Ch. 27: Drugs for Heart Failure
The nurse is reviewing a patient's serum digoxin level. At which level should the nurse expect to hold this medication and notify the healthcare provider? 2.0 ng/mL 1.4 ng/mL 1.0 ng/mL 1.7 ng/mL
2.0 ng/mL Explain: The nurse should check for serum digoxin levels prior to administration and hold the drug if the level is greater than 1.80 ng/mL. The patient should be tested often during therapy to reduce the possibility of adverse effects and toxicity. All other ranges are considered at therapeutic levels. Digoxin overdose: Can be fatal. Treated with IV digoxin immune Fab (Digibind), which consists of digoxin-specific antibodies that prevent the drug from reaching the tissue.
When caring for a patient with heart failure, the nurse notices peripheral edema and alerts the healthcare provider. Which medication should the nurse expect to be prescribed? Vasodilator Diuretic Digoxin Angiotensin-converting enzyme (ACE) inhibitor
Diuretic Explain: Diuretics are prescribed in cases where fluid retention is evident, such as peripheral edema. ACE inhibitors work to increase cardiac output by lowering blood pressure and decreasing blood volume. Vasodilators are important medications in more severe cases of heart failure, as they work to reduce preload and afterload. Digoxin is a medication used to strengthen the heart muscle so it is able to carry the workload.
The nurse is observing a patient with heart failure. Which process acts as a compensatory mechanism to maintain cardiac output for this patient? Increased afterload Increased blood pressure Increased peripheral resistance Increased preload
Increased preload Explain: Compensatory mechanisms act to maintain cardiac output when patients with heart failure begin to experience diminished cardiac capacity. An increase in preload, and contractility, will help to increase the cardiac output. An increase in peripheral resistance increases afterload, which contributes to heart failure. Increased blood pressure, hypertension, is a contributing factor to heart failure and not a trigger for compensation of cardiac output.
The nurse instructs a patient receiving medications for heart failure (HF) on actions to take at home. Which change in daily weight should the nurse instruct the patient to report to the healthcare provider? Weight loss of more than 5 kg within a 1-week period An increase in weight of more than 2 kg within a 12-hour period Any weight gain noticed within a 24-hour period Weight loss or gain of more than 1 kg in a 24-hour period
Weight loss or gain of more than 1 kg in a 24-hour period Explain: Patients should be instructed to weigh themselves daily and document results, preferably at the same time each day. A weight loss or gain of more than 1 kg in a 24-hour period should be reported to the healthcare provider. Patients should not wait until they have gained more than 1 kg to report or until they have lost 5 kg, as this could result in adverse effects. It is not necessary to report any weight gain within a 24-hour period, as there will be some minimal fluctuations in weight throughout the day. Patients with heart failure should continuously be monitored for worsening of conditions and assessed for the following signs: Increasing dyspnea or postural nocturnal dyspnea Rales or crackles in lungs Frothy pink-tinged sputum. If the nurse recognizes these symptoms, the healthcare provider should be contacted immediately. Positive inotropic drugs, such as digoxin or phosphodiesterase inhibitors, may need to be prescribed.
The nurse reviews lifestyle changes that would be helpful for a patient with heart failure (HF). Which patient statement indicates to the nurse that teaching was effective? "I can't have salt anymore, I can't eat steak, and I need to work with a personal trainer to exercise more." "I can still eat a normal diet, just without salt, and I need to stop drinking and start exercising more." "I have to give up all the good things in life and eat a bland diet with no alcohol." "I will work with a nutritionist on lowering my fat intake and my alcohol intake, and I will begin to walk each day."
"I will work with a nutritionist on lowering my fat intake and my alcohol intake, and I will begin to walk each day." Explain: The patient should be instructed to adopt a healthy lifestyle of low-fat food choices, increased exercise, decreased alcohol consumption, and smoking cessation. The other responses indicate that teaching was not effective.
A patient is prescribed a medication that suppresses the sinoatrial (SA) node and changes electrical conductivity in the atrioventricular (AV) node to slow the heart rate. For which medication should the nurse prepare teaching? Digoxin Phosphodiesterase inhibitor Vasodilator Angiotensin-converting enzyme (ACE) inhibitor
Digoxin Explain: Digoxin has the ability to suppress the SA node and slow electrical conduction through the AV node, resulting in a decrease in the heart rate. Vasodilators relax blood vessels, reducing blood pressure. Phosphodiesterase inhibitors block the enzyme phosphodiesterase, allowing for an increase in calcium available for myocardial contraction. ACE inhibitors work to reduce peripheral edema and pulmonary congestion. Additional information about digoxin is as follows: The primary benefit is a positive inotropic action, which is increasing the strength of myocardial contraction. Myocardial contractility increases, allowing an increase in cardiac output, which alleviates symptoms of HF. The higher cardiac output increases urine production, which in turn reduces blood volume, which relieves distressing symptoms of pulmonary congestion and peripheral edema.
The nurse is preparing a teaching tool identifying medications commonly prescribed to treat heart failure (HF). Which statement should the nurse use to explain the mechanism of action of a cardiac glycoside? Increases strength of myocardial contraction, which increases cardiac output. Produces higher cardiac output, allowing the urinary system to release excessive fluid from pulmonary congestion. Increases calcium availability for myocardial contractility by blocking enzymes. Dilates blood vessels, reducing blood pressure and allowing for decreased cardiac workload.
Increases strength of myocardial contraction, which increases cardiac output. Explain: A cardiac glycoside acts in an inotropic manner, which strengthens the myocardium to strengthen contractions and increase cardiac output. This alleviates symptoms of HF and also improves exercise tolerance. Phosphodiesterase inhibitors block enzymes to increase the availability of calcium for contractility. Vasodilators dilate blood vessels to lower blood pressure. Diuretics reduce fluid retention as seen with peripheral edema and pulmonary congestion. Digoxin must be gradually increased until tissues become saturated with the medication, diminishing the symptoms of HF. This graduation is referred to as digitalization and is the safest way to introduce and administer digoxin to patients and prevent adverse effects and toxicity.
For which common side effect should the nurse monitor a patient who is prescribed an angiotensin-converting enzyme (ACE) inhibitor? Orthostatic hypotension Tachycardia Dysrhythmia Electrolyte imbalance
Orthostatic hypotension Explain: Orthostatic hypotension is often experienced with this medication. The two primary actions of an ACE inhibitor include lowering peripheral resistance (lowers the blood pressure) and inhibiting aldosterone secretion (reduces blood volume). Tachycardia and dysrhythmia are not signs or adverse reactions to taking ACE inhibitors but may be experienced in medications that alter potassium levels. Electrolyte imbalance is typically seen when taking diuretics but is not associated with an ACE inhibitor. Administration considerations for ACE inhibitors: Assess blood pressure prior to administration. Older adults, especially those with chronic kidney disease, should receive lower doses. Monitor blood pressure during administration. Monitor ECG during administation. Safety and efficacy established in children age 6 and over. Discontinue use as soon as pregnancy is suspected.
A patient asks why a thiazide diuretic has been prescribed. Which information should the nurse include when responding to this patient? Is more effective than a loop diuretic Used when there is evidence of fluid retention Prescribed when blood pressure reaches hypertensive levels Prescribed primarily for severe heart failure
Used when there is evidence of fluid retention Explain: Diuretics, including thiazides and loop diuretics, are prescribed when patients have volume overload, edema, and/or pulmonary congestion. Diuretics are effective at increasing urine flow and reducing symptoms of fluid overload. While diuretics are often used to reduce blood pressure, they are used in conjunction with other medications as a method to reduce cardiac workload and improve output, not just to reduce blood pressure. Thiazides are less effective than loop diuretics and are generally used for patients with mild to moderate heart failure.
A patient is receiving milrinone (Primacor), a phosphodiesterase inhibitor, for advanced heart failure (HF). For which adverse effect should the nurse monitor this patient? Pulmonary congestion Ventricular dysrhythmia Hypertension Atrial fibrillation
Ventricular dysrhythmia Explain: Ventricular dysrhythmia is the most serious adverse effect of milrinone, as the mechanism of this medication is to create greater contractility and cardiac output, which puts a strain on the ventricles. Hypotension, not hypertension, is also an adverse effect of milrinone. Atrial fibrillation and pulmonary congestion are not adverse effects of milrinone. Precautions when administering milrinone are as follows: Use with caution in patients with pre-existing dysrhythmias. Correct hypokalemia prior to starting the infusion. Cautious use with digoxin, dobutamine, and other inotropic medications, because their positive inotropic effects on the heart may be additive.Interacts with disopyramide, causing excessive hypotension.
The nurse is describing cardiac remodeling to a colleague. Which statement by the nurse is accurate? "Cardiac muscle fibers relax to allow chambers to fill." "Heart cells continually die due to heavy workload, and fibrotic tissue fills the spaces between them." "Changes in the size, shape, and structure of the heart cells occur as a compensatory mechanism to improve stroke volume." "Contractility of the heart muscle decreases to diminish the workload on the heart."
"Changes in the size, shape, and structure of the heart cells occur as a compensatory mechanism to improve stroke volume." Explain: Cardiac remodeling refers to the changes in size, shape, and structure of the myocardium cells (myocytes) in response to the thickening ventricular walls during heart failure. This remodeling serves to efficiently maintain stroke volume and cardiac output. Cardiac remodeling is limited, and therefore myocytes continually die, and space is filled with fibrous material. Contractility increases, not decreases, with cardiac remodeling. Cardiac muscle fibers are stretched, not relaxed, in cardiac remodeling. Cardiac remodeling occurs when the wall of the left ventricle thickens and enlarges as it tries to compensate for the heavy workload of cardiac output. Myocytes (cells in the myocardium) change to accommodate the extra workload so the heart can better maintain stroke volume and cardiac output.
The nurse is teaching a patient with heart failure about the importance of maintaining a properly functioning heart. Which statement regarding decompensation should the nurse include in the teaching? "It is important to follow the recommended sodium and water restrictions so symptoms don't worsen." "Ischemia is common in patients with heart failure, so it is important to start exercising in moderation." "Eating a balanced diet and drinking plenty of fluids is important to maintain your health so symptoms don't reappear." "Renal failure could occur in patients with heart failure when medications are not taken according to the recommended dose."
"It is important to follow the recommended sodium and water restrictions so symptoms don't worsen." Explain: The most common reason for decompensation in heart failure (HF) is nonadherence to sodium and water restrictions. Ischemia and other cardiac dysfunctions can precipitate HF if adherence to interventions is not followed, but this is not the direct result. Renal failure is not a direct and immediate result of not adhering to recommendations. A balanced diet is important, but adhering to recommended restrictions is crucial to prevent decompensation. Lifestyle changes should include: Low-fat and low-sodium food choices. Increased exercise. Decreased alcohol consumption.
Which statement should the nurse use to describe heart failure to a patient? "The heart is unable to pump enough blood to keep up with the metabolic demands of the body." "Heart muscle cells continually die due to work overload, and fibrous tissue fills the empty spaces." "The left side of the heart is forced to work harder to keep up with blood volume due to hardening of the right side of the heart." "Fluid has accumulated in the lower chambers of the heart, causing it to be unable to fully contract."
"The heart is unable to pump enough blood to keep up with the metabolic demands of the body." Explain: Heart failure is the inability of the heart to keep up with the demands of the blood needed to maintain metabolic needs of the body, either by inability to receive or eject blood. Fluid accumulation in the chambers results in congestive heart failure when the left side is affected. And while left-sided failure is attributed to congestive heart failure, often the right side can be affected as well. However, left-sided and right-sided failure are only specific types of heart failure. Myocytes continually die in ventricular hypertrophy, which is not a full description of heart failure. Weakening of the cardiac muscle is a natural consequence of aging, but some conditions can accelerate or even cause heart failure. Such disorders include: Coronary artery disease (CAD) Mitral stenosis Myocardial infarction (MI) Chronic hypertension (HTN) Diabetes mellitus Dislipidemia Thyroid disorders.
For which clinical manifestation should the nurse assess in a patient with left heart failure? Peripheral edema and organ engorgement Accumulation of fluid in the lungs Fluid depletion and low blood pressure Diminished contractibility and cardiac output
Accumulation of fluid in the lungs Explain: Patients experiencing left heart failure, sometimes referred to as congestive heart failure, will present with an accumulation of fluid causing congestion in the pulmonary capillary beds, resulting in higher than normal pressure in the ventricles. Peripheral edema and organ engorgement, especially in the liver, are signs of right heart failure. Diminished contractibility and cardiac output are signs of ventricular hypertrophy. Fluid depletion and low blood pressure are not pathophysiologic results of left-sided heart failure. Although left heart failure is more common, the right side of the heart can also weaken. This can happen simultaneously with the left side or independently.
The nurse teaches a patient prescribed digoxin how to measure the peripheral pulse. Which heart rate range should indicate to the nurse that the patient understands when to take the medication? 60 to 100 beats/min 55 to 95 beats/min 70 to 110 beat/min 50 to 80 beats/min
60 to 100 beats/min Explain: Patients should be instructed to take a dose of digoxin when the pulse is between 60 and 100 beats/min and to withhold a dose when it falls below 60 or rises above 100. Less than 50 and greater than 80 is too low of a range. Less than 70 and greater than 90 has too narrow a range, and patients could stop taking medication when it is still needed and safe. Less than 55 is too low and greater than 110 is too high, and adverse effects could occur. To minimize adverse effects of medications used to treat heart failure (HF): Patients and the caregivers should be instructed on how to find a peripheral pulse that can easily be monitored and count for one full minute before taking the medication. Results should be recorded and brought to each visit with the healthcare provider. Patients should notify the healthcare provider if the pulse falls below 60 beats/min or rises above 100 beats/min. Frequent serum digoxin levels should be obtained and the dose adjusted as needed.
The nurse is caring for a patient with heart failure. The nurse should expect which immediate homeostatic response to diminished cardiac output causing an increase in the patient's heart rate? Retention of sodium and water Activation of the sympathetic nervous system (SNS) Cardiac remodeling Activation of renin-angiotensin-aldosterone system (RAAS)
Activation of the sympathetic nervous system (SNS) Explain: The homeostatic response to diminished cardiac output comes from the activation of the sympathetic nervous system (SNS), which triggers an increased heart rate to compensate for low cardiac output. Retention of sodium and water occurs from activation of the RAAS. Activation of the RAAS is a response of diminished renal flow and is not as quick as the SNS. Cardiac remodeling is seen particularly in left-sided ventricular hypertrophy and occurs over time. Two processes occur in response to decreased cardiac output as a result of heart failure: Increased sympathetic response causes an increase in heart rate and force of contraction leading to increased cardiac workload. It also causes vasoconstriction which leads to increased blood pressure and increased cardiac workload. Diminished renal blood flow triggers activation of the RAAS causing retention of water and sodium leading to increased plasma volume. As a result, pulmonary and peripheral edema occur.
The nurse is caring for a patient with chronic heart failure (HF). Which drug most commonly prescribed and preferred for chronic heart failure should the nurse expect for this patient? Beta blocker Anticoagulant Angiotensin receptor blocker (ARB) Angiotensin-converting enzyme (ACE) inhibitor
Angiotensin-converting enzyme (ACE) inhibitor Explain: ACE inhibitors have become the first-line medication for the treatment of chronic HF. All patients with HF and at risk for HF should be prescribed an ACE inhibitor. Beta blockers are not preferred as the first-line due to the difficulty in patient adherence. The use of ARBs is typically reserved for those patients who are unable to tolerate the adverse effects of ACE inhibitors. Anticoagulant therapy is implemented when there is evidence of thrombosis or another embolic event. The two primary actions of ACE inhibitors are: Lower peripheral resistance through the inhibition of angiotensin II formation. Reduced blood volume through inhibition of aldosterone secretion. Arterial blood pressure reduction is the result, which in turn diminishes afterload and increases cardiac output. ACE inhibitors dilate veins, which reduces pulmonary congestion and peripheral edema. The combination of reductions in preload, afterload, and blood volume from this treatment decreases the workload of the heart substantially and allows it to work more efficiently.
Testing has shown that a patient with heart failure has an increased preload. The nurse should recognize that which physiological adaptation has occurred? Increased afterload Hypertension Decreased contractility Compensatory mechanism
Compensatory mechanism Explain: The degree to which the myocardial fibers are stretched just prior to contraction is called preload. An increase in preload will cause an increase in cardiac output. This, as well as increase in the contractility of the heart muscle, will act as a compensatory mechanism for heart failure. Increased afterload is caused by increased peripheral resistance due to increased blood pressure (hypertenson). These are not compensatory mechanisms.
An older patient receiving digoxin is lethargic, has a pulse rate of 54 beats/min, and experiences nausea and vomiting. Which action should the nurse take first? Contact the healthcare provider Repeat vital sign measurement Administer a prescribed antacid Raise the head of the bed
Contact the healthcare provider Explain: The patient is demonstrating signs of digoxin toxicity that should be reported immediately to the healthcare provider. Vital signs can be measured at any time. An antacid will not counteract the effects of digoxin toxicity. Raising the head of the bed will not counteract the effects of digoxin toxicity. Digoxin should be administered with caution to older adults because these patients experience a higher incidence of adverse effects.
The nurse plans to monitor vital signs, electrolytes, renal function, and drug levels for a patient with heart failure. Which medication should the nurse expect to provide to this patient? Nonsteroidal anti-inflammatory drug (NSAID) Diuretic Nitroglycerin Anticoagulant
Diuretic Explain: Vital signs, electrolytes (especially potassium), renal function, and drug levels are all important when a patient is taking a diuretic. This monitoring would not be appropriate for nitroglycerin, NSAIDs, or anticoagulants. Additional teaching for a patient taking a diuretic includes: Monitoring for hypotension Measuring daily weight Assessing for hearing changes (ototoxicity) Monitoring for signs of dehydration Encouraging lifestyle changes.
A patient has a health problem in which the heart cannot pump enough blood to keep up with the demands needed in the body. Which general cardiovascular disorder should the nurse suspect this patient is experiencing? Ventricular hypertrophy Cardiac remodeling Congestive heart failure Heart failure
Heart failure Explain: Heart failure is a general term describing the cardiovascular disorder where the heart has an inability to pump enough blood volume through the body to keep up with the metabolic demands. Ventricular hypertrophy is manifested by enlargement of the myocardium. Congestive heart failure is a form of HF that typically affects the left side of the heart and is due to access fluid in the pulmonary capillary beds. Cardiac remodeling is a process which occurs over time in heart failure where myocardial cells (myocytes) change in size, shape, and structure. Weakening of the cardiac muscle is a natural consequence of aging, but some conditions can accelerate or even cause heart failure. Such disorders include: Coronary artery disease (CAD) Mitral stenosis Myocardial infarction (MI) Chronic hypertension (HTN) Diabetes mellitus Dislipidemia Thyroid disorders.
The nurse instructs a patient and spouse on measuring the peripheral pulse. For which pulse range should the nurse instruct to withhold taking a dose of digoxin? Less than 55 and greater than 110 beats/min Less than 70 and greater than 90 beats/min Less than 60 and greater than 100 beats/min Less than 50 and greater than 80 beats/min
Less than 60 and greater than 100 beats/min Explain: Patients should be instructed to take a dose of digoxin when the pulse is between 60 and 100 beats/min and to withhold a dose when it falls below 60 or rises above 100. The margin of a therapeutic dose and toxic dose of digoxin is narrow. Less than 50 and greater than 80 is too low of a range. Less than 70 and greater than 90 has too narrow a range, and patients could stop taking medication when it is still needed and safe. Less than 55 is too low and greater than 110 is too high, and adverse effects could occur. To minimize adverse effects of medications used to treat heart failure (HF): Patients and the caregivers should be instructed on how to find a peripheral pulse that can easily be monitored and count for one full minute before taking the medication. Results should be recorded and brought to each visit with the healthcare provider. Patients should notify the healthcare provider if the pulse falls below 60 beats/min or rises above 100 beats/min. Frequent serum digoxin levels should be obtained and the dose adjusted as needed.
Through which route should the nurse expect to administer milrinone, a phosphodiesterase inhibitor? Intramuscular Intravenous Subcutaneous Oral
Intravenous Explain: Milrinone is only given intravenously, with an onset of 2 to 10 minutes and peak effect at 10 minutes. This medication is not available in oral, intramuscular, or subcutaneous administration routes. The pharmacokinetics of milrinone are: Ventricular dysrhythmia (occurs in 1 of every 10 patients) Hypotension Headache Nausea Vomiting
The nurse continuously monitors the cardiac rhythm of a patient receiving milrinone, a phosphodiesterase inhibitor. Which additional intervention should the nurse implement to assess for adverse effects of this medication? Monitor vital signs, counting apical pulse for one full minute Monitor for nausea, vomiting, and anorexia Measure weight weekly Teach lifestyle changes
Monitor vital signs, counting apical pulse for one full minute Explain: One important nursing intervention is monitoring vital signs, as bradycardia and hypotension can be adverse effects of milrinone. Weight should be measured daily. While educating a patient on lifestyle changes is important, this is not a nursing intervention to assess for adverse effects. Nausea and vomiting are not adverse effects of this medication. All patients receiving pharmacotherapy for heart failure should be assessed for adverse effects such as: Hypotension Fatigue Dizziness Drowsiness Bradycardia Nausea, vomiting, anorexia Visual changes (e.g., halos around lights, yellow or yellowish-green tint to colors). The following adverse effects should be reported to the healthcare provider immediately: Pulse rate below 60 or above 100 beats/min Palpitations Significant dizziness or syncope Dyspnea Persistent anorexia or vomiting Vision changes.
A patient with pulmonary congestion is prescribed a diuretic. Which intervention should the nurse include in this patient's plan of care? Monitor for chronic anorexia with nausea and vomiting and decreased renal output Monitor and document intake and output (I&O) every 4 hours Institute fluid restrictions while monitoring weight and intake and output (I&O) Monitor vital signs, electrolytes, renal function, and drug levels
Monitor vital signs, electrolytes, renal function, and drug levels Explain: Vital signs, electrolytes (especially potassium), renal function, and drug levels are all important when a patient begins taking diuretics, as the dosing must be increased as tolerated to reach optimal effects. While monitoring I&O is important in diuretic treatment, additional monitoring should occur. Anorexia with nausea and vomiting may be seen in some patients who cannot tolerate the medications; however, this is not the primary intervention. Restricting all fluids in a patient receiving a diuretic is not recommended. Additional teaching for a patient taking a diuretic includes: Monitoring for hypotension Measuring daily weight Assessing for hearing changes (ototoxicity) Monitoring for signs of dehydration Encouraging lifestyle changes.
A patient is prescribed a test to assess for substances that are secreted in response to increased pressure in the heart. Which substance should the nurse explain is being tested? Natriuretic peptides Angiotensin II Electrolytes Increased plasma volume
Natriuretic peptides Explain: When heart failure occurs, the ventricles begin to secrete B-type natriuretic peptide (BNP) in response to increased stretch on the ventricular walls. Electrolytes are not secreted in response to changes in heart pressure. Angiotensin II acts as a compensatory mechanism with aldosterone, but it can contribute to ventricular hypertrophy. Increased plasma volume is the result of the activation of the renin-angiotensin-aldosterone system (RAAS) in response to decreased cardiac output and a work overload of the SNS.
For which common side effect should the nurse monitor a patient who is prescribed an angiotensin-converting enzyme (ACE) inhibitor? Orthostatic hypotension Electrolyte imbalance Dysrhythmia Tachycardia
Orthostatic hypotension Explain: Orthostatic hypotension is often experienced with this medication. The two primary actions of an ACE inhibitor include lowering peripheral resistance (lowers the blood pressure) and inhibiting aldosterone secretion (reduces blood volume). Tachycardia and dysrhythmia are not signs or adverse reactions to taking ACE inhibitors but may be experienced in medications that alter potassium levels. Electrolyte imbalance is typically seen when taking diuretics but is not associated with an ACE inhibitor. Administration considerations for ACE inhibitors: Assess blood pressure prior to administration. Older adults, especially those with chronic kidney disease, should receive lower doses. Monitor blood pressure during administration. Monitor ECG during administation. Safety and efficacy established in children age 6 and over. Discontinue use as soon as pregnancy is suspected.
The nurse notes that a patient is prescribed a beta-adrenergic antagonist. Which information should the nurse include when discussing this new medication with the patient? Blocks norepinephrine to limit the autonomic nervous system Reduces cardiac workload by strengthening myocardial muscles Dilates vessels to allow for increased cardiac output, thus decreasing workload Slows heart rate and reduces blood pressure, decreasing the cardiac workload
Slows heart rate and reduces blood pressure, decreasing the cardiac workload Explain: Beta-adrenergic antagonists block the cardiac actions of the sympathetic nervous system (SNS), slowing the heart rate and reducing blood pressure, which ultimately decreases the workload of the heart. Beta-adrenergic antagonists do block norepinephrine in the sympathetic, not the autonomic, nervous system. Digoxin is a medication that would be prescribed to strengthen the myocardium, and vasodilators are used to dilate vessels for increased cardiac output. Dosing of beta-adrenergic antagonists is very specific, starting with an initial dose of 1/10 to 1/20 of the target dose. Doses are then doubled every 2 to 4 weeks until the target dose is reached. If not administered in this manner, or if administered too quickly, it can result in worsening of HF. When treating HF, beta blockers are almost always combined with other HF drugs.
The nurse is administering an angiotensin-converting enzyme (ACE) inhibitor drug to a patient. For which concern should the nurse realize this medication is being prescribed? Risk of heart failure Risk of peripheral edema Risk of pulmonary congestion Risk of hypotension
Risk of heart failure Explain: ACE inhibitors have become the the first-line mediation for patients with heart failure or at risk for heart failure. While ACE inhibitors do reduce pulmonary congestion, hypertension, or peripheral edema, they are not prescribed to reduce the risk of these conditions. The two primary actions of ACE inhibitors are: Lower peripheral resistance through the inhibition of angiotensin II formation. Reduced blood volume through inhibition of aldosterone secretion. Arterial blood pressure reduction is the result, which in turn diminishes afterload and increases cardiac output. ACE inhibitors dilate veins, which reduces pulmonary congestion and peripheral edema. The combination of reductions in preload, afterload, and blood volume from this treatment decreases the workload of the heart substantially and allows it to work more efficiently.
A patient is prescribed a phosphodiesterase inhibitor to be administered immediately. For which reason should the nurse realize this medication is prescribed? Pulmonary congestion has been discovered along with peripheral edema. Renal function has halted and peripheral edema has begun to infiltrate into the upper extremities. The patient is experiencing decompensated heart failure and is approaching organ failure. The patient has developed a sudden rise in blood pressure with tachycardia.
The patient is experiencing decompensated heart failure and is approaching organ failure. Explain: Phosphodiesterase inhibitors are used in emergency situations for short-term periods and are used for a patient with decompensated HF approaching organ failure. While pulmonary congestion and peripheral edema, as well as a sudden rise in blood pressure, are signs of HF, these symptoms do not indicate an emergency situation requiring phosphodiesterase inhibitor intervention. Renal failure resulting in peripheral edema would be treated with various medications, and not particularly phosphodiesterase inhibitors. Considerations for the administration of Milrinone (Primacor), a phosphodiesterase inhibitor: Administer IV using a microdrip and infusion pump Safety and efficacy has not been established in geriatric and pediatric patients. Monitor blood pressure during administration. Monitor ECG during administration. Pregnancy class: C. Onset: 2 to 10 minutes. Peak: 10 minutes. Duration: 3 to 5 hours.
The nurse is reviewing the cardiac rhythm of a patient receiving digoxin. The nurse should recall that which medication describes how digoxin slows the heart rate? An increase in urine production results in a reduction in blood volume, which relieves symptoms of pulmonary congestion. Calcium available for myocardial contraction is increased, relieving strain on the heart. Blood vessels relax and lower blood pressure, creating less workload on the heart. The sinoatrial (SA) node is suppressed, which slows the electrical conductivity through the atrioventricular node.
The sinoatrial (SA) node is suppressed, which slows the electrical conductivity through the atrioventricular node. Explain: Digoxin is able to suppress the SA node and slow electrical conduction through the AV node, resulting in a decrease in heart rate. This mechanism allows greater diastolic filling of the ventricles. Digoxin also has an effect on cardiac output, which increases urine production and results in a desirable reduction in blood volume, but this is not how the heart rate is slowed. Digoxin does not relax blood vessels or increase calcium. Additional information about digoxin is as follows: The primary benefit is a positive inotropic action, which is increasing the strength of myocardial contraction. Myocardial contractility increases, allowing an increase in cardiac output, which alleviates symptoms of HF. The higher cardiac output increases urine production, which in turn reduces blood volume, which relieves distressing symptoms of pulmonary congestion and peripheral edema.
A patient has been prescribed a medication that lowers blood pressure by relaxing the blood vessels. For which medication should the nurse prepare teaching? Diuretic Vasodilator Digoxin Angiotensin-converting enzyme (ACE) inhibitor
Vasodilator Explain: Vasodilators are important medications in more severe cases of heart failure, as they work to reduce preload and afterload by relaxing blood vessels to reduce blood pressure. Diuretics are prescribed to treat fluid retention. ACE inhibitors work to lower peripheral resistance and inhibit aldosterone secretion. Digoxin is prescribed to strengthen the myocardium to reduce cardiac workload. Vasodilators serve a limited role in HF, and the three most commonly prescribed ones are: Hydralazine with isosorbide dinitrate (BiDil): acts on arterioles to decrease peripheral resistance, reduce afterload, and increase cardiac output Isosorbide dinitrate (Isordil): a long-acting organic nitrate that reduces preload by directly dilating veins Nesiritide (Natrecor): causes vasodilation, which reduces preload.
A patient is receiving milrinone (Primacor), a phosphodiesterase inhibitor, for advanced heart failure (HF). For which adverse effect should the nurse monitor this patient? Atrial fibrillation Hypertension Ventricular dysrhythmia Pulmonary congestion
Ventricular dysrhythmia Explain: Ventricular dysrhythmia is the most serious adverse effect of milrinone, as the mechanism of this medication is to create greater contractility and cardiac output, which puts a strain on the ventricles. Hypotension, not hypertension, is also an adverse effect of milrinone. Atrial fibrillation and pulmonary congestion are not adverse effects of milrinone. Precautions when administering milrinone are as follows: Use with caution in patients with pre-existing dysrhythmias. Correct hypokalemia prior to starting the infusion. Cautious use with digoxin, dobutamine, and other inotropic medications, because their positive inotropic effects on the heart may be additive.Interacts with disopyramide, causing excessive hypotension.
