Confused with new onset CHF

AnnaN5 · Mar 14, 2015

The EF only tells us about the left ventricle systolic function. Does he have diastolic dysfunction? Any valve abnormalities? Right sided failure?

CTrain · Mar 14, 2015

As far as I know, there was no mention of valve dysfunction, and no mention of right side having any issues.

The pt. denied SOB with exertion but was on bedrest, so that may be why he denied it. I checked for edema around the sacrum and it was not present. He was very asymptomatic, and most of his s/s were blamed on the anemia which is always a possibility.

Majority of his care was aimed at the anemia, yet his dx was CHF. I'm just confused as to why their care plan had decreased cardiac output when he wasn't showing any hard signs of decreased cardiac output like I'm used to with other patients.

dah doh, BSN, RN · Mar 14, 2015

Things to think about...

Why is pt hgb low? Acute vs chronic?

Why is pt have clubbing? That's usually chronic hypoxia. Hyper inflated lungs - COPD vs emphysema...smoker right?? sob from that or low hgb due to less O2 carrying capacity vs fluid overloaded.

Bad heart...crackles & sob & elevated BNP = fluid overload. How's the right side of pt heart? Is heart cardiomyopathy?

dah doh, BSN, RN · Mar 14, 2015

His chief complaints were SOB, weakness, dizziness...all can be symptoms of low cardiac output and can be caused by hypovolemic state including anemia. Many times tachycardia is a compensatory state for low circulatory volume.

CTrain · Mar 14, 2015

So, is it possible that he has early emphysema that could also be interfering with O2 exchange. He does have home albuterol, and clubbing of the fingers which shows me something has been going on for a while. But by the same token he clearly has a lack of RBCs, iron, H&H which would cause a low O2 sat.

I guess I'm looking at this like he has chronic infection, anemia, CHF, and now a respiratory problem that are all requiring an O2 demand beyond what he can supply, but I'm trying to decipher what is causing what or if they are completely separate. I feel like the lines between the conditions are becoming blurred even with a concept map. SOB and weakness are symptoms from anemia, CHF, and emphysema.

Guest03/15/15, BSN, RN · Mar 14, 2015

The pulmonary edema present on the chest X-ray.

nurseprnRN, BSN, RN · Mar 14, 2015

A few ideas:

1) Remember it's always possible to have more than one thing wrong c you. He has LOTS of things wrong c him.

Clubbing is a late symptom of chronic hypoxia. Usually, people c chronic hypoxia compensate for growing a lot more RBCs-- people who live at altitude in the mountains where the partial pressure of oxygen is lower than it is at sea level are expected to have higher Hct and hgb. He has signs of chronic hypoxia r/t COPD...but his red cells are quite low, meaning he has even less oxygen-carrying capacity than he used to have, and comparatively a lot less than you and I.

COPD can also give you RIGHT heart failure, because the destruction of functioning lung units means that the R heart has to pump the same amount of blood as ever through fewer and fewer capillaries. Think what would happen if you had a big tank of water to pump through an array of garden hoses, and think how hard that would be. Now, decrease the number of garden hoses, but you still have to move the same amount of water. You have to pump a lot harder, don't you? Same thing. R heart strain. "Cor pulmonale" (heart looks like this due to lung disease) is the term you might see.

So, you have somebody who's not carrying as much oxygen to his tissues (including his coronary arteries). This can certainly annoy a heart (and other places). He does have a decent EF, but that may be a max he can generate. If you're tachy trying to compensate for lousy oxygen delivery (or high oxygen extraction like with exercise, same effect) your heart increases its contractility. He maybe can't do that anymore.

He has a wet chest, so the first thing you think of is CHF. He's not too SOB, but all he's doing is lying in bed, right? I bet he desaturates in a heartbeat (so to speak) with any kind of activity, because he has such lousy oxygen-carrying capacity and bad lungs and no way to compensate further because his heart is working towards getting maxed out...

off the top of my head...

guest*Nurse · Mar 20, 2015

There is never going to be clear cut lines in a complex case like this. You just have to think that everything may somehow relate to one another. For his CHF you say he is not currently SOB. How was he on admission ? What was the reason he came into the ER? Was he SOB then? Usually CHF patients tend to put off coming in until something happens to impair their daily living... ex: their breathing becomes impaired. Crackles shows fluid build up in their lungs... that's another sign there. They may have admitted him for CHF but that doesn't mean they won't treat other things going on with him.

SRDAVIS · Mar 21, 2015

psu_213, BSN, RN · Mar 21, 2015

This is a gentleman with many medical problems. As others have said, he likely has multiple things going on at once. Clubbing with hyperinflation on the X-ray leads me to COPD. Elevated BNP with pulmonary edema point to CHF.

I'm not sure of the time interval between the labs, but what changes to his labs do you see? What does this indicate? How might that be playing into the clinical picture? Anything of interest in the UA?

How would you assessment, combined with lab/radiology results, direct your nursing care?

la_chica_suerte85, BSN, RN · Mar 22, 2015

Also, remember that bnp is not the only way of looking at HF. The New York Heart Association functional class levels are important, too. Like GrnTea said, if he gets SOB on activity (depending on minimal to higher level exertion), that can tell you a whole lot more than bnp and ejection fraction (I've seen people with normal EFs who have CHF, too, and this is usually why, COPD not withstanding).