ch 25 complications of heart disease
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? "I sleep on three pillows each night." "My feet are bigger than normal." "My pants don't fit around my waist." "I don't have the same appetite I used to."
"I sleep on three pillows each night." Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.
s/s of acute pulmonary edema
-SOB & Dyspnea -Cyanosis -Pink frothy sputum -Pale -Diaphoresis -Restlessness -Anxiety -Feeling f suffocating -Dyspnea when lying flat, -Awake at night breathless
B-type natriuretic peptide (BNP)
A neurohormone secreted by the heart in response to ventricular expansion.
The nurse is providing care for a client with pulmonary edema. Which assessment method should the nurse prioritize to monitor the respiratory status of this individual? Arterial blood gas (ABG) analysis Pulse oximetry Skin color assessment Lung sounds
ABGs ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy. Although a nurse can use any of the options to detect pulmonary changes, assessment of skin color and assessment of lung fields commonly are subject to interpretation by practitioners. The use of pulse oximetry is unreliable, especially in the case of severe vasoconstriction as is present in pulmonary edema.
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound? a first heart sound (S1). a third heart sound (S3). a fourth heart sound (S4). a murmur.
An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.
BNP
B-type natriuretic peptide
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? Intubation of the airway BP and pulse measurements every 15 to 30 minutes Insertion of a central venous catheter Hourly administration of a fluid bolus
BP and pulse measurements every 15 to 30 minutes Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? Observe for mist in the endotracheal tube. Listen for breath sounds over the epigastrium. Call for a chest x-ray. Attach a pulse oximeter probe and obtain values.
Call for a chest x-ray. A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.
The nurse is caring for a client in the hospital with chronic heart failure who has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, the client becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)? Class I (Mild) Class II (Mild) Class III (Moderate) Class IV (Severe)
Class III (Moderate)
The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience? Increased urine output Gradual unexplained weight gain Increased perspiration Sleeping in a chair or recliner
Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output.
A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved? Decrease in central venous pressure (CVP) Increase in CVP Decrease in blood pressure Absence of cough
Decrease in central venous pressure (CVP) A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.
A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? The pericardial space is eliminated with scar tissue and thickened pericardium. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).
A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? blood pressure of 125/80 urine output of 300 mL in eight hours atrial fibrillation rhythm heart rate of 55 beats per minute
HR <55 BPM Digoxin is a positive inotropic (beats strong) and negative chronotropic (beats slow)
The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding? The woman is demonstrating the early signs of cardiogenic shock. The woman has left-sided heart failure. The woman is also likely to experience shortness of breath. The woman may be experiencing an exacerbation of right-sided HF.
JVD- this is characteristic of right-sided HF
A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with a health care provider's order that will relieve anxiety and slow respiratory rate? Furosemide Nitroglycerin Dopamine Morphine sulfate
Morphine sulfate Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Furosemide is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety.
Heart Failure Class I
No limitations of physical activity
The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide? BNP of 100 Sodium level of 135 Hemoglobin of 12 Potassium level of 3.1
Potassium level of 3.1 Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely.
A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) Jugular vein distention Dyspnea Cough Ascites Pulmonary crackles
Pulmonary crackles Dyspnea Cough
Heart Sounds S1 S2 S3 S4
S1 - Produced by closure of the mitral valve S2 - Produced by closure of the aortic valve S3 - Occurs after the mitral valve opens; rapid ventricular filling S4 - Occurs during atrial contraction
Heart Failure Class II
Slight limitations of activity; no S&S at rest; dyspnea with moderate activity
A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?
The BNP level is a key diagnostic indicator of HF; high levels are a sign of high cardiac filling pressure and can aid in both the diagnosis and management of HF (Institute for Clinical Systems Improvement [ICSI], 2011).
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? The development of chronic obstructive pulmonary disease (COPD) The development of left-sided heart failure The development of right-sided heart failure The development of cor pulmonale
The development of left-sided heart failure
orthopnea
difficulty breathing when lying down
Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Echocardiogram Serum electrolytes Blood urea nitrogen (BUN)
echo An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.
Heart Failure Class IV
inability to carry on any physical activity without discomfort Symptoms of cardiac insufficiency at rest
Heart Failure Class III
marked limitations of activity; no S&S at rest; dyspnea with mild activity
paroxysmal nocturnal dyspnea
sudden awakening from sleeping with shortness of breath
how many tablets of nitroglycerin can you dispense?
up to 3, then the provider needs to be notified if it is not effective
S/S of cardiogenic shock
↑ HR, ↑ RR, ↓ BP, ↓ urinary output, restless, diaphoretic, cool/clammy skin change in mental status
