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Concept Mapping CHF: Step By By: ELMSN Student
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Mr. Hill, 80 y/o African American male, is admitted to you Cardiac unit for exacerbation of his CHF. On admission he is confused, weak, and appears flushed. He is short of breath, taking deep, rapid breaths and refuses to lie down. He is also complaining of a head ache and chest pain. His Vitals are: BP=164/94, HR= 84, Temp= 101, RR= 30. On exam he is found to have 4+ pitting edema in both legs, bilateral jugular vein distention (JVD), and a bounding heartbeat. The pt now weighs 175 lbs, when his usual weight is 150 lbs. EKG does not indicate an active MI, but reveals flattened T waves and ST depression. Chest X-Ray (CXR) reveals consolidation in Rt. Lower lobe of the lung, and hypertrophy of left ventricle of the heart. Labs are: pCO2= 48, pH=7.31, Hgb= 9.0, Hct= 30.0, WBC= 17,000, Na= 155, K= 3.3, BUN=52, Crt=16. History reveals a history of Diabetes II, hypertension, smoking x 20 yrs, and arthrosclerosis. Pt takes Lisinopril and Metoprolol for HTN. Pt has been able to control glucose by diet and exercise. The Pt has been trying to quit smoking. He is using a nicotine patch. However, he states that he “cheated” and was smoking also.
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How would you concept map Mr. Hill’s case?
Upon admission, Mr. Hill was put on 4L of O2 via mask. An IV was started and 10 M Eq KCL, Normal saline was administered. Pt was started on a course of IV Ceftriaxone and Azythromyacin. He was also given Lasix and Lisinopril IV Push and ordered IV Morphine as needed for pain. Metoprolol was discontinued. On the second day, his Urine output dropped to 15 cc/hr and his labs jumped to BUN=150 and Crt=118. Hemodialysis was ordered. How would you concept map Mr. Hill’s case?
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Risk Meds/TX S/Sx Labs/Diag
There is a lot of info in this case study. Lets start by separating out into manageable categories: Risk Arthrosclerosis DM II Smoking HTN Age Race Metoprolol Meds/TX Ceftriaxone AzythromyacinLasix Lisinopril Morphine O2 KCl Hemodialysis S/Sx Headache Chest Pain Weakness Confusion Orthopnea SOB Flushing Weight gain Pitting edema JVD Bounding Heart Beat BP=164/94 HR= 84 Temp= 101 RR= 30 UO= 15 cc/hr Labs/Diag pCO2= 48 pH=7.31 Hgb= 9.0 Hct= 30.0, WBC= 17,000 Na= 155 K= 3.3 BUN= 150 Crt= 180 CXR= Consolidation LV hypertrophy EKG= Flat T waves and ST depression.
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That’s great but… It still looks like a list of stuff. We don’t know what is going on with Mr. Hill. We need to know more. Since we know that CHF is the problem, we can start by looking it up in the book, on the internet, or other resources until we feel we have a good idea about the CHF disease process.
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CHF Basics Although it says Coronary, CHF effect also involves the lungs and can effect the kidneys. Basically, the pressure in the blood vessels increases making it hard for the left ventricle to pump out the blood. The blood backs up into the lungs causing problems there. This leads to accumulation of CO2 which can lead to Resp. Acidosis. It can also lead to Bacterial growth and Pnuemonia. As the heart fails to keep up, the kidneys’ blood supply is cut. The Kidneys and the ANS will attempt to compensate by raising the blood pressure (to squeeze blood into the kidneys). After a while, the kidneys fails which leads to a whole set of problems (remember that the kidneys control RBC production and HCO3 to neutralize acid).
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Now we are ready to start mapping Divide your paper into three areas
We place the heart in the middle because we know that it is the central organ here and that the damage of the other organs stems from it Now we are ready to start mapping Divide your paper into three areas Kidney Heart Lungs
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Start in the middle top of your paper.
Arthrosclerosis, DM II, race, Smoking, HTN, Age Increased Nicotine intake ↑Systemic Vascular Resistance BP=164/94 Remodeling CXR= LV Hypertrophy ↑Afterload Metoprolol Start in the middle top of your paper. ↑LV contraction ↑O2 Requirement Hypoxia of Cardiac tissue ↓LV contraction force
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↑LV End Diastolic Volume ↑ Pulm. Vascular resistance
Blood back up in lungs Pulmonary Edema ↑ Pulm. Vascular resistance Blood backs up to Rt. Side of heart ↑RV preload Heart Failure
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↓Oxygenation of alveoli
SOB Orthopnea Pulmonary Edema O2 mask ↓Oxygenation of alveoli “Pulmonary Edema” leads us to the first lung problem: The inablility to Oxygenate the blood ↑CO2 ↑pCO2= 48 RR=30 ↓pH ↓pH=7.31 Respiratory Acidosis HA, Weakness, Confusion Flushed Respiratory Failure
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Inflammatory response Vasodilatation, Immune response, and clotting
Ceftriaxone Azythromycin ↑Bacterial Growth Inflammatory response Temp=101° Pain “Pulmonary Edema” can also lead to Pnumonia Vasodilatation, Immune response, and clotting Morphine PNA ↑WBC=17,000 CXR=Consolidation Pulmonary Edema
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“↓LV contraction force.”
↓Systemic BP ↓LV contraction force If we go back to the heart column, we will be able to trace how the kidney is effected and trys to compensate. Starts at the “↓LV contraction force.” ↓Renal Blood flow ADH release Renin Release Angiotesin 1+2 release KCl Lisinopril Arrhythmia MI Aldosterone release ↓K Lasix ↑H2O and Na retention ↑Na=155 Fluid volume excess ↓K= 3.3 EKG= Flat T waves and ST depression Weight gain= 25 lbs Pitting Edema Bounding Heart beat JVD ↓Hgb=9.0 ↓Hct= 30.0
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↑Systemic Vascular Resistance ↑Peripheral arteries constriction
HA, weak Confusion RR=30 ↓Hgb=9.0 ↓Hct= 30.0 However, if the kidney cannot compensate… ↑Peripheral arteries constriction Metabolic Acidosis “↓Systemic BP” also triggers the ANS to respond ↓RBC synthesis ↓HCO3 ↓Erythropoetin ↑Epinephrine ↓pH=7.31 Renal Failure ↓Systemic BP HD ↓GFR ↓Renal Blood flow ↑BUN= 150 ↑Crt= 118 ↓Urine output UO=15cc/hr
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We can now make additional connections
Congestive Heart Failure Increased Nicotine intake Arthrosclerosis, DM II, race smoking, HTN, age ↑Systemic Vascular Resistance BP=164/94 Remodeling CXR= LV Hypertrophy ↑Afterload HA, weak Confusion RR=30 Metoprolol ↓Hgb=9.0 ↓Hct= 30.0 ↑LV contraction Ceftriaxone Azythromycin ↑Peripheral arteries constriction ↑Bacterial Growth Metabolic Acidosis ↓RBC synthesis ↑O2 Requirement Inflammatory response Temp=101° Pain We can now make additional connections ↑Epinephrine ↓HCO3 ↓Erythropoetin Hypoxia of Cardiac tissue Which returns us to where we started Vasodilatation, Immune response, and clotting Renal Failure Morphine ↓pH=7.31 ↓Systemic BP ↓LV contraction force PNA ↓GFR HD ↓Renal Blood flow ↑LV End Diastolic Volume ↑WBC=17,000 CXR=Consolidation ADH release ↑BUN= 150 ↑Crt= 118 ↓Urine output Renin Release Blood back up in lungs SOB Orthopnea UO=15cc/hr Angiotesin 1+2 release Pulmonary Edema O2 mask KCl Lisinopril Arrhythmia MI ↓K Aldosterone release ↓Oxygenation of alveoli ↑ Pulm. Vascular resistance Lasix ↑H2O and Na retention ↑pCO2= 48 ↑CO2 RR=30 ↓K= 3.3 EKG= Flat T waves and ST depression Blood backs up to Rt. Side of heart ↑Na=155 Fluid volume excess ↓pH=7.31 ↓pH ↑RV preload Respiratory Acidosis Weight gain= 25 lbs Pitting Edema Bounding Heart beat JVD ↓Hgb=9.0 ↓Hct= 30.0 Heart Failure HA, Weakness, Confusion Flushed Respiratory Failure Patho S/Sx Labs/diag Risk Meds/Tx Sequelae Kidney Heart Lungs
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You have completed the CHF map with Lung and Kidney involvement.
Congratulations!!! You have completed the CHF map with Lung and Kidney involvement. Many of the concepts in it are probably new to you. Don’t panic about understanding every detail of the pathway. You will probably cover them in future units.
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