Assessment of Heart Failure Flashcards
What is heart failure (HF)?
• Complex clinical syndrome
• Dyspnea, congestion, fatigue
• Decrease cardiac output
• Inability to meet the body’s metabolic demands
• Any structural or functional disorder that impairs ventricular (right or
left) filling (diastolic) or ejection (systolic) of blood
• Intrinsic (within the heart) or extrinsic
• Similar clinical symptoms despite multiple causes
Syndrome: despite cause, the clinical symtpoms are the same
Signs and Symptoms of HF
right HF: congestion of peripheral tissues –> dependent edema/ascities, liver congestion (impaired liver fxn), GI tract congestion (anorexia, GI distress, weight loss)
left HF: decreased CO –> activity intolerance, dec tissue perfusion
pulmonary congestion –> impaired gas exchange (cyanosis, hypoxia), pulmonary edema (cough withfrothy sputum, orthopnea, paroxysmal noc dyspnea)
Biventricular failure; typically left side fails first
Approach to heart failure assessment
- Symptoms assessment
- What symptom of HF does the patient have
- Functional assessment
- How do symptoms of HF impact daily functioning
- Fluid assessment
- Is the patient congested? Is the patient dehydrated?
SYMPTOM ASSESSMENT
Dyspnea
- Sensation of difficult or uncomfortable breathing
- Subjective and reported by the patient
• Different than:
– Tachypnea – increase respiratory rate
– Hyperventilation – increase minute ventilation relative to metabolic need
– Hyperpnea – disproportional increase in minute ventilation relative to an increase in metabolic need
• Objective findings, not always associated with dyspnea
Evaluating Dyspnea
2 rules
Rule #1: Establish a baseline activities
Be practical – think daily activities
• Start by finding out what patients do in their usual daily lives
Rule #2: Establish a timeline
Do they describe sighing? Housework Walking on flat surface Housework Walking uphill Climbing stairs Strenuous work Aerobic exercise Dressing bathing
at rest to max exertion
terms pt may use for dyspnea
– Your definition of dyspnea is not always the same as patient. Listen
carefully to the patient.
– If in doubt get the patient to describe it to you
– Use the same terminology
winded, running out of air, cant get enough air in, puffing
Evaluating Orthopnea
• Orthopnea
– Sensation of breathlessness in the recumbent position, relieved by sitting or standing
• Ask
- “Are you able to lie flat in bed without shortness of breath?”
- “How many pillows do you use? Do you need to sleep in a recliner/sitting up?”
- Be aware of mechanical beds, elevated heads of the bed and personal comfort
Sleep in a recliner, can’t lay flat in bed
Evaluating PND
• Paroxysmal Nocturnal Dyspnea (PND)
– Sensation of SOB that suddenly awakens a patient, often after 1-2
hours of sleep, usually relieved in upright position after 10 + minutes;
may be associated with coughing and wheezing
– Beware of snoring or sleep apnea
Wake up and gasp and sleep is not pnd
Sleeo apnea does not require them to wake up
gasping for air, choking, coughing
Orthopnea & PND:
Mechanism
Patient lies flat
I
Redistribution of blood from periphery to heart
• Heart overwhelmed, chamber pressures increase
• Pressure increase transmitted back into pulmonary circulation
I
Pulmonary congestion
• Alveoli surrounded by interstitial fluid leading to decreased lung compliance = decreased pulmonary compliance
I
Receptors triggered, CNS activated
• Orthopnea
• PND
Fatigue
• ARE YOU FATIGUED RIGHT NOW?
• Non-specific
• Sleeping more, napping more, change in functional capacity
• Patients often interchange fatigue and SOB
Played out, I need to take more breaks, No energy
FUNCTIONAL ASSESSMENT
NYHA classification
Symptoms: Dyspnea, fatigue, chest pain, palpitations, syncope
Class I: no limitation of physl activity, ordinary physl activtiy doesn’t cause symptoms
Class II: slight limiation, comfortable at rest; ordinary physl ability causes symptoms
ClassIII: marked limitation, comf at rest, but less than ordinary activity causes symptoms
Class IV: severe limitation and discomfort with any physl activity, symptoms even at rest
assessing disability
what activities can be done w/o symptoms for NYDA classes 1-4?
I • Carry objects >80 lbs or carry >25 lbs up 8 steps • Shovel snow, spade soil • Ski, play basketball • Jog/walk 5 miles/h METs >7
II • Sexual intercourse without stopping • Garden, rake, weed • Play golf, dance foxtrot • Walk 4 miles/h on level ground METs >5-6
III • Mop floors, strip & make bed • Push lawnmower • Shower and dress without stopping • Walk 2.5 miles/h METs 2-4
IV Cannot perform any of the above without symptoms METs <2
Fluid Assessment
hyper vs hypovolemia
see slide 26
Edema:
Accumulation of fluid in the interstitium
changes in intravascular hydrostatic pressure intravascular oncotic pressure permeability interstitial oncotic pressure
↑ intravascular hydrostatic pressure
• Heart failure
• Venous: stasis, varicose veins, DVT
• Lymphatic obstruction
↓ intravascular oncotic pressure
• Cirrhosis
• Nephrotic syndrome
• Malnutrition, protein-losing enteropathy
↑ permeability
• Hypothyroidism
• Drugs
• Anaphylaxis
↑ interstitial oncotic pressure
• Lipedema
Rule: Not every patient with edema has heart failure
Edema: Heart Failure
which pts of body affected?
- Lungs
- Abdomen
- Legs
- Sacrum
- Testicles
Sacrum = lower back
Swelling all thru legs including testilcules
