Heart Failure with Johnny Crash: LEFT VENTRICULAR EJECTION FRACTION (LVEF) SYMPTOMATOLOGY: Assess VENTRICULAR DYSFUNCTION HEART FAILURE:
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1 Heart Failure with Johnny Crash: Joan E. King, PhD, ACNP-BC, ANP-BC Melissa Smith, DNP, ANP-BC Vanderbilt University School of Nursing HEART FAILURE: Heart Failure (HF): a complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to FILL with blood or EJECT blood. (Yancy, et al. 2013) LEFT VENTRICULAR EJECTION FRACTION (LVEF) A measure of how well the Heart is pumping Percentage of blood volume ejected with each contraction Normal is >55% HEART FAILURE WITH REDUCED EJECTION FRACTION HFrEF HEART FAILURE WITH PRESERVED EJECTION FRACTION HFpEF VENTRICULAR DYSFUNCTION HFrEF SYSTOLIC FAILURE Poor contractility can t squeeze well Ejection Fraction </= 45% HFpEF DIASTOLIC FAILURE Ventricle noncompliant and can not fill well Ejection Fraction > 45% Frequently the result of hypertrophy SYMPTOMATOLOGY: Assess HOW WELL THE HEART IS PUMPING HOW WELL THE PATIENT IS PERFUSING WHERE IS THE FLUID BACKING UP? LUNGS? SYSTEMIC CIRCULATION? BOTH? 1
2 GENERAL SIGNS SYMPTOMS: FATIGUE (INSUFFICIENT BLOOD SUPPLY TO MUSCLES) EDEMA WEIGHT GAIN (2.2 POUNDS = 1 LITER OF FLUID) EARLY SATIETY SIGNS SYMPTOMS OF FLUID BACKING UP INTO THE PULMONARY BED EXERTIONAL DYSNPNEA COUGH (Chronic non-productive cough) ORTHOPNEA (requires elevation of HOB) PAROXYSMAL NOTURNAL DYSPNEA (PND) CRACKLES (may or may not be present) PULMONARY CONGESTION (X-RAY) EXTRA HEART SOUNDS (S3 or S4 or both) SIGNS SYMPTOMS: BACKUP INTO THE VENOUS CIRCULATION: ELEVATED VENOUS PRESSURES Elevated central venous pressures (CVP) Elevated jugular venous pressures (JVD) HEPATOMEGALY POSITIVE HEPTOJUGULAR REFLUX PERIPHERAL or DEPENDENT EDEMA ANOREXIA inadequate blood supply to the gut EARLY SATIETY inadequate blood supply to the gut ASCITES fluid leaks out into peritoneal cavity SOB Air Hungry Changes on Chest x-ray: Increase in cardiac silhouette May or may not have crackles Elevated CVP Hepatomegaly Venous Distension (JVD 8cm) Peripheral Edema Cyanosis 2
3 THE HISTORY: PRESENCE OR CHANGES SHORTNESS OF BREATH DYSPNEA ON EXERTION ORTHOPNEA # pillows or elevation HOB PND COUGH (NON-PRODUCTIVE) PEDAL EDEMA NOCTURIA CHEST PAIN SATIETY FATIGUE ACTIVITY LEVEL PHYSICAL EXAM: HEAD TO TOE NEURO: LEVEL OF CONSCIOUSNESS AWAKE, ALERT ORIENTED X 4 CARDIAC ECG: HEART RATE RHYTHM BP: HYPOTENISVE? HYPERTENSIVE? INSEPCTION: LIFT or HEAVE PALPATION: THRILL, HEAVE PALPATION: PMI (DISPLACED OR SUSTAINED) ASCULTATION: S1, S2, S3, S4, MURMURS CAROTIDS: ASCULTATE FOR BRUITS JUGULAR VENOUS DISTENSTION (JVD) ( V WAVE WITH INCREASE IN RIGHT ATRIAL PRESSURE) AUSCULTATION OF HEART SOUNDS S3 THE THIRD HEART SOUND DIFFICULTY WITH PASSIVE FILLING OF A NONCOMPLIANT VENTRICLE S4 THE FOURTH HEART SOUND DIFFICULTY WITH ACTIVE FILLING (Atrial Kick) OF A NONCOMPLIANT VENTRICLE SUMMATION GALLOP (S3 S4) MURMURS ( WHICH MAY BE THE RESULT OR THE CAUSE OF THE HEART FAILURE) RESPIRATORY SaO2 RESPIRATORY RATE, DEPTH & EFFORT BREATH SOUNDS (ANTERIOR & POSTERIOR) CRACKLES AT THE BASES (TRANSUDATION OF FLUID INTO ALVEOLI) EXPIRATORY WHEEZES (SECONDARY TO FLUID BACKED UP INTO THE LUNGS) BIBASILAR DULLNESS TO PERCUSSION (PLEURAL EFFUSIONS) DON T BE FOOLED!! IF YOUR PATIENT HAS CLEAR BREATH SOUNDS, THEY CAN STILL BE IN HF A PATIENT CAN BE VOLUME OVERLOADED HAVE CLEAR BREATH SOUNDS 3
4 PERIPHERAL VASCULAR PERIPHERAL VASCULAR PULSES: UPPER LOWER EXTREMITIES BILATERALLY EQUAL: STRONG, WEAK, THREADY CAPILLARY REFILL (< 3 SECONDS) PRESENCE OF PRETIBIAL EDEMA (PERIPHERAL EDEMA DEPENDENT EDEMA) CYANOTIC NAILBEDS (Integument) EXTREMITIES (VASOCONSTRICTION) BOWEL SOUNDS ASCITES ASSESS THE LIVER: HEPATMEGALY (PASSIVE CONGESTION) MAY OR MAY NOT HAVE ABDOMINAL TENDERNESS HEPATOJUGULAR REFLUX (>1 CM INCREASE IN JVD WITH A SUSTAINED PRESSURE OVER THE LIVER) GI RENAL PERFUSION VS VOLUME STATUS: HF ASSESSEMNT CONCEPTUAL MODEL UOP Labs: Cr+, BUN PERFUSION VOLUME WHERE IS JOHNNY CRASH? VOLUME = FLUID RETENTION PERFUSION = CARDIAC OUTPUT EXAM TECHNIQUES AUSCULTATION 4
5 POINT OF MAXIMUN IMPULSE AUSCULTATING FOR CAROTID BRUITS JUGULAR VENOUS DISTENSTION MEASURING JVD 5
6 V WAVE WITH JVD WITH TRICUSPID REGURGITATION HEPATOMEGALY PERCUSSION OF THE LIVER PERCUSSING FOR HEPATOMEGALY ASSESSING FOR ASCITES HEPATOMEGALY REFLUX FIRM PRESSURE ON THE LIVER PRODUCES A RISE IN THE JVD 6
7 ASSESSING FOR PERIPHERAL EDEMA PERIPHERAL EDEMA: BEFORE AFTER GRADE IT FROM 1 TO 4 PUTTING IT ALL TOGETHER PERFUSION VS VOLUME STATUS: HF ASSESSEMNT CONCEPTUAL MODEL PERFUSION VOLUME VOLUME = FLUID RETENTION PERFUSION = CARDIAC OUTPUT 7
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