Echo interpret- R or L sided HF?

Daytonite, BSN, RN · Oct 24, 2009

there is no mention of right of left sided heart failure. it is not our job to medically diagnose patients. why do you think the patient has heart failure? did you assess him for arrhythmias? assess his lung status?

medical diagnoses are:

history of htn, cad, chf, mi, aortic stenosis, copd, glaucoma.
he is currently dehydrated. how do you suppose that happened?

what is abnormal about his echocardiogram is:

mild l. vent hypertrophy, moderate global hypokinesis, moderately reduced l. vent systolic function (estimated ejection fraction=35% (this is decreased cardiac output).
mild r. vent enlargement
mild r atrial enlargement.
sclerotic aortic valve (this is the cad), biprosthetic mitral valve, thickened tricuspid valve, thickened pulmonic valve.

if this were my care plan that i was working on, i'd be at step #1 of the nursing process (assessment) and looking for signs and symptoms of dehydration and going over my cardiovascular assessment. his chf was in his past history. he's probably got deficient fluid volume.

RNstudentc/o2010 · Oct 25, 2009

thank you for your help. i do that a lot, i really need to break myself of trying to figure out the medical dx. i'll probably stop doing that when i get used to the nursing process.

i think that several factors are at play with his dehydration. i think that he is probably dehydrated because of excess diuretic use (can i say this?) prescribed to treat his htn. i just find it odd that he is still taking a diuretic when his admitting dx is dehydration. i know that circulation comes before fluid status, but it just seems like they would consider prescribing something else. perhaps his heart is easily overloaded because of its poor condition created from poor htn management. he is also malnourished, so maybe these two go together. i know that he lives by himself and that a hospitalist comes by to help him with his adl's and home care, but other than that i don't think that he has anyone really checking on him that often. :sniff: he cannot walk, so i am thinking that a lot of this malnutrition and dehydration is attributed to the fact that he cannot just get up and walk to the refrigerator to get something to drink or something to eat. he is forced to rely on others because of his medical condition. dehydration/malnutrition are risks of several of the meds that he is on as well (protonix, lasix, coreg, atrovent, and prednisone).

his 24h i&o was really imbalanced: 750 cc i to 4400 cc o, and all that he ate was his breakfast. :eek: he told me that he did not like the food at the hospital, and he could not tell me his favorite foods that he usually eats at home. so, he probably disagrees with his dietary restrictions (cardiac diet). i don't think that he eats every day, really. he told me that he only has 1 bm a week, and he says that they are normal. also, i think he has a knowledge deficit because when i asked him why he thinks that he only has 1 bm/wk, he said that he did not eat that much. these last two visits to the h have been a result of the hospitalist referral, never family referral. when i explained to him why he needed to drink more fluids to motivate him to drink more (because he is in the hospital for not having enough fluids in his body), he appeared confused and did not say anything.

so, maybe the dehydration is r/t limited mobility, diuretic use, overall decreased intake, knowledge deficit, and elevated rr. maybe the malnutrition is r/t overall decreased intake, food preference, dietary restriction, decreased mobility, lack of appetite (common in old age).

am i missing something here? his admitting dx is dehydration and they later confirmed chronic renal failure. the past few times that he was admitted to the h was for either dehydration or low bp.

here are the ndx's that i have created. do you think that i have made any errors?

1.impaired gas exchange r/t chronic respiratory process, alveolar-capillary membrane changes, ventilation perfusion imbalance and hypoxic drive to breathe aeb abnormal abg's, elevated rr, shallow respirations, i>e, periods of apnea of 5 second duraction, dyspnea at rest, verbalized difficulty breathing, pt request for inhaler, hypercapnia, hypercarbia, hypoxemia, nasal flaring during respiration, observation of pt engaging in pursed-lip breathing, supraclavicular retractions, and observation of accessory muscle use during inhalation.

2. deficient fluid volume r/t diuretic use, inadequate fluid intake, active fluid loss, and failure of regulatory mechanisms aeb change in mental state, bp lower than normal, alternating pulse pressure, poor skin turgor, dry oral mucosa, increased urine output, output exceeding intake, dry skin , increased urine cx, weakness, verbalized absence of thirst, fissured tongue, and low h&h.

3. imbalanced nutrition: less than body requirements r/t inability to digest food, lack of knowledge concerning daily requirements, dislike of dietary restrictions, absence of appetite, economic status, and limitations in physical ability aeb aversion to eating, body weight over 20% below the ibw, hyperactive bowel sounds, lack of interest in food, decrease in appetite, poor muscle tone, reported intake less than rda, and magenta-colored tongue lacking tastebuds, verbalized dislike of facility food, verbalized dislike of home meal arrangement, order in chart for cardiac dietary restrictions, high creatinine, increased rdw, low lymphocyte count, low h&h, low mchc, and low rbc anemia

thank you for helping me with my care plan and clarifying these things for me. i can't find some of the stuff i need to know on the web or in my texts. it gets so confusing!

allnurses Guide · Oct 25, 2009

i'm not going to address the nursing care plan, but will try to give you some info to understand the pathophysiology of the patient's condition.

the patient has left sided heart failure, as evidenced by an ef of 35%. this is due to left ventricular hypertrophy which was most likely due to longstanding hypertension. the increased lv ejection force required to overcome the hypertensive pressure leads to a floppy left ventricle (and the previous mi means there are various areas of the lv that just don't work). once the lv is floppy and unable to pump properly due to overstretching, it needs higher filling pressures to create adequate cardiac output. if the patient gets dehydrated, they get hypotensive due to the inability of the ventricle to fill.

does the patient have a history of atrial fibrillation at all? this is commonly the reason for right atrial enlargement. there is no right-sided heart failure, as evidenced by the normal/preserved right ventricle. the way that lv failure leads to rv failure is because once it fails to pump, the fluid backs up through the lungs and into the rv and causes it to stretch and fail.

hope that helps a bit.

RNstudentc/o2010 · Oct 25, 2009

Well, thank you. That clarifies a lot. I was leaning towards that concept, but I was not sure. When one side fails, the blood has to go somewhere, right? :yeah:

Daytonite, BSN, RN · Oct 25, 2009

1.impaired gas exchange r/t chronic respiratory process, alveolar-capillary membrane changes, ventilation perfusion imbalance and hypoxic drive to breathe aeb abnormal abg's, elevated rr, shallow respirations, i>e, periods of apnea of 5 second duration, dyspnea at rest, verbalized difficulty breathing, pt request for inhaler, hypercapnia, hypercarbia, hypoxemia, nasal flaring during respiration, observation of pt engaging in pursed-lip breathing, supraclavicular retractions, and observation of accessory muscle use during inhalation.

problem: impaired gas exchange. definition:excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
etiology:
- chronic respiratory process (this is merely restating that the patient has copd in different words and does not reflect or explain the pathophysiology process going on)
- alveolar-capillary membrane changes (this is the true pathophysiology problem: physiologic changes occurring at the alveolar-capillary membrane that causes problems with the oxygen/carbon dioxide gas exchange)
- ventilation perfusion imbalance and hypoxic drive to breathe (this impediment to oxygen/carbon dioxide gas exchange occurs when the alveoli are obstructed with secretions or exudate from infection and that is not what is going on here. so, this is an incorrect assignment of the etiology.)
[*]symptoms:
- abnormal abg's (i would give the actual abg values)
- elevated rr (this should be combined with the shallow respirations to show that the respiratory rate and depth is abnormal and fluctuating)
  - shallow respirations
  [*]i>e (what is this--inspiration greater than expiration followed next by a symptom of apnea? what is it's significance to the respiratory gasses?)
  - periods of apnea of 5 second duration (this is a symptom of ineffective breathing pattern)
  [*]dyspnea at rest (not sure what you are getting at with this but it sounds like a symptom of activity intolerance)
  [*]verbalized difficulty breathing (this is a symptom of ineffective breathing pattern)
  [*]pt request for inhaler (this is a symptom of ineffective breathing pattern)
  [*]hypercapnia (list the symptoms)
  [*]hypercarbia (list the symptoms)
  [*]hypoxemia (list the symptoms)
  [*]nasal flaring during respiration (although this is a symptom of impaired gas exchange, it is also a symptom of ineffective breathing pattern and you have enough of a number of those mixed in with these symptoms to establish that there is another nursing problem here that you need to identify and treat along with the impaired gas exchange.)
  - ineffective breathing pattern. definition:inspiration and/or expiration that does not provide adequate ventilation
  [*]observation of pt engaging in pursed-lip breathing (this is a symptom of ineffective breathing pattern)
  [*]supraclavicular retractions (this is a symptom of ineffective breathing pattern)
  [*]observation of accessory muscle use during inhalation. (this is a symptom of ineffective breathing pattern)
[*]my suggestion for construction: impaired gas exchange r/t alveolar-capillary membrane changes secondary to copd aeb abnormal abgs, hypoxia, hypercapnia, hypercarbia, dyspnea with fluctuating depth and rates of breathing, and nasal flaring. and then, ineffective breathing pattern r/t hyperventilation and fatigue secondary to copd and dehydration aeb dyspnea, periods of apnea greater than 5 seconds, nasal flaring, pursed-lip breathing, supraclavicular retractions, use of accessory muscles during inhalation, and patient's verbalization of difficulty breathing and requests for an inhaler to help him breathe.

2. deficient fluid volume r/t diuretic use, inadequate fluid intake, active fluid loss, and failure of regulatory mechanisms aeb change in mental state, bp lower than normal, alternating pulse pressure, poor skin turgor, dry oral mucosa, increased urine output, output exceeding intake, dry skin , increased urine cx, weakness, verbalized absence of thirst, fissured tongue, and low h&h.

problem: deficient fluid volume. definition: decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium. (the key words here are fluid loss)
etiology (the causes must explain how fluid got lost):
- diuretic use
- inadequate fluid intake (this is explaining how fluid didn't get replaced, not how it got lost so it is really not an etiology that should be used)
- active fluid loss (but do you know how and if so, use that as the etiology--see above: diuretic use)
- failure of regulatory mechanisms (which mechanism failed? identify it.)
[*]symptoms:
- change in mental state (what change? you have to describe how the patient's mental status went from one state to another.)
- bp lower than normal (again, you have to give the changes.)
- alternating pulse pressure (ditto, as above.)
- poor skin turgor
- dry oral mucosa
  - increased urine output (combine these 2 symptoms to show how fluid is being lost from the body)
  - output exceeding intake
  [*]dry skin
  [*]increased urine cx
  [*]weakness
  [*]verbalized absence of thirst (no, this is not a symptom. i'm not thirsty right now and i'm not dehydrated.)
  [*]fissured tongue
  [*]low h&h.
[*]my suggestion for construction: deficient fluid volume r/t active fluid loss secondary to diuretic therapy aeb hypotension, alternating pulse pressure, changes in mental orientation, large urinary losses, low h&h, dry skin, poor skin turgor, dry oral membranes, fissured tongue and weakness.

3. imbalanced nutrition: less than body requirements r/t inability to digest food, lack of knowledge concerning daily requirements, dislike of dietary restrictions, absence of appetite, economic status, and limitations in physical ability aeb aversion to eating, body weight over 20% below the ibw, hyperactive bowel sounds, lack of interest in food, decrease in appetite, poor muscle tone, reported intake less than rda, and magenta-colored tongue lacking taste buds, verbalized dislike of facility food, verbalized dislike of home meal arrangement, order in chart for cardiac dietary restrictions, high creatinine, increased rdw, low lymphocyte count, low h&h, low mchc, and low rbc anemia

problem: imbalanced nutrition: less than body requirements. definition: intake of nutrients insufficient to meet metabolic needs.
etiology (cause of the problem): [suggested related factor from nanda taxonomy: inability to ingest or digest food or absorb nutrients due to biological, psychological, or economic factors]
- inability to digest food (digest or ingest? which is it? you might want to look these two terms up in a medical dictionary.)
- lack of knowledge concerning daily requirements (this is a symptom and belongs with the aeb items)
- dislike of dietary restrictions (this is a symptom and possibly belongs with the aeb items. if the patient does not follow a prescribed or suggested dietary plan that is evidence of the nursing diagnosis of ineffective health maintenance.)
- absence of appetite (this is a symptom and belongs with the aeb items)
- economic status (you should better identify what the economic problem is)
- limitations in physical ability (this is a symptom and belongs with the aeb items and may even be a symptom of feeding self-care deficit an adl problem.)
[*]symptoms:
- aversion to eating
- body weight over 20% below the ibw
- hyperactive bowel sounds
- lack of interest in food
- decrease in appetite
- poor muscle tone (which muscles? how do you know the tone is poor?)
- reported intake less than rda (reported by who?)
- magenta-colored tongue lacking taste buds
- verbalized dislike of facility food
- verbalized dislike of home meal arrangement
- order in chart for cardiac dietary restrictions (this is an ordered medical treatment, not a symptom found through assessment)
- how do these relate to the patient's nutritional state? are you trying to show some kind of malnutrition?
  - high creatinine
  - increased rdw
  - low lymphocyte count
  - low h&h
  - low mchc
  - low rbc anemia
[*]my suggestion for construction: imbalanced nutrition: less than body requirements r/t inability to ingest food and [limited finances?] aeb body weight over 20% below the ibw, hyperactive bowel sounds, magenta-colored tongue lacking taste buds, lack of appetite, lack of interest in food, aversion to eating, reported intake less than rda, verbalized dislike of facility food and home meal arrangement and lack of knowledge concerning daily requirements.

belle87RN · Oct 27, 2009

To answer your question regarding the L sided heart failure causing R sided heart failure. In this case you need to think about your patho. What is going on in L sided heart failure and where is the blood going. In L sided heart failure, the heart usually increases it's afterload which means that when the blood returns from the lungs it can't fill the L ventricle as it normally does. So blood eventually backs up into the lungs, now that blood is backed up into the lungs, the right side of the heart has to work harder to pump blood out to the lungs. Eventually blood can't fill the right side of the heart either so it causes hepatomegally and splenomegally.

So definitely not a good situation. I hope I explained that well, and correctly :). But yes that basically is what happens.