move forwardClick to move forward

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Left-Sided Heart Left-Sided Heart FailureFailure

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

(Porth, 2004)(Porth, 2004)

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What symptoms would you What symptoms would you observe with left-sided observe with left-sided

heart failure?heart failure? HypoxiaHypoxia Dependent edemaDependent edema Cough with frothy sputumCough with frothy sputum OrthopneaOrthopnea Jugular vein distentionJugular vein distention

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Fabulous!!Fabulous!!

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

Click here to return to questionClick here to return to question Click here to move Click here to move

forwardforward

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Oops, sorry.Oops, sorry.

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

Click here to return to questionClick here to return to question

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Great job!Great job!

The cough occurs due to the The cough occurs due to the congestion in the pulmonary congestion in the pulmonary

vasculature.vasculature.Click here to return to question Click here to move forwardClick here to return to question Click here to move forward

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Great thinking!Great thinking!

Orthopnea occurs when the Orthopnea occurs when the patient is reclined and the blood patient is reclined and the blood from the peripheral vasculature from the peripheral vasculature settles in the pulmonary system.settles in the pulmonary system.Click here to return to question Click here to move forwardClick here to return to question Click here to move forward

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Let’s think about this.Let’s think about this.

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

Click here to return to the questionClick here to return to the question

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Chronic Heart FailureChronic Heart Failure

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

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How does blood How does blood pressure affect heart pressure affect heart

failure?failure?

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HypertensionHypertension

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

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

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

(Porth, 2004)(Porth, 2004)

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

(Porth, 2004)(Porth, 2004)

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

(Porth, 2004)(Porth, 2004)

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Atherosclerosis and Atherosclerosis and Coronary Artery Coronary Artery

DiseaseDisease Atherosclerosis is defined as fatty Atherosclerosis is defined as fatty

lesions developing in the intimal lesions developing in the intimal lining of the aorta, coronary lining of the aorta, coronary arteries, and the large arteries arteries, and the large arteries that supply blood to the brain. that supply blood to the brain.

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Joe has hypertension.Joe has hypertension. How does Joe develop How does Joe develop

CHF?CHF?

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Hypertension

Vessel Wall

Damage

Coronary

ArteryDiseas

e

Atherosclerosis

Myocardial

Infarction

VentricularDysfunction

CHF

Click to see how comorbidities

might fit together.

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How bad is Joe’s CHF?How bad is Joe’s CHF?

There are different classification There are different classification systems:systems:

New York Heart AssociationNew York Heart Association American College of Cardiology/ American College of Cardiology/

American Heart Association American Heart Association guidelinesguidelines

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New York Heart New York Heart Association Association

classificationclassification Based on the ability to functionBased on the ability to function Level I – No symptoms, no activity limitsLevel I – No symptoms, no activity limits Level II – Mild symptoms, slight limits, Level II – Mild symptoms, slight limits,

comfortable at restcomfortable at rest Level III – Moderate limited activity, Level III – Moderate limited activity,

comfortable only at restcomfortable only at rest Level IV – Severe restrictions, symptomatic at Level IV – Severe restrictions, symptomatic at

restrest (Porth, 2004)(Porth, 2004)

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ACC/AHA Heart Failure ACC/AHA Heart Failure GuidelinesGuidelines

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

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

Stage B – Structural heart disease, no Stage B – Structural heart disease, no symptoms symptoms

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

Stage D – Refractory HFStage D – Refractory HF (Hunt et al, 2005)(Hunt et al, 2005)

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Joe becomes very short of Joe becomes very short of breath and presents to the breath and presents to the

emergency room:emergency room:

56 YEAR OLD MALE56 YEAR OLD MALE Hx: diabetes, CAD, HTNHx: diabetes, CAD, HTN C/O SOB, “light headed”C/O SOB, “light headed”

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Admitted by Dr. HeartAdmitted by Dr. Heart

Diagnosis: CHFDiagnosis: CHF Physician orders:Physician orders:

– Chest XRAYChest XRAY– Chemistry panel, BNP, CBCChemistry panel, BNP, CBC– EKGEKG– EchocardiogramEchocardiogram– 2 gram sodium diet2 gram sodium diet– Activity as toleratedActivity as tolerated

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For the next three For the next three days you monitor Joe:days you monitor Joe:

Daily weightDaily weight

Intake and outputIntake and output

Blood sugarsBlood sugars

Vital signsVital signs

Activity levelActivity level

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Dr. Heart discharges Joe Dr. Heart discharges Joe and tells you to do patient and tells you to do patient

education prior to education prior to discharge.discharge.

What do you teach?What do you teach?

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

(Clark & Dunbar, 2003)(Clark & Dunbar, 2003)

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What do we teach?What do we teach?

Medications and side effectsMedications and side effects

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Which classification of medications Which classification of medications promotes the excretion of fluid, promotes the excretion of fluid,

reduces preload, and operates at an reduces preload, and operates at an optimal part of the Frank-Starling optimal part of the Frank-Starling

curve?curve?

Diuretics

DigitalisACE inhibitors

Beta blockers

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Great Job!!Great Job!!

Click hereClick here

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Sorry, let’s think about Sorry, let’s think about that again.that again.

Click hereClick here

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Which group of drugs increase the Which group of drugs increase the force and strength of ventricular force and strength of ventricular

contraction, decreases heart rate, contraction, decreases heart rate, and increases diastolic filling time?and increases diastolic filling time?

Diuretics

DigitalisACE inhibitors

Beta blockers

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You are so smart!You are so smart!

Click hereClick here

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You may need to You may need to review.review.

Click hereClick here

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Which group of drugs interferes Which group of drugs interferes with the RAA pathway?with the RAA pathway?

Diuretics

DigitalisACE inhibitors

Beta blockers

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Great Job!!Great Job!!

Click hereClick here

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Sorry, let’s think about Sorry, let’s think about that again.that again.

Click hereClick here

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Which group of drugs decrease left Which group of drugs decrease left ventricular dysfunction associated ventricular dysfunction associated

with the sympathetic nervous with the sympathetic nervous system?system?

Diuretics

DigitalisACE inhibitors

Beta blockers

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Very good!Very good!

Click hereClick here

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Sorry.Sorry.

Click hereClick here

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Common side effects that your Common side effects that your patient should be aware of:patient should be aware of:

Diuretics:Diuretics: excessive urination, hypotension excessive urination, hypotension & dizziness, hypokalemia& dizziness, hypokalemia

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

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

Digitalis:Digitalis: bradycardia, toxicity bradycardia, toxicity

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Medications such as diuretics can Medications such as diuretics can alter the levels of electrolytes alter the levels of electrolytes such as potassium within the such as potassium within the

blood. Nutrition can be an blood. Nutrition can be an important factor in maintaining a important factor in maintaining a balance for the patient with CHF.balance for the patient with CHF.

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NutritionNutrition

Low Sodium DietLow Sodium Diet– Define “What is a low sodium diet?”Define “What is a low sodium diet?”

2000 milligrams or less per 24 hours2000 milligrams or less per 24 hours

– How to read food labels.How to read food labels. Low sodium means 140mg or less per Low sodium means 140mg or less per

servingserving

Patients must also monitor their daily Patients must also monitor their daily fluid intake. fluid intake.

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How does sodium How does sodium work?work?

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

(Porth, 2004)(Porth, 2004)

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High sodium foodsHigh sodium foods

Canned foodsCanned foods Ham, bacon, sausageHam, bacon, sausage Deli meats and hot dogsDeli meats and hot dogs Prepared mixes, frozen dinners, Prepared mixes, frozen dinners,

seasoning packagesseasoning packages Salad dressingsSalad dressings Fast foodsFast foods

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How does potassium How does potassium work?work?

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

(Porth, 2004)(Porth, 2004)

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What about What about potassium?potassium? Some diuretics cause potassium Some diuretics cause potassium

loss.loss.– Loop diureticsLoop diuretics– Thiazide diureticsThiazide diuretics– Thiazide-like diureticsThiazide-like diuretics

Also, excessive vomiting/diarrhea.Also, excessive vomiting/diarrhea.

Potassium excess is typically caused by Potassium excess is typically caused by renal insufficiency or failure.renal insufficiency or failure.

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Do you know which Do you know which foods are rich in foods are rich in

potassium?potassium? Click on the foods rich in Click on the foods rich in

potassium.potassium.

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VEGETABLES !!!VEGETABLES !!!

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

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FRUIT!!FRUIT!!

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

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Turkey, fish, & beef!!Turkey, fish, & beef!!

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

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Candy?? Candy??

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

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Potato chips??Potato chips??

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

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The kidneys regulate The kidneys regulate electrolytes.electrolytes.

The function of the kidneysThe function of the kidneys

are to filter the blood andare to filter the blood and

maintain fluid andmaintain fluid and

electrolyte balance. The electrolyte balance. The

kidneys produce 1.5 literskidneys produce 1.5 litersof urine per day. of urine per day. (Porth, 2004)(Porth, 2004)

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

increasing, they shouldincreasing, they should

notify their doctor.notify their doctor.

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When do I call the When do I call the doctor?doctor?

Weight gain > 2 Weight gain > 2 lbs. in 24 hourslbs. in 24 hours

Trouble sleepingTrouble sleeping Shortness of breathShortness of breath Dry coughDry cough Increased swelling Increased swelling

in abdomen or in abdomen or extremitiesextremities

FatigueFatigue

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Congestive heart failure affects and is Congestive heart failure affects and is affected by multiple body systems. With affected by multiple body systems. With your increased understanding comes an your increased understanding comes an

improved foundation for patient improved foundation for patient education and improved patient education and improved patient

outcomes.outcomes.

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THANK YOU!THANK YOU!Thank you for Thank you for

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

Good Luck!Good Luck!

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ReferencesReferences Hunt, S.A., Abraham, W.T., Chin, M.H., Feldman, A.M., Francis, G.S., Ganiats, T.G., Jessup, M., Konstam, M.A., 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 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 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 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 Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American College of Cardiology Web Site. Available at: College of Cardiology Web Site. Available at: http://http://www.acc.org/clinical/guidelines/failure//index.pdfwww.acc.org/clinical/guidelines/failure//index.pdf..

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

Clark, P.C., & Dunbar, S.B. (2003). Family partnership intervention: A guide for a family approach to care of Clark, P.C., & Dunbar, S.B. (2003). Family partnership intervention: A guide for a family approach to care of patients with heart failure. patients with heart failure. AACN Clinical Issues: Advanced Practice in Acute Critical Care, 14(4), 467-476.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, Sheffield, S., (2007). Get Body Smart-The respiratory system – Anatomy & physiology. Retrieved May 11,

2007 from http://getbodysmart.com/ap/respiratorysystem/menu/menu.html.2007 from http://getbodysmart.com/ap/respiratorysystem/menu/menu.html.