MS 3 Ch 38 Heart Failure

Heart failure patient teaching:

Take you meds as prescribed, cardiac rehab, low sodium diet, restrict fluids, weight themselves at the same time every day (call for significant weight changes), monitor HR, be aware of electrolytes and for patients taking diuretics hypokalemia and hyperkalemia.

Systolic Heart Failure Pathophysiology:

Heart failure with reduced EF results from the heart's inability to pump blood

effectively. Common causes include, MI, increased afterload, cardiomyopathy,

and mechanical problems like heart valve disease.

o The left ventricle does not generate enough pressure to eject blood forward

through the aorta. Over time the left ventricle dilates and hypertrophies. The

weakened heart muscle cannot generate adequate stroke volume, which impairs

cardiac output

Drug Therapy Treatments for Heart Failure:

ACE Inhibitors –pril (first line)

-Decreases Mortality, hospitalizations, and symptoms by blocking the

RAAS system.

 

o ARBs for patients unable to tolerate ACE

o Beta Blockers (metoprolol)

o NARIs (valsartan)

o Loop Diuretics (furosemide)

-Reduce symptoms of fluid overload by promoting renal excretion of

sodium and water.

Left Sided Heart Failure Manifestations

Pulmonary Congestion and Edema

o Dyspnea

o Orthopnea

o Paroxysmal Nocturnal Dyspnea

▪ Sudden dyspnea that awakes pt during the night, feels like being

suffocated

Right sided Heart Failure Manifestations

o L Sided HF is the most common cause, can also be caused by PE.

• Occurs when the right ventricle does not pump effectively; fluid backs up into the

venous system, causing movement of fluid into the tissues and organs.

 

o Jugular Venous Distention

o Peripheral Edema

o Hepatomegaly due to backed up blood circulation

Heart Transplant Complications:

• Infection

▪ Pneumonia

▪ Wound infections

▪ UTIs

▪ Due to immunosuppressant medications

o Rejection

▪ Most often occurs in the first 6 months after transplantation.

▪ Treatment

• Usually reversible with additional immunosuppressive therapy

▪ Chronic Rejection

• Occurs over months or years and is irreversible

Heart Failure Complications:

Atrial Fibrillation: Very common in HF patients, we see afib especially because of damage to the heart.

o Ventricular Dysrhythmias

o Thrombus formation

o Edema

o Mental Status Changes

Paroxysmal nocturnal dyspnea:

SOB that awakes a person during sleep, happens when laying down, this is a classic sign of heart failure. For sudden SOB we want to reposition the patient so sit them up, check O2 and vitals, listen to then, want to know is it new or not new, have they had it before, how does it feel, can they talk in a full sentence.

PND is caused by fluid accumulation in the pulmonary vessels entering the alveoli while the patient is supine. While lying flat, fluid redistributes from the lower extremities into the pulmonary circulation, increasing pulmonary pressures, and causing alveolar edema.

Acute decompensated heart failure (ADHF)- priority nursing care

Positioning and Oxygenation

▪ High fowlers position with feet horizontal in bed or dangling is critical for

patients with dyspnea.

▪ Ensure adequate oxygenation through pulse oximetry monitoring.

Heart failure-assessment

The main goal is to find the underlying cause of HF.

Main goal in heart failure is symptom management and quality of life.

o Lab Studies

▪ BNP

• When Diastolic BP increases, BNP is released from the ventricles.

Diagnostic Studies For Heart Failure:

Imaging Studies

▪ Echocardiogram: Shows EF

• Heart valve function

• Wall thickness and motion

• Presence of effusion or thrombus

▪ Chest xray

• Shows pulmonary congestion, cardiomegaly, pleural effusions

• lab studies (BNP)

While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicate

Increased ventricular filling pressure
Increased right atrial pressure

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?

Reduced dyspnea with the head of bed at 30 degrees

Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%?

Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)?

Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors

IV sodium nitroprusside is prescribed for a patient with acute pulmonary edema. Which reassessment finding indicates that the nurse should decrease the rate of nitroprusside infusion?

SBP <90 mmHg

A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" How would the nurse document this finding?

Paroxysmal nocturnal dyspnea

During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for the patient is

Activity intolerance related to fatigue.

Which statement by a patient newly diagnosed with heart failure indicates to the nurse that teaching was effective?

"I will use an additional pillow if I am short of breath at night."

Which foods would the nurse recommend limiting for a patient on a 2000-mg sodium diet?

Yogurt and milk products

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and HCTZ (HydroDIURIL). Appropriate instructions for the patient include:

Notify the health care provider if nausea develops

While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." What would the nurse include in the discharge plan?

Referral to a home health care agency

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. Which medication topic would the nurse anticipate including in discharge teaching?

Angiotensin-converting enzyme (ACE) inhibitor

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

B-type natriuretic peptide

Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?

Monitor blood pressure frequently

A hospitalized patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?

"I will call for help when I need to get up to use the bathroom."

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication would the nurse question before giving?

Carvedilol (Coreg) 3.125 mg

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?

Auscultate the breath sounds.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor is on a low-sodium diet. The patient tells the home health nurse about a 5-lb weight gain in the past 3 days. Which action is the nurse's priority?

Assess the patient for manifestations of acute heart failure.

A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action would the nurse take first?

Give PRN IV morphine sulfate 4 mg.

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient would the nurse assess first?

A patient who has new-onset confusion and restlessness.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires immediate action by the nurse?

Oxygen saturation of 88%

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?

Serum potassium level 3.0 mEq/L after 1 week of therapy

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider?

Blood pressure 88/42 mm Hg

A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action would be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

Monitor the patient's blood pressure and heart rate every hour.

After receiving change-of-shift report, which patient would the nurse assess first?

Patient who is taking digoxin and has a potassium level of 3.1 mEq/L

Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)?

How to take and record daily weight
Date and time of follow-up appointment
Symptoms indicating worsening HF
Actions and side effects of prescribed medications