Chapter 20: Heart Failure and Circulatory Shock PATHO TAKEN FROM http://thepoint.lww.com/Book/Show

When lecturing to a group of students about the pathophysiological principles behind heart failure, the instructor explains that cardiac output represents: a) The amount of blood the heart pumps each minute b) Strength of the right ventricular pump to move blood c) The amount of blood pumped out of the heart with each beat d) The volume of blood stretching the heart muscle at the end of diastole

The amount of blood the heart pumps each minute Cardiac output, which is the major determinant of cardiac performance, reflects how often the heart beats each minute (heart rate) and how much blood it ejects with each beat (stroke volume). Preload reflects the volume of blood that stretches the ventricle at the end of diastole, just before the onset of systole.

A nurse is administering morning medications to a number of patients on a medical unit. Which of the following medication regimens is most suggestive that the patient has a diagnosis of heart failure? a) Beta-blocker, potassium supplement, anticoagulant b) Anticoagulant, antihypertensive, calcium supplement c) Diuretic, ACE inhibitor, beta-blocker d) Antihypertensive, diuretic, antiplatelet aggregator

c) Diuretic, ACE inhibitor, beta-blocker Diuretics, ACE inhibitors and beta-blockers are all commonly used in the treatment of heart failure. Antiplatelet aggregators, calcium and potassium supplements and anticoagulants are less likely to relate directly to a diagnosis of heart failure.

A 30-year-old male brought to the emergency department has the following admission data: Blood pressure 50/30, pulse 100, respiratory rate 12, temperature 101°F. The nurse does not know the exact cause but does know that patient is in shock because of which of the following readings? a) Elevated temperature b) Slow respiratory rate c) Elevated pulse rate d) Low blood pressure

d) Low blood pressure Low blood pressure is characteristic of most occurrences of shock. Elevated pulse rate may be a compensatory effort to support blood pressure. Elevated temperature can occur with septic shock. Decreased respiratory rate is not characteristic of shock

A client who has progressed to late-stage heart failure is experiencing sympathetic stimulation. The nurse would assess the client for: Select all that apply. a) Increased cardiac contractility b) Vasoconstriction c) Increased oxygen demand d) Arrhythmias e) Bradycardia

• Vasoconstriction • Arrhythmias • Increased oxygen demand The sympathetic nervous system response is meant to maintain blood pressure and cardiac output; however, it quickly becomes maladaptive and contributes to the deterioration of heart function. An increase in sympathetic activity can lead to tachycardia, vasoconstriction, and cardiac arrhythmias. Acutely, tachycardia significantly increases the workload of the heart, thus increasing myocardial oxygen demand and leading to cardiac ischemia, myocyte damage, and decreased contractility (inotropy).

A patient in the nursing home wonders why he is having these signs and symptoms of left-sided failure. Which of the following explanations will the nurse give the patient? a) "The left ventricle is pumping excessive amounts of blood through the carotid arteries causing headache." b) "The left ventricle is not adequately perfusing your gastrointestinal tract, leading to diarrhea and vomiting." c) "The left ventricle is having problems pumping blood forward, and this is causing blood to back up into your lungs." d) "The left ventricle is having problems pumping blood forward so blood is backing up systemically causing edema in your feet."

"The left ventricle is having problems pumping blood forward, and this is causing blood to back up into your lungs." In left-sided failure, the left ventricle pumps inefficiently, blood backs up in the pulmonary circulation, and less, rather than more, blood enters the carotid arteries. Right-sided rather that left-sided failure causes blood to back up in the venous circulation resulting in edema. Congestion of the gastrointestinal tract is usually characteristic of advanced heart failure.

In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which of the following levels indicates inadequate renal perfusion? a) 40—20 mL/hour b) 60—40 mL/hour c) 80—60 mL/hour d) 20 mL/hour

20 mL/hour In hypovolemia, renal vasculature is constricted in a compensatory attempt to circulate blood to more vital organs. Urinary output at 20 mL/hour or below indicates that renal perfusion is too inadequate.

The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is: a) 40 mL/hour b) 20 mL/hour c) 80 mL/hour d) 60 mL/hour

20 mL/hour Urine output decreases very quickly in hypovolemic shock. Compensatory mechanisms decrease renal blood flow as a means of diverting blood flow to the heart and brain. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion. (less)

A client is rushed to the emergency department with symptoms of urticaria, wheezing, chest tightness, and difficulty in breathing. The client is most likely experiencing which type of shock? a) Anaphylactic b) Cardiogenic c) Septic d) Neurogenic

Anaphylactic Signs and symptoms associated with impending anaphylactic shock include abdominal cramps; apprehension; warm or burning sensation of the skin, itching, and urticaria (i.e., hives) and coughing, choking, wheezing, chest tightness, and difficulty in breathing. The other options do not have these manifestations.

A 20-year-old male client is experiencing a severe immunologically mediated reaction in which histamines have been released into the blood. Select the type of reaction most likely occurring with this client. a) Anaphylatic shock b) Septic shock c) Neurogenic shock d) Distributive shock

Anaphylatic shock Anaphylactic shock is initiated through an immunologically mediated reaction to an irritant. Neurogenic shock is caused by decreased sympathetic control of blood vessel tone due to a defect in the vasomotor center in the brain stem or the sympathetic outflow to the blood vessels. Distributive or vasodilatory shock is characterized by loss of blood vessel tone, enlargement of the peripheral vascular compartment, and displacement of the vascular volume away from the heart and central circulation. Septic shock, which is the most common type of distributive shock, is associated with the systemic immune response to severe infection.

The nurse is caring for a client who has just experienced an acute myocardial infarction and is diagnosed with "pump failure." The nurse is aware that the client is experiencing which type of shock? a) Neurogenic b) Hypovolemic c) Cardiogenic d) Septic

Cardiogenic Cardiogenic shock occurs when the heart fails to pump blood sufficiently to meet the body's demands. Clinically, it is defined as decreased cardiac output, hypotension, hypoperfusion, and indications of tissue hypoxia despite an adequate intravascular volume. Cardiogenic shock most commonly occurs from an acute myocardial infarction

The nurse is developing a plan of care for a client with heart failure. The most important information for the nurse to consider would be: a) Decreased retention of sodium b) Increased ejection fraction c) Decreased cardiac output d) Increased renal blood flow

Decreased cardiac output In heart failure with a reduced ejection fraction, a decrease in cardiac output and renal blood flow leads to increased sodium and water retention by the kidney with a resultant increase in vascular volume and venous return to the heart and an increase in ventricular end-diastolic volume.

A patient has developed pericarditis. The nurse knows that this condition will increase the risk for development of which condition? a) Distributive shock b) Systolic dysfunction c) Diastolic dysfunction d) Obstructive shock

Diastolic dysfunction Pericarditis, or inflammation of the pericardial membrane covering the heart, can yield excess pericardial fluid which fills the space between the heart and the pericardium and impedes ventricular filling. Pericarditis does not affect myocardial contractility, and has no bearing on cardiogenic or hypovolemic shock

For which of the following types of shock might intravenous antibiotic therapy be indicated? a) Hypovolemic shock b) Distributive shock c) Cardiogenic shock d) Obstructive shock

Distributive shock Septic shock is a subtype of distributive shock. The treatment of sepsis and septic shock focuses on control of the causative agent and support of the circulation and the failing organ systems. The administration of antibiotics that are specific for the infectious agent is essential. Swift and aggressive fluid administration is needed to compensate for third spacing, though which type of fluid is optimal remains controversial. Equally, aggressive use of vasopressor agents, such as norepinephrine or epinephrine, is needed to counteract the vasodilation caused by inflammatory mediators.

The nurse working in the ICU knows that chronic elevation of left ventricular end-diastolic pressure will result in the patient displaying which of the following clinical manifestations? a) Chest pain and intermittent ventricular tachycardia. b) Muscle cramping and cyanosis in the feet. c) Petechia and spontaneous bleeding. d) Dyspnea and crackles in bilateral lung bases.

Dyspnea and crackles in bilateral lung bases. Although it may preserve the resting cardiac output, the resulting chronic elevation of left ventricular end-diastolic pressure is transmitted to the atria and the pulmonary circulation, causing pulmonary congestion

All of the following interventions are ordered stat for a patient stung by a bee who is experiencing severe respiratory distress and faintness. Which priority intervention will the nurse administer first? a) Epinephrine (Adrenalin). b) Diphenhydramine (Benadryl). c) Normal saline infusion. d) Dexamethasone (Decadron).

Epinephrine (Adrenalin). Treatment includes immediate discontinuation of the inciting agent; close monitoring of CV and respiratory function; and, maintenance of respiratory gas exchange, cardiac output and tissue perfusion. Epinephrine is given in an anaphylactic reaction because it constricts blood vessels and relaxes the smooth muscle in the bronchioles.

While in the ICU, a client's status changes. The health care providers suspect heart failure. Which of the following diagnostic procedures would give the staff information about pulmonary capillary pressures, which will lead to the most appropriate interventions? a) Hemodynamic monitoring b) Echocardiography c) Cardiac magnetic resonance imaging d) Radionuclide ventriculography

Hemodynamic monitoring Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. These monitoring methods include central venous pressure (CVP), pulmonary artery pressure monitoring, measurements of cardiac output, and intra-arterial measurements of blood pressure. Echocardiography plays a key role in assessing ejection fraction, right and left ventricular wall, wall thickness, ventricular chamber size, valve function, heart defects, and pericardial disease. Radionuclide ventriculography is recommended if there is reason to suspect coronary artery disease or ischemia as the underlying cause for heart failure. Cardiac magnetic resonance imaging and cardiac computed tomography are used to document ejection fraction, ventricular preload, and regional wall motion

Increased cardiac workload with left heart failure can result in which of the following change to the myocardial cells? a) Hyperplasia b) Dysplasia c) Atrophy d) Hypertrophy

Hypertrophy Myocardial hypertrophy is a compensatory mechanism in heart failure as the heart attempts to maintain adequate pumping ability. Paradoxically, hypertrophy can gradually decrease cardiac efficiency.

A 20-year-old college student has a pelvic fracture and a severed leg from a motorcycle accident. She lost several units of blood. When the student arrived in the emergency department, her blood pressure was very low, her pulse was high, and her skin was pale. The nurse knows that this patient has developed which of the following types of shock? a) Distributive b) Cardiogenic c) Hypovolemic d) Obstructive

Hypovolemic Hypovolemic shock occurs when there has been extensive blood or body fluid loss. Cardiogenic shock occurs when the heart loses its ability to pump sufficient blood to meet oxygenation needs of body tissues. Distributive shock is loss of blood vessel tone, resulting in expansion of the vascular compartment. Obstructive shock is an inability of the heart to fill or empty properly.

The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be: a) Placing a stent for fluid drainage from the heart b) Eliminating CHF through curing the disease c) Maintaining higher oxygen levels to decrease the work of breathing d) Improving quality of life by relieving symptoms

Improving quality of life by relieving symptoms A primary treatment goal for a client with CHF is to improve the quality of life through symptom management. CHF will not be cured, and maintaining a higher oxygen level will assist with dyspnea associated with CHF. A stent is not an option for treatment of CHF.

Anaphylactic shock is the most severe form of systemic allergic reaction. Immunologically medicated substances are released into the blood, causing vasodilation and an increase in capillary permeability. What physiologic response often accompanies the vascular response in anaphylaxis? a) Uterine smooth muscle relaxation b) Gastrointestinal relaxation c) Bronchodilation d) Laryngeal edema

Laryngeal edema Anaphylaxis is a clinical syndrome that represents the most severe form of systemic allergic reaction. Anaphylactic shock results from an immunologically mediated reaction in which vasodilator substances such as histamine are released into the blood. The vascular response in anaphylaxis is often accompanied by life-threatening laryngeal edema and bronchospasm, circulatory collapse, contraction of gastrointestinal and uterine smooth muscle, and urticaria (hives) or angioedema.

The diagnosis is right-sided heart failure. The nurse knows that which organ is primarily affected in this type of heart failure? a) Gastrointestinal tract b) Kidneys c) Liver d) Jugular veins

Liver As right-sided heart failure occurs, blood backs up in the venous circulation including the hepatic veins that drain into the inferior vena cava. The liver becomes engorged, and with prolonged right-sided failure, hepatic cell death occurs. The kidneys are further down in the venous circulation and are less affected. The jugular veins and gastrointestinal tract are affected, but are not organs.

Increased secretion of renin in heart failure is caused by which of the following events? a) Increased renal blood flow b) Arrhythmias c) Hypertension d) Low cardiac output

Low cardiac output Low cardiac output reduces renal blood flow which activates the renin-angiotensin-aldosterone system (RAAS). This system produces the vasoconstrictor angiotensin-ll and aldosterone which increases sodium and water retention. Both of these actions attempt to increase renal perfusion. Hypertension and arrhythmias do not activate RAAS.

A patient has developed left heart failure. Which of the following symptoms might have precipitated this condition? a) Pulmonary edema b) Stroke c) Hypotension d) Myocardial infarction

Myocardial infarction Myocardial infarction causing damage to the left ventricular wall can decrease ventricular efficiency and result in left-sided failure. Pulmonary edema, hypotension, and stroke are not causes of left heart failure.

A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged and resulted in a pulmonary embolism. Which of the following types of shock is this client at risk of experiencing? a) Obstructive shock b) Cardiogenic shock c) Distributive shock d) Hypovolemic shock

Obstructive shock Obstructive shock results from mechanical obstruction of the flow of blood through the central circulation, such as the blockage that characterizes a pulmonary embolism.

On a holiday trip home, the nurse's mother states that the nurse's father was diagnosed with right heart failure. Which of the following manifestations exhibited by the father does the nurse know might have preceded this diagnosis? a) Vertigo, headache b) Weakness, palpitations c) Peripheral edema weight gain d) Dyspnea, cough

Peripheral edema weight gain In right failure. blood backs up into the venous side of the circulatory system causing increased hydrostatic pressure in capillaries and leakage of plasma which forms peripheral edema and becomes apparent as weight gain. The other manifestations listed are not characteristic of right-sided failure

A nurse preceptor is evaluating the skills of a new registered nurse (RN) caring for clients experiencing shock. Which action by the new RN indicates a need for more education? a) Administration of 2L of oxygen by nasal cannula b) Inserting an IV to begin a normal saline infusion c) Raising the head of the bed to a high Fowler's position d) Placing a pulse oximeter on the client to monitor oxygenation status

Raising the head of the bed to a high Fowler's position Treatment measures include close monitoring of cardiovascular and respiratory function; maintenance of respiratory gas exchange, cardiac output, and tissue perfusion; and the administration of oxygen, antihistamine drugs, and corticosteroids. The person should be placed in a supine position. This is extremely important because venous return can be severely compromised in the sitting position. This in turn produces a pulseless mechanical contraction of the heart and predisposes to arrhythmias. In several cases, death has occurred immediately after assuming the sitting position. (less)

A 20-year-old college student being treated for a kidney infection developed a temperature of 104ºF in spite of treatment with antibiotics. Her pulse was high, her blood pressure was low, and her skin was hot, dry, and flushed. The nurse knows that this patient most likely is experiencing which of the following types of shock? a) Neurogenic b) Septic c) Anaphylactic d) Cardiogenic

Septic Septic shock can result with the body's response to a severe infection. Neurogenic shock is a loss of sympathetic (adrenergic) control of systemic blood vessel tone. Cardiogenic shock is a loss of cardiac efficiency, and anaphylactic shock is a severe allergic reaction.

A patient in the intensive care unit has a blood pressure of 87/39 and has warm, flushed skin accompanying his sudden decline in level of consciousness. The patient also has arterial and venous dilatation and a decrease in systemic vascular resistance. What is this client's most likely diagnosis? a) Hypovolemic shock b) Obstructive shock c) Septic shock d) Neurogenic shock

Septic shock Low blood pressure accompanied by warm, flushed skin and cognitive changes is indicative of septic shock, as is vessel dilatation and decreased vascular resistance.

A patient is told that she has cardiac valve leaflets, or cusps, that are floppy and fail to shut completely, permitting blood flow even when the valve should be completely closed. The nurse knows that this condition can lead to heart failure and is referred to as which of the following? a) Infective endocarditis b) Pericardial effusion c) Valvular stenosis d) Valvular regurgitation

Valvular regurgitation When cardiac valves such as the aortic or mitral fail to close properly, blood does not efficiently exit from the left ventricle. This condition is valvular regurgitation. Valvular stenosis is a narrowing of the lumen of the valve. Pericardial effusion, an accumulation of fluid in the pericardial sac causes obstructive shock, as it impedes ventricular filling. Infective endocarditis could trigger septic shock

An elderly client asks the nurse why so many older people develop heart failure. The best response would be increased: a) Cardiac tone and compliance b) Response to Ϝ-adrenergic stimulation c) Myocardial metabolism d) Vascular stiffness

Vascular stiffness There are four changes associated with aging that contribute to the development of heart failure in the elderly. Reduced responsiveness to Ϝ-adrenergic stimulation limits the heart's capacity to maximally increase heart rate and contractility during an increase in activity or stress. A second major effect of aging is increased vascular stiffness; third, in addition to increased vascular stiffness, the heart itself becomes stiffer and less compliant with age. Fourth, aging alters myocardial metabolism at the level of the mitochondria.

A patient is diagnosed with right-sided heart failure. The nurse knows that a frequent sign of this type of failure is peripheral edema, evidenced by which of the following? a) Shortness of breath b) Weight gain c) Decreased blood pressure d) Copious urination

Weight gain In right-sided heart failure, blood backs up into the venous system and increased capillary hydrostatic pressure forces plasma out of the circulatory system, resulting in edema. The accumulation of fluid is evidenced by rapid weight gain. Shortness of breath and decreased renal perfusion and output are characteristic of left-sided failure

A nurse is performing client health education with a 68-year-old man who has recently been diagnosed with heart failure. Which of the following statements demonstrates an accurate understanding of his new diagnosis? a) "I'm trying to think of ways that I can cut down the amount of salt that I usually eat." b) "I'm going to avoid as much physical activity as I can so that I preserve my strength." c) "I'll be sure to take my beta blocker whenever I feel short of breath." d) "I know it's healthy to drink a lot of water, and I'm going to make sure I do this from now on."

a) "I'm trying to think of ways that I can cut down the amount of salt that I usually eat." Salt and fluid restrictions are indicated for most clients with heart failure (HF). Beta blockers do not address shortness of breath, and cardiac medications are not normally taken in response to acute symptoms. Clients should be encouraged to maintain, and increase, physical activity within the limits of their condition.

A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right-sided. Which of the following statements best describes the presentation that the nurse should anticipate? The client: a) has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain. b) complains of dyspnea and has adventitious breath sounds on auscultation (listening). c) has cyanotic lips and extremities, low urine output, and low blood pressure. d) has a distended bladder, facial edema, and nighttime difficulty breathing.

a) has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain. Right-sided failure is associated with peripheral edema, fatigue, and, on occasion, upper right quadrant pain. Abdominal distention can occur with right-side failure when the liver becomes engorge. Facial edema, pulmonary edema, peripheral cyanosis, low urine output and low blood pressure are less associated with right-sided failure. Left-sided failure is primarily associated with pulmonary signs/symptoms like dyspnea, pulmonary edema, frothy pink sputum, and respiratory congestion.

The pathophysiology of heart failure involves an interaction between decreased pumping ability and the ________ to maintain cardiac output. a) parasympathetic system b) electrical conductivity c) aortic hypertrophy d) compensatory mechanisms

compensatory mechanisms The pathophysiology of heart failure involves a decrease in pumping ability of the heart with a consequent decrease in the cardiac output, and activation of compensatory mechanisms that attempt to maintain cardiac output, but also contribute to the progression of heart failure. Stimulation of the sympathetic nervous system plays an important role in the compensatory mechanisms and the pathogenesis of heart failure. Heart failure is a muscle contractility problem, unrelated to the electrical conduction that stimulates it.

The health care provider has determined that a client diagnosed with cardiogenic shock will now require treatment with the intra-aortic balloon pump. The expected effect of the treatment is: a) decreased afterload. b) increased preload. c) increased afterload. d) decreased cardiac output.

decreased afterload. The intra-aortic balloon pump, also referred to as counterpulsation, enhances coronary and systemic perfusion, yet decreases afterload and myocardial oxygen demands.

A client has just returned from his surgical procedure. During initial vital sign measurements, the nurse notes that the client's heart rate is 111 beats/minute and the BP is 100/78 (borderline low). In this early postoperative period, the nurse should be diligently monitoring the client for the development of: a) Hypovolemic shock due to acute intravascular volume loss b) Side effects from versed administration causing excessive vasoconstriction c) Pulmonary embolism due to development of deep vein thrombosis d) Renal failure due to an overdose of medication

hypovolemic shock due to acute intravascular volume loss Hypovolemic shock is characterized by diminished blood volume such that there is inadequate filling of the vascular compartment. Hypovolemic shock also can result from an internal hemorrhage or from third-space losses, when extracellular fluid is shifted from the vascular compartment to the interstitial space or compartment, without fluid movement in/out of the cells. Within seconds after the onset of hemorrhage or the loss of blood volume, compensatory manifestations of tachycardia, vasoconstriction, and other signs of sympathetic and adrenal medullary activity appear. There is no indication that this client has developed a pulmonary embolism, is having side effects from versed administration, or is going into renal failure due to an overdose of medication.

Which of the following conditions reflect failure of the circulatory system? Select all that apply. a) Renal dysfunction b) Orthostasis c) Circulatory shock d) Heart failure e) Suppression of the renin-agiotensin-aldosterone system (RAAS)

• Circulatory shock • Heart failure Heart failure and circulatory shock are both failures of the circulatory system to provide an adequate supply of oxygen and nutrients to all body tissues. Orthostasis is a temporary decrease of blood flow to the central nervous system, causing dizziness. Renal dysfunction can be a result of impaired blood flow to the kidneys. Suppression of RAAS can cause vasodilation and decreased blood volume but usually does not completely disrupt systemic circulation.

What are the physiologic signs and symptoms of cardiogenic shock? (Select all that apply.) a) Increased urine output related to increased renal perfusion b) Rise in central venous pressure (CVP) c) Increased extraction of O2 from hemoglobin d) Decrease in mean arterial blood pressures e) Hypercapnic lips and nail beds

• Decrease in mean arterial blood pressures • Rise in central venous pressure (CVP) • Increased extraction of O2 from hemoglobin Signs and symptoms of cardiogenic shock include indications of hypoperfusion with hypotension, although a preshock state of hypoperfusion may occur with a normal blood pressure. The lips, nail beds, and skin may become cyanotic because of stagnation of blood flow and increased extraction of oxygen from the hemoglobin as it passes through the capillary bed. Mean arterial and systolic blood pressures decrease due to poor stroke volume, and there is a narrow pulse pressure and near-normal diastolic blood pressure due to arterial vasoconstriction. Urine output decreases due to lower renal perfusion pressures and the increased release of aldosterone. Elevation of preload is reflected in a rise in CVP and pulmonary capillary wedge pressure. Neurologic changes, such as alterations in cognition or consciousness, may occur due to low cardiac output and poor cerebral perfusion. The other physiologic occurrences are not signs or symptoms of shock.

Which of the following consequences of cardiogenic shock will the nurse monitor? Select all that apply. a) Decreased cardiac output b) Decreased stroke volume c) Increased afterloading d) Decreased preloading e) Decreased blood volume

• Decreased stroke volume • Decreased cardiac output • Increased afterloading As ventricular pumping ability declines, stroke volume and cardiac output fall. Preloading increases, as blood returning to the heart adds to that which is not efficiently pumped forward. Sympathetic (adrenergic) reflexes are activated attempting to support cardiac output; this causes tachycardia and vasoconstriction, which increases afterloading. Decreased renal perfusion activates the renin-angiotensin-aldosterone system, promoting sodium and water retention and increased blood volume.

Following coronary bypass graft (CABG) surgery for a massive myocardial infarction (MI) located on their left ventricle, the ICU nurses are assessing for clinical manifestations of cardiogenic shock. Which of the following assessment findings would confirm the client may be in the early stages of cardiogenic shock? Select all that apply. a) Urine output 15 mL last hour. b) Low BP reading of 86/60. c) Decreasing mean arterial pressure (MAP). d) Periods of confusion. e) Low pulmonary capillary wedge pressure (PCWP).

• Decreasing mean arterial pressure (MAP). • Low BP reading of 86/60. • Urine output 15 mL last hour. • Periods of confusion. S/S of cardiogenic shock include indications of hypoperfusion with hypotension (BP 96/60), decrease in mean arterial pressure (MAP) due to poor stroke volume and a narrow pulse pressure. Urine output decreases because of lower renal perfusion pressures. PCWP is usually elevated due to increased preload. Periods of confusion or altered cognition/ consciousness may occur because of low cardiac output

A patient is diagnosed with heart failure. Which of the following types of drugs is to be used to manage this disorder? Select all that apply. a) Diuretics b) Beta-adrenergic blockers c) Angiotensin-converting enzyme inhibitors (ACEI) d) Nonsteroidal anti-inflammatory drugs (NSAID) e) Digitalis

• Diuretics • Digitalis • Beta-adrenergic blockers • Angiotensin-converting enzyme inhibitors (ACEI) ACEI decrease the production of angiotensin II, allowing for vasodilation, which enables the left ventricle to pump more efficiently. Also decreased is the release of aldosterone, which promotes sodium and fluid retention and increases blood volume, which also can exacerbate heart failure. Diuretics foster excretion of body water thus decreasing blood volume, relieving edema, and decreasing cardiac workload. Beta blockers inhibit ineffective activation of the sympathetic nervous system. Digitalis or digoxin (Lanoxin) will improve ventricular efficiency by increasing the force of contraction. NSAIDs such as ibuprofen (Motrin, Nuprin) are best avoided as they decrease renal perfusion and increase retention of body water.

At the cellular level, cardiac muscle cells respond to an increase in ventricular volume to the point of overload by: Select all that apply. a) Elongating the cardiac muscle cells b) Symmetrically widening and lengthening the hypertrophy c) Decreasing the ventricular wall thickness d) Replicating the myofibrils e) Thickening of the individual myocytes

• Elongating the cardiac muscle cells • Decreasing the ventricular wall thickness At the cellular level, cardiac muscle cells respond to stimuli from stress placed on the ventricular wall by pressure and volume overload by initiating several different processes that lead to hypertrophy. With ventricular volume overload, the increase in wall stress leads to replication of myofibrils in series, elongation of the cardiac muscle cells, and eccentric hypertrophy. Eccentric hypertrophy leads to a decrease in ventricular wall thickness or thinning of the wall with an increase in diastolic volume and wall tension. Production of a symmetric hypertrophy occurs with a proportionate increase in muscle length and width, as occurs in athletes; concentric hypertrophy with an increase in wall thickness, as occurs in hypertension; and eccentric hypertrophy with a disproportionate increase in muscle length, as occurs in dilated cardiomyopathy. When the primary stimulus for hypertrophy is pressure overload, the increase in wall stress leads to parallel replication of myofibrils, thickening of the individual myocytes, and concentric hypertrophy. Concentric hypertrophy may preserve systolic function for a time, but eventually the work performed by the ventricle exceeds the vascular reserve, predisposing to ischemia.

The nurse will monitor which of the following respiratory manifestations of heart failure? Select all that apply. a) Chronic dry cough b) Orthopnea c) Exertional dyspnea d) Cheyne-Stokes respiration e) Hyperventilation

• Exertional dyspnea • Orthopnea • Cheyne-Stokes respiration • Chronic dry cough Explanation: Exertional dyspnea occurs with increased physical activity. Orthopnea is shortness of breath when lying down, as fluid from the lower body is redistributed to the pulmonary circulation. Cheyne-Stokes breathing is an increase in respiratory depth and rate followed by a decrease and apnea. Congestion of the bronchial mucosa due to poor circulation causes chronic cough. Hyperventilation (which differs from Cheyne-Stokes) is not characteristic of heart failure.

The diagnosis is left-sided heart failure. The nurse knows that the most common causes of left-sided failure include which of the following? Select all that apply. a) Hypertension b) Acute myocardial infarction c) Tricuspid valve dysfunction d) Impaired renal blood flow e) Chronic pulmonary disease

• Hypertension • Acute myocardial infarction The most common causes of left-sided failure are acute myocardial infarction and hypertension. Chronic pulmonary disease and tricuspid valve regurgitation can cause right-sided failure. Impaired renal blood flow can be a consequence rather than a cause of heart failure.

Which of the following statements regarding heart failure are true? Select all that apply a) In compensated heart failure, cardiac output is normal. b) Myocardial infarction is a frequent cause of right-sided failure. c) In uncompensated left heart failure, there is pulmonary congestion and edema. d) Pulmonary hypertension is a frequent cause of left-sided failure. e) In uncompensated right heart failure, there is peripheral venous congestion and edema.

• In uncompensated left heart failure, there is pulmonary congestion and edema. • In compensated heart failure, cardiac output is normal. • In uncompensated right heart failure, there is peripheral venous congestion and edema. In compensated failure, many mechanisms are activated to support normal cardiac output. In uncompensated right failure, blood backs up in the systemic circulation and causes peripheral congestion and edema. In left-sided failure, blood backs up in the pulmonary circulation and causes pulmonary edema. Myocardial infarction is a frequent cause of left failure. Pulmonary hypertension causes right failure.

In heart failure patients, the nurse knows that many compensatory mechanisms attempt to support cardiac output. Included among these mechanisms are which of the following? Select all that apply. a) Decreased endothelin release b) Decreased sodium and water retention c) Activitation of the renin angiotensin system (RAAS) d) Vasoconstriction e) Increased heart rate

• Increased heart rate • Vasoconstriction • Activitation of the renin angiotensin system (RAAS) In heart failure, tachycardia and vasoconstriction are reflex responses to decreased cardiac output and decreased tissue perfusion. Decreased renal perfusion activates the RAAS, which yields the vasoconstrictor angiotensin II, and aldosterone which increases sodium and water retention. There are increased levels of endothelin, which causes release of aldosterone and catecholamines with resultant retention of sodium and water and vasoconstriction.

A client has arrived in the emergency department in cardiogenic shock. Which of the following assessment findings confirm this diagnosis? Select all that apply. a) Diminished breath sounds in the bases, bilaterally b) Bright red color noted in the nail beds and lips c) Less than 5 mL dark, concentrated urine in the past hour d) Difficult to arouse with changes in level of consciousness e) BP reading of 80/65

• Less than 5 mL dark, concentrated urine in the past hour • BP reading of 80/65 • Difficult to arouse with changes in level of consciousness The signs and symptoms of cardiogenic shock are consistent with those of end-stage heart failure. The lips, nail beds, and skin may become cyanotic because of stagnation of blood flow. Mean arterial and systolic blood pressures decrease due to poor stroke volume, and there is a narrow pulse pressure because of arterial vasoconstriction. Urine output decreases because of lower renal perfusion pressures and the increased release of aldosterone. Neurologic changes, such as alterations in cognition or consciousness, may occur because of low cardiac output and poor cerebral perfusion. (less)

A patient diagnosed with diastolic heart failure asks the nurse to explain why this has developed. The nurse knows that which of the following are often associated with diastolic failure? Select all that apply. a) Valvular stenosis b) Myocardial hypertrophy c) Volume overload d) Ischemic heart disease e) Constrictive pericarditis

• Myocardial hypertrophy • Ischemic heart disease • Constrictive pericarditis The conditions that cause diastolic failure are those that impede expansion of the ventricles (e.g., pericarditis), those that increase wall thickness and reduce chamber size (e.g., myocardial hypertrophy), and those that delay diastolic relaxation (e.g., ischemic heart disease). Volume overload and valvular stenosis are related to systolic failure.

The nurse knows that factors that affect stroke volume include which of the following? Select all that apply a) Myocardial contractility b) Heart rate c) Preload d) Ventricular automaticity e) Afterload

• Preload • Afterload • Myocardial contractility Stroke volume (the amount of blood ejected with each ventricular contraction) is determined by preload (volume of blood in the left ventricle just before systole), afterload (peripheral vascular resistance) and the force of myocardial contraction. Heart rate will affect cardiac output. Ventricular automaticity (ability of ventricular cells to spontaneously depolarize) does not affect stroke volume but can affect heart rate if the sinoatrial node loses its ability to control the rate of ventricular contraction.

The diagnosis is hypovolemic shock. The nurse knows that causes of hypovolemic shock include which of the following? Select all that apply. a) Severe dehydration b) Fifteen percent blood volume loss c) Myocardial infarction d) Excessive vasoconstriction e) Severe burns

• Severe burns • Fifteen percent blood volume loss • Severe dehydration Hypovolemic shock is characterized by diminished blood volume with inadeaquate filling of the vascular compartment. Causes include extensive whole blood loss, severe burns with extensive loss of plasma, severe dehydration, and shifting of extracellular fluid from the circulatory system to interstitial spaces. Myocardial infarction can cause cardiogenic shock. Excessive vasoconstriction can be a compensatory mechanism in hypovolemic shock