Have the patient turn their head to the left, then examine the jugular vein. The patient needs to be at a 45 degree angle for proper evaluation gravity lessens JVP if upright and increases JVP if supine. When a patient is fluid-overloaded, the right heart pressures increase and transmit back to the jugular vein, causing jugular venous distention. The jugular venous pressure is a quick way to assess volume status. Observe jugular venous pressure, jugular venous distension. This means a patient can be volume-overloaded without any pitting edema at all, which is why using all these steps are important. Some patients with decompensated heart failure just don’t seem to retain fluid in the legs ― especially the younger patients, who may retain fluid more centrally. But if you examined the patient 1 month ago, and you see the legs are bigger, that will work fine. If you see that diagnosis on the chart, then don’t use pitting edema alone as a measure of volume status. A patient’s legs can be the size of tree trunks with skin breakdown and weeping of fluid just from venous insufficiency. Venous insufficiency can also cause pitting edema and is quite common. Sounds simple, right? Although the presence of pitting edema may be a sign of heart failure, it is not a perfect method to determine if a patient’s symptoms are from volume overload. Note that orthopnea is different than platypnea. Ask what position the patient sleeps in if on 3 to 4 pillows or up in a recliner, then be concerned that he or she has decompensated heart failure. Orthopnea, the sensation of dyspnea while laying flat, occurs when fluid redistributes to the lungs from the abdomen or legs ― because when upright gravity acts to pull fluid away from the lungs. Ask about orthopnea, paroxysmal nocturnal dyspnea. Some other conditions can cause fluid retention and weight gain including liver failure (ascites) and renal failure. Attentive heart failure patients should monitor their weight and document it on a daily bases. Ask the patient if they watch their weight. Look through the chart or office visits to find the most recent weight to compare to the current. If the patient has gained 40 pounds in a month, it is probably fluid, and they have decompensated heart failure. Hopefully, this information will be available, as it can sometimes easily solve the problem. If structural heart abnormalities including reduced ejection fraction or left ventricular hypertrophy already exist, patients are classified as Stage B even if they have never had definite symptoms. hypertension, coronary artery disease, etc. The American College of Cardiology/American Heart Association Heart Failure Classification categorizes patients with risk factors for HF ― i.e. This means that it’s always important to not only view the patient as if he or she has congestive HF, but also look at the most recent echocardiograms or other testing to see what the systolic and diastolic function looks like.Įven if the patient does not have a history or direct evidence of congestive HF, risk factors should be considered. Consider history of HF, risk factors for congestive HF.Ĭertainly, a patient with a history of congestive heart failure is more likely to be volume-overloaded from this cause than other issues, right? That is correct. Steven Lome Is Decompensated Congestive Heart Failure Present?Īre the patient’s symptoms from heart failure, or are they pulmonary in etiology? Are the physical exam findings cardiac, or are they from other causes? Wouldn’t it be nice if this was a simple question to answer? Let's look at how we can tell if a patient is volume-overloaded from heart failure in 10 steps.
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