UNIT 6 HEART FAILURE CHAPTER 32 Flashcards
What is heart failure?
Heart failure , also called pump failure, is a general term for the inability of the heart to work effectively as a pump. It results from a number of acute and chronic cardiovascular problems that are discussed in this chapter and within the cardiovascular unit.
Both acute and chronic HF can be life threatening if they are not adequately treated or if the patient does not respond to treatment.
What are the different types of heart failure?
left-sided and right sided
What is the purpose of the heart?
- The purpose of the heart is to carry necessary supplies out to the
tissues. - There are components
- The pump
- The electrical system
- The vascular system
- The blood volume
Right-sided heart failure
Right-sided heart (ventricular) failure may be caused by left ventricular failure, right ventricular myocardial infarction (MI), or pulmonary hypertension. In this type of heart failure (HF), the right ventricle cannot empty completely. Increased volume and pressure develop in the venous system, and peripheral edema results.
Signs of systemic congestion occur as the right ventricle fails, fluid is retained, and pressure builds in the venous system. Edema develops in the lower legs and may progress to the thighs and abdominal wall. Patients may notice that their shoes fit more tightly, or their shoes or socks may leave indentations on their swollen feet. They may have removed their rings because of swelling in their fingers and hands. Ask about weight gain. An adult may retain 4 to 7 L of fluid (10 to 15 lb [4.5 to 6.8 kg]) before pi ing edema occurs.
Left-sided heart failure
. Typical causes of left-sided heart (ventricular) failure include hypertension, coronary artery disease, and valvular disease. Decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels indicate left ventricular failure (LVF).
As the amount of blood ejected from the left ventricle diminishes, hydrostatic pressure builds in the pulmonary venous system and results in fluid-filled alveoli and pulmonary congestion, which results in a cough. The patient in early HF describes the cough as irritating, nocturnal (at night), and usually nonproductive. As HF becomes very severe, he or she may begin expectorating frothy, pink-tinged sputum—a sign of life-threatening pulmonary edema.
Risk Factors of Heart Failure? Name 3
Heart failure (HF) is caused by systemic hypertension in most cases. Some patients experiencing myocardial infarction (MI, “heart a ack”) also develop HF. T
he next most common cause is structural heart changes, such as valvular dysfunction, particularly pulmonic or aortic stenosis, which leads to pressure or volume overload on the heart.
- Hypertension
- Coronary artery disease
- Cardiomyopathy
- Substance abuse (alcohol and illicit/prescribed drugs)
- Valvular disease
- Congenital defects
- Cardiac infections and inflammations
- Dysrhythmias
- Diabetes mellitus
- Smoking/tobacco use
- Family history
- Obesity
- Severe lung disease
- Sleep apnea
- Hyperkinetic conditions (e.g., hyperthyroidism)
S/S of left sided heart failure
- Weakness
- Fatigue
- Dizziness
- Acute confusion
- Pulmonary congestion * Breathlessness
- Oliguria (scant urine output)
-crackles in both lungs
-wheezes in lungs
-tachypnea
-tachycardia
-S3 gallop
-frothy, pink-tinged sputum
-hacking cough, worse at night
-pallor
-pulmonary edema
A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply.
A. Peripheral edema
B. Crackles in both lungs
C. Tachycardia
D. Ascites
E. Tachypnea
F. S3 gallop
B. Crackles in both lungs
C. Tachycardia
E. Tachypnea
F. S3 gallop
S/S of right-sided heart failure
- Systemic congestion
- Jugular (neck vein) distention (JVD_
- Enlarged liver and spleen (Hepatomegaly) (Splenomegaly)
- Anorexia and nausea
- Dependent edema (legs and sacrum)
- Distended abdomen
- Swollen hands and fingers
- Polyuria at night
- Weight gain
- Increased blood pressure (from excess volume) or decreased blood pressure (from failure)
-bounding pulse
What is the best indicator of weight loss or weight gain with a patient with right-sided heart failure?
A. weighing them in the morning with the same clothes before breakfast.
B. assessing the degree of their edema
C. restricting free fluids
D. monitoring intake and output
A. weighing them in the morning with the same clothes before breakfast.
Edema is an extremely unreliable sign of HF. Be sure that accurate daily weights are taken to document fluid retention. Assessing weight at the same time of the morning using the same scale is important. Weight is the most reliable indicator of fluid gain and loss!
What are some of patient centered goals for a patient with heart failure?
- Improve Perfusion and Cardiac Output
- Increased gas exchange in lungs and tissues
- Decrease complications such as pulmonary edema and peripheral
edema
The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education?
A. “I may need to take this drug every other day according to lab values.”
B. “I need to take potassium supplements with this medication.”
C. “I will try my best not to use table salt on my food.”
D. “This medication will cause me to urinate more often.”
B. “I need to take potassium supplements with this medication.”
- The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, “I feel short of breath.” Which action will the nurse take first?
A. Contact respiratory therapy.
B. Increase the oxygen to 4 L.
C. Place the client in a high-Fowler position.
D. Draw arterial blood for arterial blood gas analysis.
C. Place the client in a high-Fowler position.
Which of the following body systems are correct when a patient is experiencing heart failure?
A. Antidiuretic hormone increased
B. bradycardia
C.bradypnea
D. perfusion is intact
A. Antidiuretic hormone increased
COMPENSATORY MECHANISMS OF HEART FAILURE
Sympathetic nervous system stimulation (fight/flight)
* Renin-angiotensin system activation
* Chemical responses (BNP)
* Hypertrophy
Chronic Heart Failure: Clinical
Manifestations
F - fatigue
A - limitation of activities
C - chest congestion & cough
E - edema
S - shortness of breathe
Heart Failure Diagnostic/Labs that are needed?
Pump – heart failure
* Additional diagnosis:
* Electrolytes (always monitor electrolytes with fluid imbalance)
* Kidney function (always monitor kidneys with fluid imbalance)
* I’s and O’s (always monitor I’s and O’s with fluid imbalance)
* BNP (A BNP is always assessed to rule in/rule out and monitor heart failure) USED TO DETERMINE HEART FAILURE
* Urinalysis
* EKG
* ABG
- A client with a history of type 2 diabetes is admitted to the hospital with chest pain and scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the proce- dure and for 48 hours after the procedure?
- Glipizide
- Metformin
- Repaglinide
- Regular insulin
- Metformin
Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the con- trast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld before and after cardiac catheterization.
- A client with myocardial infarction suddenly be- comes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating- ing the client’s breath sounds?
- Stridor
- Crackles
- Scattered rhonchi
- Diminished breath sounds
- Crackles
Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not asso- ciated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway. Test-Taking Strategy: Focus on the subject, breath sounds characteristic of pulmonary edema. Recalling that fluid pro- duces sounds that are called crackles will assist you in eliminat- ing the incorrect options.
- While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the primary health care provider immediately.
d. Transfer the client to the intensive care unit.
a. Assess for symptoms of left-sided heart failure.
ANS: A
The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
- A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How would the nurse respond?
a. Weight is the best indication that you are gaining or losing fluid.
b. Daily weights will help us make sure that you are eating properly.
c. The hospital requires that all clients be weighed daily.
d. You need to lose weight to decrease the incidence of heart failure.
ANS: A
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention or loss.
- A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client’S discharge teaching?
a. Avoid drinking more than 3 quarts (3 L) of liquids each day.
b.Eat six small meals daily instead of three larger meals.
c. When you feel short of breath, take an additional diuretic.
d. Weigh yourself daily while wearing the same amount of clothing.
ANS: D
Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.
Nursing Intervention for Dyspnea
Provide the necessary amount of supplemental oxygen within a range prescribed by the health care provider to maintain oxygen saturation at 90% or greater. If the patient has dyspnea, place in a high-Fowler’s position with pillows under each arm to maximize chest expansion and improve gas exchange. Repositioning and performing coughing and deep- breathing exercises every 2 hours helps to improve gas exchange and prevents atelectasis. Interprofessional collaboration with the respiratory therapist is important to plan the most effective methods for assisting with ventilation.
Is weighing a pt that has heart failure essential
YES
Weigh the patient daily or delegate this activity to UAP and supervise that it is done. Keep in mind that 1 kg of weight gain or loss equals 1 L of retained or lost fluid. The same scale should be used every morning before breakfast for the most accurate assessment of weight. Monitor for an expected decrease in weight because excess fluid is excreted from the body.
A patient who is taking lisinopril for heart failure, has recently been experiencing a nonproductive cough, What drug does the nurse anticipate the doctor to order to replace this medication?
A. Phenelizine
B. Diazepam
C. Clopidrel
D. Valsartan
D. Valsartan
ARBs are also effective and can be used as an initial agent for those who do not tolerate ACE inhibitors, usually due to a nagging dry cough. For patients with acute HF, the health care provider may prescribe an IV-push ACE inhibitor such as Vasotec IV.
