The heart fails to pump effectively, causing decreased perfusion forward of the failure and fluid back behind the failure. Heart failure can be left sided, right sided or both. When both sides are failing, it is called congestive heart failure (CHF). Heart failure is measured by ejection fraction. Normally functioning hearts have an ejection fraction of 55-75%. Anything less than 50% is concerning for heart failure.
Any issue with the cardiovascular system could potentially cause CHF (or put the patient at a much higher risk for CHF), such as myocardial infarction, coronary artery disease, hypertension, cardiomyopathy, valve disorders, arrhythmias, etc. Also any other comorbidities such as diabetes, thyroid issues, HIV, etc. contribute to heart failure occurring. If the CHF is acute in nature, it may have been caused by a virus, infection, or blood clot.
maximized cardiac functionality as well as decreased stress on the cardiovascular system.
Get a 12 lead ECG
Water follows salt! The patient has too much fluid on board and needs to get rid of it, restricting the sodium helps with this.
This means educating the patient on dietary changes that need to happen and be adhered to.
Caution with salt substitute in renal insufficiency – it is made with potassium chloride and can raise the patient’s K+!
Normal range: <100 pg/mL
Brain natriuretic peptide (BNP): is a hormone made by the heart. When the heart is stressed or working hard to pump blood, it releases BNP.
Fluid can back up into the lungs and cause shortness of breath, especially upon exertion. Be careful about laying these patients flat as you can put them in respiratory distress.
Place the patient on O2 as needed to help them keep their O2 levels adequate – usually above 92% or as ordered by the provider.
We need to get all this fluid out of the patient… The best way to do this is administer diuretics.
The FIRST thing you do BEFORE you administer a diuretic is have a pee plan. Do not under any circumstances administer a diuretic without a bathroom plan. And a word to the wise, have a backup plan. Meaning if you have an independent patient with functioning arms and a strong call light finger, I still would set up a bedside commode just.in.case. I walk them to the bathroom or assist them in any way needed, but it is possible that they do not know how urgent their situation is and you can clean up pee, but you can’t clean up that patients dignity.
Diuretics work on different parts of the nephrons. The goal of diuretics is to help the kidneys rid the body of salt (notice I didn’t say sodium (Na+)?) and fluids. It is important to note for every Na+ molecule there is a compound of one water (H20) that follows it. Psssst: potassium is a salt, too…
There are three kinds of diuretics: Loop, Thiazide, and potassium sparing.
Most commonly used diuretics in congestive heart failure are loop and sometimes thiazides are used with loop diuretics:
These patients should only have around 8 cups of fluid or just slightly under 2 liters of fluid per day. This can change per patient and per doctor recommendation, so make sure to get a goal from the physician.
Strict I&O means measuring every drop that goes in or out of that patient.
Edema is caused by volume overload due to congestion within the system. Worsening edema can indicate worsening heart failure.
Edema is measured by pressing over a bony prominence, usually the top of the foot or the tibia and is charted by a number and whether the skin bounces back or stays pitted (called pitting edema).
Daily weights should be done at the same time of the day, same clothes (or none), same scale. A weight gain of 1 kg is equivalent to 1 L of fluid – notify HCP for gain of 2 lbs in a day or 5 lbs in a week.
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