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
Assessing Edema: Lungs
ACEi is associated with cough in 20% of pt
• Evaluation of pulmonary function
– Other reasons for dyspnea, cough, cyanosis, etc.
• Cardiac: signs of fluid overload – Symptoms: • SOB, PND, orthopnea, cough – Percussion: • Fluid in lungs, pleural effusion • “dullness” – Auscultation: • Crackles – bubbly, “rice crispies” • Rhochi – coarse rattle
Assessing Edema: Abdomen
• Signs and symptoms:
– Bloating, fullness, early satiety
– Increase girth:
• Letting out a belt loop, pants don’t fit
– Gaining weight over short period of time
• not eating but still gaining
• Evaluation of GI system:
– Other reasons for CP, bloating, etc.
• Cardiac: – Signs of fluid overload • Hepatomegaly – Percussion: liver border, abnormal > 3cm below R subcostal border Enlargement of liver Tapping on liver border to see how big it is Palpation to seee where it is sitting – Palpation • Ascites (Intra-abdominal fluid) – fluid wave – shifting dullness – bulging flanks
Assessing Edema: Peripheral
• The following drug classes are associated peripheral edema?:
a) ARBS
b) Beta-blockers
c) Calcium Channel Blockers
d) ACEi
• Legs – bilateral, pitting – does not resolve overnight – shoes are tight or don’t fit – Onset of swelling associated with other CV symptoms
Bewta blockers dont cause it, it may worsen with underlyying heart failure
Assessing Edema: Technique
– look for peripheral edema in the lower legs
– use your thumb, press firmly, but gently for >5 sec over a bony prominence
• pitting vs. non-pitting
– start behind the medial malleolus (ankle bone), move over the dorsum, then over the shins
– rate severity (scale) and note extent of distribution
– evaluate skin:
• tight, shiny, erythematous = “acute” edema
• dry, scaly, hyperpigmented (ulcer/dermatitis) = chronic edema
0+ no pitting
1+ mild pitting, 2mm depression
2+ mod pitting, 4mm that disappears in 10-15 s
3+ mod severe, 6mm last >1min
4+ severe, 8mm >2min
This scale is subjective and not well standardized.
Assessing Central Venous Pressure
• Jugluar venous pressure (JVP):
– Assessed via the right internaljugular vein, anatomical straight to RA
– Reflects pressure in right atrium
– excellent reflector of the function of the right heart, volume status
• Soft, undulating pulsation
• Rarely palpable
• Pulsation eliminated by soft pressure
• Double vs single waveform (a-wave, v-wav
It will compress Vein, not an artery Feel your own pulse Goes up and down
Backs up into the heart
Increases volume in venous system which increases pulse and internal jugular vein
Measuring the JVP
Lay them to 30 degrees
Look for the jug vein
Use a ruler to measure across to see where the pulsation is
Measure from the sternal angle to the highest point of the pulse
Normal < 4cm
Increase JVP: Causes
- Hypervolemia – fluid overload
- Right ventricular dysfunction
- Pericardial disease
- Tricuspid valve disease
- Obstruction of superior vena cava
Cardiac Auscultation:
Heart Sound
pathologi c heart souds (2)
Listen for diff things on the chest
• S3:
• Also known as ventricular gallop
• “Ken-tuck-y” or “lub-dub-ta”
• Associated with HFrEF + fluid overload
• will result with euvolemia
• May be normal in children / young adults
rapid ventricular filling, early diastole
• S4:
• Also known as atrial gallop
• “Tenn-es-see” or “ta-lub-dub”
• Associated with a long-standing HTN, HFpEF
“atrial kick” (atrial systole), late diastole
Mr. Smythe
• He first noticed being “short on air” while walking 2 mos ago.
• He used to walk to the mall and back (4 blocks), daily without
stopping. A month ago, he had to stop 4 times and two weeks ago he
had to take a taxi home because of he was so SOB.
• He also notes that the breathing was so bad, he was avoiding the
stairs in house and is needing to sleep upright in a recliner
whcih class?
class 3 Severe symptoms but class III SOB at rest, think sitting on chair not doing anything
Can also be 4
