Hinkle Chapter 29: Management of Patients With Complications from Heart Disease
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?
"Experiences exertional dyspnea when walking 3 feet; states, I cannot catch my breath." Exertional dyspnea is the effort at breathing when active. Answer A is vague and does not give a more detailed explanation for documentation purposes. Orthopnea is the inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being awakened by breathlessness.
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
BP and pulse measurements every 15-30 minutes Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
The triage nurse in the Emergency Department (ED) is admitting a client with a history of Class III heart failure. What symptoms would the nurse expect the client to exhibit?
The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. Class III (Moderate): There is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. This makes options A, B, and D incorrect.
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 third heart sound (S3) 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.
The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?
ascites Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, ascites, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough. Mixed heart failures can have all symptoms of right and left plus cool extremities, resting tachycardia, and weight gain.
The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?
atrial fibrillation Cardiac dysrhythmias such as atrial fibrillation may either cause or result from heart failure; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.
Which is a key diagnostic indicator of heart failure?
brain natriuretic peptide (BNP) BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. BUN, creatinine, and a CBC are included in the initial workup.
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving.
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) 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 is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client?
digoxin immune FAB Digibind binds with digoxin and makes it unavailable for use. The digibind dosage is based on the digoxin level and the patient's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.
Which assessment parameter is important for the client diagnosed with congestive heart failure?
distended veins During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate, counts radial heart rate, measures BP, checks for distended neck veins, and documents any signs of peripheral edema, lethargy, or confusion. The nurse need not examine joints for crepitus, eyes for excess tearing, or signs of photosensitivity because these are not symptoms of congestive heart failure.
Frequently, what is the earliest symptom of left-sided heart failure?
dyspnea on exertion Dyspnea on exertion is often the earliest symptom of left-sided heart failure.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
echocardiogram 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.
A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?
echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.
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?
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).
The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure?
fatigue Fatigue is commonly the earliest symptom of chronic heart failure; it is caused by decreased cardiac output and tissue oxygenation. Pedal edema and nocturia are symptoms of heart failure, but they occur later in the course of the condition. An irregular pulse can be a complication of heart failure, but it is not necessarily an early indication of the condition.
The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure?
furosemide Loop diuretics such as furosemide, bumetanide, and torsemide are the preferred first-line diuretics because of their efficacy in patients with and without renal impairment. Spironolactone is a potassium diuretic. Mannitol is an osmotic diuretic not used for heart failure. Metolazone is a potassium diuretic not used for first treatment for heart failure. Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage.
A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload?
head of the bed elevated 45 degrees and lower arms supported by pillows Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.
A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?
heart rate 55 beats per minute Digoxin therapy slows conduction through the AV node. A heart rate of 55 is slow and the digoxin therapy may slow the heart rate further. Blood pressure of 125/80 is normal. Urine output of 300 mL is adequate, so the kidneys are functioning. Atrial fibrillation is not a parameter to hold medication.
The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?
heart transplantation Heart transplantation involves replacing a person's diseased heart with a donor heart. This is an option for advanced HF patients when all other therapies have failed. A ventricular access device, ICD, and cardiac resynchronization therapy would be tried prior to a heart transplant.
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?
increased pulmonary artery diastolic pressure Increased pulmonary artery diastolic pressure suggests left-sided heart failure. Central venous pressure increases in heart failure rather than decreases. The cardiac index decreases in heart failure. The mean pulmonary artery pressure increases in heart failure.
The pathophysiology of pericardial effusion is associated with all of the following except:
increased venous return Venous return is increased because there is an increase in the pericardial fluid, which raises the pressure within the pericardial sac and compresses the heart.
A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia?
it reduced ventricular ejection volume Reducing ventricular ejection volume because diastole, during which the ventricle fills with blood (preload), is shortened as a result of a tachydysrhythmia. Causing a loss of elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased not increased.
The nurse identifies which symptom as a characteristic of right-sided heart failure?
jugular vein distension JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.
Which is the hallmark of heart failure?
low ejection fraction (EF)
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
nausea and vomiting Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints.
A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?
orthopnea Decreased left ventricular function would be characterized by orthopnea, dyspnea, anorexia, bibasilar rales not cleared with coughing, and resting tachycardia.
Which describes difficulty breathing when a client is lying flat?
orthopnea Orthopnea occurs when the client is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.
A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?
peripheral edema Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.
The client with cardiac failure is taught to report which symptom to the physician or clinic immediately?
persistent cough Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.
The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?
potassium level 2.8 mEq/L Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.
Which is a classic sign of cardiogenic shock?
tissue hypoperfusion Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). Low blood pressure is a classic sign of cardiogenic shock. Hypoactive bowel sounds are classic signs of cardiogenic shock. Decreased urinary output is a classic sign of cardiogenic shock.
A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
vision changes Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.
A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?
30% The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure. The normal EF is 55%-65%. An EF of 5% is not life sustaining and an EF of 30% is about half the normal percentage.
A client with stage IV heart failure has a living will indicating a ventilator may not be used. The client begins experiencing severe dyspnea. What should the nurse who is caring for this client do?
administer oxygen, morphine, and a bronchodilator for client comfort. A living will is a statement of a client's wishes in the event that a life-threatening illness or injury occurs. The client's comfort should be paramount and the nurse should respect the client's wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will enable the client to breathe more easily. The nurse shouldn't arrange for intubation without the client's consent or ask family members for permission to initiate mechanical ventilation.
The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg?
administer the third sublingual nitroglycerin tablet The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.
The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?
administration of vasodilating drug (as ordered by health care provider) Preload is the amount of blood presented to the ventricles just before systole. Anything that decreases the amount of blood returning to the heart will decrease preload, such as vasodilation or blood pooling in the extremities. Anything that assists in returning blood to the heart (antiembolic stockings) or preventing blood from pooling in the extremities will increase preload.
The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause increased preload. Which response by the student indicates understanding?
application of antiembolic stockings Preload is the amount of blood presented to the ventricles just before systole. Anything that assists in returning blood to the heart (e.g., antiembolic stockings) or preventing blood from pooling in the extremities will increase preload. Anything that decreases the amount of blood returning to the heart will decrease preload, such as vasodilation or blood pooling in the extremities.
The nurse is teaching a group of clients with heart failure about how to decrease leg edema. What dietary advice will the nurse give to clients with severe heart failure?
avoid the intake of processed and commercially prepared foods Until edema resolves, a client with severe heart failure requires restriction of sodium to 500 to 1,000 mg/day. Therefore, processed and commercially prepared foods are eliminated. Vegetables with natural sodium, for example, beets, carrots, and "greens," should be avoided. Fresh, frozen, and canned fruit and fruit juices are not restricted. Increased intake of red meat should not be encouraged; it should be restricted to 6 oz per day.
A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart's conduction system.
The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?
elevate the head of the bed The nurse's priority action is to elevate the head of bed to help with breathing. The pulse oximetry reading provides more data, but is not the priority intervention. Reporting a decrease urine output is not a priority for the client. Notification of the family is not a priority to help with breathing.
The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse?
hold the medication and call the health care provider A combination of hydralazine and isosorbide dinitrate may be another alternative for patients who cannot take ACE inhibitors (ICSI, 2011). Nitrates (e.g., isosorbide dinitrate) cause venous dilation, which reduces the amount of blood return to the heart and lowers preload. Hydralazine lowers systemic vascular resistance and left ventricular afterload. If these medications lead to severe hypotension, the nurse should hold the medication and call the health care provider.
A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure?
hypertension causes the hearts chambers to enlarge and weaken Hypertension causes the heart's chambers to enlarge and weaken, making it impossible for the ventricles to eject all the blood they receive.
Which feature is the hallmark of systolic heart failure?
low ejection fraction (EF) A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.
A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
low serum potassium level Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.
A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?
mask Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen is one of the first tools used to fight pulmonary edema. A mask, rather than nasal cannula, is needed to deliver the maximum percentages of oxygen. Intubation is reserved for when respiratory failure occurs. Mechanical ventilation is applied once respiratory failure occurs.
A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus?
measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally To determine pulsus paradoxus, the nurse should measure blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Unless the client has cardiac tamponade, the two measurements are usually less than 10 points apart.
Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?
monitor blood pressure frequently Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to clients with severe HF, including those who are waiting for a heart transplant. Because the drug causes vasodilation, the client's blood pressure is monitored before administration because if the client is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and after infusions of milrinone.
A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?
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.
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?
pitting edema The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoxemia.
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform?
place the client in high fowlers position The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of
pulmonary embolism Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.
A client has been diagnosed with heart failure. What is the major nursing outcome for the client?
reduce the workload on the heart Specific objectives of medical management of heart failure include reducing the workload on the heart by reducing preload and afterload. The other choices are objectives that may be supportive of a healthy lifestyle, but are not specific to a client with heart failure.
Which is a manifestation of right-sided heart failure?
systemic venous congestion Right-sided heart failure causes systemic venous congestion and a reduction in forward flow. Left-sided heart failure causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues. Some clients with left-sided heart failure get episodes of dyspnea at night, known as paroxysmal nocturnal dyspnea.
A client has been diagnosed with congestive heart failure. This client's cardiac function has been compromised since the client suffered a myocardial infarction 3 years ago. Heart failure is classified by:
the amount of activity restriction the failure imposes Chronic heart failure is classified based on the amount of activity restriction it imposes. Although organizations that develop the classifications may have varying stages, they are all based on the level of activity restriction.
Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit?
the client is going into cardiogenic shock This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.
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 left sided heart failure When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
ventricular assisted device (VAD) A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
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?
B-type natriuretic peptide (BNP) 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).
The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity. Under what classification does the nurse understand this patient would be categorized?
II Classification II of heart failure is indicated by the patient being comfortable at rest, but experiencing fatigue, palpitation, or dyspnea during ordinary physical activity.
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?
JVD is noted 4 cm above the sternal angle JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.
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.)
Pulmonary crackles Dyspnea Cough The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
dyspnea on exertion Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?
respiratory alkalosis At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired. Respiratory acidosis and metabolic alkalosis are incorrect distractors.
The nurse recognizes which symptom as a classic sign of cardiogenic shock?
restlessness and confusion Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.
A patient has missed 2 doses of digitalis. What laboratory results would indicate to the nurse that the patient is within therapeutic range?
2.0 mg/mL For many years, digitalis was considered an essential agent for the treatment of HF, but with the advent of new medications, it is not prescribed as often. Digoxin increases the force of myocardial contraction and slows conduction through the atrioventricular node. It improves contractility, increasing left ventricular output.
A client has had an echocardiogram to measure ejection fraction. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?
55% Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.
The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP) BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.
A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply.
Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist.
The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?
Valsartan (Diovan) Valsartan (Diovan) is the only angiotensin receptor blocker listed. Digitalis/digoxin (Lanoxin) is a cardiac glycoside. Metolazone (Zaroxolyn) is a thiazide diuretic. Carvedilol (Coreg) is a beta-adrenergic blocking agent (beta-blocker).
A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The nurse knows that these are symptoms of what?
acute pulmonary edema Clients with acute pulmonary edema exhibit sudden dyspnea, wheezing, orthopnea, restlessness, cough (often productive of pink, frothy sputum), cyanosis, tachycardia, and severe apprehension. These symptoms do not indicate progressive heart failure, pulmonary hypertension, or cardiogenic shock.
A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?
an LVAD only supports a failing left ventricle A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.
A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)?
decrease in renal perfusion A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.
The diagnosis of heart failure is usually confirmed by which of the following?
echocardiogram Although the chest X-ray can indicate cardiomegaly and the ECG can indicate a left ventricular abnormality, it is the echocardiogram that is diagnostic. This test measures ejection fraction (EF) which, if greater than 40% and accompanied with signs and symptoms of heart failure, indicates diastolic dysfunction and impaired ventricular relaxation.
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?
pulmonary congestion When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.
A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?
pulmonary crackles High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
A client with a history of heart failure is returning from the operating room after inguinal hernia repair and the nurse assesses a low pulse oximetry reading. What is the most important nursing intervention?
titrate oxygen therapy The nurse needs to titrate oxygen therapy to increase the client's oxygen levels. Assessing for jugular vein distention and examining the surgical incision area will not meet the oxygen demands. Administering pain medication will not increase oxygenation levels.
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" 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.
A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?
administer epinephrine PEA can be caused by hypovolemia, hypoxia, hypothermia, hyperkalemia, massive pulmonary embolism, myocardial infarction, and medication overdose (beta blockers, calcium channel blockers). PEA is treated with epinephrine according to advanced life support protocol. Applying oxygen or analyzing an arterial blood gas will not change the client's heart rhythm. PEA is treated until there is no change in the client's rhythm after treatments.
The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?
arterial blood gases In left-sided heart failure, arterial blood gases may be obtained to assess ventilation and oxygenation.
The nurse is caring for a client in the hospital with chronic heart failure that 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, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?
class III (moderate) Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.
The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?
decrease left ventricular workload The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The therapeutic effect is decreased left ventricular workload. The IABP does not change right ventricular workload. The IABP increases perfusion to the coronary and peripheral arteries. The renal perfusion is not affected by IABP.
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?
dizziness Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.
The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart?
echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. An MRI, pulmonary arterial pressure, and nuclear angiography do not give diagnostic information about the heart's ejection fraction.
The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?
inadequate cardiac output Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.
The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?
left ventricular function The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.
The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival?
lisinopril Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as *lisinopril, beta-blockers, and diuretics such as bumetanide*. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.
A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?
myocardial ischemia Myocardial dysfunction and HF can be caused by a number of conditions, including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of clients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, myocardial cell death, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left-sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?
weight Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.
