AG1: Heart Failure

Compensatory mechanisms of the body in response to low cardiac output:

-RAAS system activates and causes vasoconstriction and sodium/ water retention -SNS activates to increase HR and vasoconstrict -Myocardial hypertrophy (cardiac remodeling)

Integumentary and Neurovascular assessment for HF:

-Skin color, temperature, peripheral pulses, and capillary refill time -Pale or cyanotic color, cool extremities, weak peripheral pulses, and sluggish refill time result from inadequate cardiac output. -Cap Refill >4-5 seconds—late sign in disease process

____________ and _____________ may be present when fluid accumulates in the lungs because of left-sided HF.

-Tachypnea -decreased oxygen saturation

Systolic heart failure

-heart can't contract and eject -increased preload with decreased contractility -Increased afterload -% drops from 50-70 (normal) to BELOW 40% (side effects: Afib) -Fluid backs up in lungs (may have strange cough) -Meds may elevate to 30 or 40% from 20%

What should be done if a PT gains 4-7 kg?

-need to give Lasix and prepare for them to urinate right after (give call light or have the patient know that they should use the bedpan) Works very fast

Cardiac resynchronization therapy

-pacemaker and defibrillator

The nurse is unable to assess a pedal pulse in the client diagnosed with peripheral arterial disease. Which intervention should the nurse implement first? A. Complete a neurovascular assessment. B. Use the Doppler device. C. Instruct the client to hang the feet off the side of the bed. D. Wrap the legs in a blanket.

A. Complete a neurovascular assessment.

Right Sided HF: Cause and what it is?

-May be caused by left ventricular failure, RT ventricular MI, or pulmonary HTN, COPD -RT ventricle cannot empty completely resulting in increased vascular volume and peripheral edema -Decreased cardiac output and venous congestion

Heart rate and rhythm assessment for HF:

-Monitoring for irregular heart rhythm or dysrhythmias. Dysrhythmias are a common adverse effect of HF and medications used to treat HF. -EKG will show A-fib or V-Tach—will not see a normal sinus rhythm

Manifestations of LT-sided HF:

-Pulmonary edema with low SpO2, pink and frothy sputum, dyspnea, paroxysmal nocturnal dyspnea, initial compensation of tachycardia -Fatigue -Weakness -Chest pain or palpitations, fast rate -Renal failure with high creatinine -Can't carry groceries w/o SOB and chest pain -Pillows to sleep indicate fluid in lungs -Sleeping in a chair -Nighttime cough

What should you ask relating to fatigue, weakness, and LT-sided HF?

-Ask about their ability to perform simultaneous arm and leg work (e.g., walking while carrying a bag of groceries). -Ask about their most strenuous task in the past week because people may unconsciously limit themselves n response to fatigue and dyspnea

How is urinary output assessment helpful for a PT with HF?

-Assessed if there is decreased renal perfusion and effectiveness of diuretics

How does LT sided HF affect Cardiac Output and pulmonary venous pressure?

-Decrease CO -Increased Pulmonary venous pressure

2 major characteristics of HF:

-Decreased contractility -Decreased cardiac output (and how the body compensates)

How should activity tolerance be assessed in a PT with HF?

-Dyspnea on exertion, weakness, and fatigue indicate decreased cardiac output and worsening heart failure.

Typical Causes of LT sided HF:

-HTN -CAD -Valvular Disease -Not all cases involve fluid accumulation

Causes/Risk Factors fo HF:

-HTN -CAD leading to muscle damage -Cardiomyopathy -Substance abuse -Valvular disease -Congenital defects -Dysrhythmias -Diabetes -Smoking/tobacco -Hyperkinetic conditions (Hyperthyroidism) -Severe lung disease

The compensatory mechanisms involved with HF lead to:

-Increase in myocardial oxygen demands with increased HR and vasoconstriction -Increase in vascular volume because cardiac muscle can't keep up and there is no place for the fluid to go

Clinical manifestations of RT-Sided HF:

-JVD -Increased abdominal girth -Dependent edema -Hepatomegaly -Ascites -Renal failure from decreased blood to kidneys -Peripheral pitting edema -4-7 liter weight gain (1L=1kg) -Fluid overload (restriction needed) -Displaced apical to LT side -Sacral edema

Diastolic heart failure

-Left ventricle can't relax and fill -Ejection fraction is more the 40% but ventricular compliance decreases over time because more pressure is needed to move blood -Ventricles stiffen over time

New York Heart Association HF Classifications 1-4:

1: Cardiac disease with no symptoms or limitations in ordinary exercise 2: Mild symptoms and slight limitation 3: Significant limitation and comfort only at rest 4: Severe limitation and symptoms at rest

Less than ____ mL/hr of urine output should be reported to the provider.

30

What is a normal cardiac output?

4 and 6 liters of blood per minute

A patient is admitted to the ER with HF exacerbation complaining of SOB, heart palpitations, and cough. Which of the following does the nurse anticipate the provider ordering? SATA A. Complete Metabolic Panel B. Echocardiogram C. Insertion of a foley catheter D. 1L NS E. Administer O2 via NC F. EKG

A. Complete Metabolic Panel B. Echocardiogram E. Administer O2 via NC F. EKG

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? A. "Chest pain is caused by decreased oxygen to the heart muscle." B. "There is ischemia to the myocardium as a result of hypoxemia." C. "The heart muscle is unable to pump effectively to perfuse the body." D. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

A. "Chest pain is caused by decreased oxygen to the heart muscle."

The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

The nurse is caring for four patients. Which of the following are experiencing issues with afterload? SATA A. 45 y/o M with a BP of 176/98 B. 76 y/o F with a history of smoking and atherosclerosis C. 53 y/o M with varicose veins D. 65 y/o F with a cardiac dysrhythmia

A. 45 y/o M with a BP of 176/98 B. 76 y/o F with a history of smoking and atherosclerosis

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A. Digoxin therapy daily

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. A. Encourage a low-fat, low-cholesterol diet. B. Instruct the client to walk 30 minutes a day. C. Decrease the salt intake to two (2) g a day. D. Refer to a counselor for stress reduction techniques. E. Teach the client to increase fiber in the diet.

A. Encourage a low-fat, low-cholesterol diet. B. Instruct the client to walk 30 minutes a day. D. Refer to a counselor for stress reduction techniques. E. Teach the client to increase fiber in the diet.

The nurse is assessing the client diagnosed with long-term peripheral arterial disease. Which assessment data support the diagnosis? A. Hairless skin on the legs. B. Brittle, flaky toenails. C. Petechiae on the soles of feet. D. Nonpitting ankle edema.

A. Hairless skin on the legs.

Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply. A. Include the significant other in the discussion. B. Stop smoking or using any type of tobacco products. C. Maintain a sedentary lifestyle as much as possible. D. Avoid stressful situations. E. Daily isometric exercises are important.

A. Include the significant other in the discussion. B. Stop smoking or using any type of tobacco products.

Which nursing intervention should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? SATA A. Keep protamine sulfate readily available B. Avoid applying pressure to venipuncture sites C. Assess for overt and covert signs of bleeding D. Avoid invasive procedures and injections E. Administer stool softeners as ordered

A. Keep protamine sulfate readily available C. Assess for overt and covert signs of bleeding D. Avoid invasive procedures and injections E. Administer stool softeners as ordered

A nurse comes onto shift in the ER and receives report that one of her patients is suspected to have pneumonia. Which of the following symptoms would the nurse expect to see? SATA A. Tachypnea B. Diaphoresis C. Hemoptysis D. Bradycardia E. WBC 5,000 F. Hypotension

A. Tachypnea B. Diaphoresis C. Hemoptysis F. Hypotension

Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? A. The client demonstrates the correct way to pursed-lip breathe B. The client list three signs/ symptoms to report to the HCP C. The client will drink at least 2,500 mL of water daily D. The client will be able to ambulate 100 feet with dyspnea

A. The client demonstrates the correct way to pursed-lip breathe

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? A. The client diagnosed with myocardial infarction who has an audible S3 heart sound. B. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. C. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. D. The client with chronic renal failure who has an elevated creatinine level.

A. The client diagnosed with myocardial infarction who has an audible S3 heart sound.

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

B. "I need to take potassium supplements with this medication."

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. A. Administer morphine intramuscularly. B. Administer an aspirin orally. C. Apply oxygen via a nasal cannula. D. Place the client in a supine position. E. Administer nitroglycerin subcutaneously.

B. Administer an aspirin orally. C. Apply oxygen via a nasal cannula.

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? A. Medicate the client with intravenous morphine. B. Assess the client's chest dressing and vital signs. C. Encourage the client to turn from side to side. D. Check the client's telemetry monitor.

B. Assess the client's chest dressing and vital signs.

A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

B. Crackles in both lungs C. Tachycardia E. Tachypnea F. S3 gallop

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? A. Midepigastric pain and pyrosis. B. Diaphoresis and cool, clammy skin. C. Intermittent claudication and pallor. D. Jugular vein distention and dependent edema.

B. Diaphoresis and cool, clammy skin.

The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? A. Large amount of thick white sputum B. Oxygen flowmeter set on eight (8) liters C. Use of accessory muscles during inspiration D. Presence of a barrel chest and dyspnea

B. Oxygen flowmeter set on eight (8) liters

Which of the following patients are at risk of developing pneumonia? SATA A. A college student living in shared dorms B. Patient undergoing a swallow study C. Patient who has stayed at the hospital for 30 days D. Patient diagnosed with the flu

B. Patient undergoing a swallow study C. Patient who has stayed at the hospital for 30 days

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? A. Put a nitroglycerin tablet under the tongue. B. Stop the activity immediately and rest. C. Document when and what activity caused angina. D. Notify the health-care provider immediately.

B. Stop the activity immediately and rest.

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. A. Notify the health-care provider of a weight gain of more than one (1) pound in a week. B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. C. Instruct the client to remove the salt shaker from the dinner table. D. Encourage the client to monitor urine output for change in color to become dark. Discuss the importance of taking the loop diuretic furosemide at bedtime.

B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. C. Instruct the client to remove the salt shaker from the dinner table.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? A. The client will be able to ambulate in the hall by date of discharge. B. The client will have an audible S1 and S2 with no S3 heard by end of shift. C. The client will turn, cough, and deep breathe every two (2) hours. D. The client will have a SaO2 reading of 98% by day two (2) of care.

B. The client will have an audible S1 and S2 with no S3 heard by end of shift.

_______ is produced and released by the ventricles as they stretch in response to fluid overload from HF

BNP: Brain Natriuretic peptide

You are caring for a patient who is 6 hours post PCI. Which of the following findings would the provider need to be notified of? A. Blood pressure of 109/73 B. Fresh blood on the dressing site C. Diminished peripheral pulses D. SpO2 of 95%

C. Diminished peripheral pulses

A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

C. "I need to take a full course of antibiotics prior to my colonoscopy."

Which medication should the nurse expect the health-care provider to order for a client diagnosed with peripheral arterial disease? A. An anticoagulant medication. B. An antihypertensive medication. C. An antiplatelet medication. D. A muscle relaxant.

C. An antiplatelet medication.

The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis? A. Glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues. B. Diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis. C. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels. D. The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels.

C. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels.

Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease? A. Encourage the client to use a heating pad on the lower extremities. B. Demonstrate to the client the correct way to apply elastic support hose. C. Instruct the client to walk daily for at least 30 minutes. D. Tell the client to check both feet for red areas at least once a week.

C. Instruct the client to walk daily for at least 30 minutes.

The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.

C. Place the client in a high-Fowler position.

What can be done to prevent complications if a patient has a high BNP?

Can put on low-sodium

What imaging assessment is used to assess for cardiomegaly?

Chest xray

MAWDS

Client education: Heart failure -medication -activity -weight -diet -symptoms

PTs with CAD and early stages of HF may use what to keep the alveoli open longer?

Continuous positive airway pressure (CPAP)

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? A. Sponge the client's forehead. B. Obtain a pulse oximetry reading. C. Take the client's vital signs. D. Assist the client to a sitting position.

D. Assist the client to a sitting position.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? A. Measure intake and output. B. Provide two (2)g sodium diet. C. Weigh the client daily. D. Plan for frequent rest periods

D. Plan for frequent rest periods

The nursing is caring for the client diagnosed with end-stage COPD. Which data warrants immediate intervention by the nurse? A. The client's pulse oximeter reading is 92%? B. The client's arterial blood gas level is 74 C. The client has shortness of breath when walking to the bathroom D. The client's sputum is rusty colored

D. The client's sputum is rusty colored

The _______________ scan is a highly accurate test used to determine the heart's pumping function

Muga

What imaging assessment is used to calculate ejection fraction?

Echocardiography

What does the EF measure?

Efficiency of left ventricle

T/F: Cap Refill >4-5 seconds is an early indicator of HF:

False; this is a late sign

Most common reason for hospital admission for people >65 y/o

HF

How does HF impact Preload?

High preload; compensatory increase in volume to increase ventricular preload to serve the organs

BNP abnormal:

High: More than 400 pg/mL. Between 100 to 400 pg/mL should see MD.

What can you ask to assess how much fluid is collecting in the lungs while a patient is laying flat?

How many pillows do you need to sleep? Do you sleep in a chair?

What is the earliest sign of HF?

Increased HR because the body needs more blood

How does HF impact HR?

Increases to compensate

A patient who has an ejection fraction of <30% is a candidate for what?

implantable cardioverter/defibrillator (ICD) to reduce risk of sudden cardiac death

How does HF impact contractility?

Less contractility

What test is used to look at valve function?

MUGA scan: multigated acquisition scan (also called equilibrium radionuclide angiogram or blood pool scan) is a noninvasive diagnostic test used to evaluate the pumping function of the ventricles -radioactive tracer is injected into a vein and a camera detects radiation

What is the difference in treatment for Systolic Vs Diastolic HF?

Medications; Nursing interventions are the same

Nursing interventions involved with HF:

Monitor intake and output: -I&O, daily weight, fluid restriction, educate team about recording all fluids Monitor labs: -BNP, BUN, Creatinine, electrolytes Depression: -high rates with HF, and can impact self-management Social support

Where would most of the fluid be with left-sided heart failure?

Peripheral, abdomen (ascites), JVD, Hepatomegaly

Crackles indicated what in PT with HF?

Pulmonary congestion

How can an MI lead to HF?

Scar tissue

What is essential in preventing readmissions for HF patients?

Self-management education and transitional care interventions

Crackles above the bases of the lungs indicates what with HF?

Significant fluid overload

What has shown to be an independent predictor of mortality among HF patients?

Social isolation -need to assess appropriate support for PT

Left-sided heart failure can be divided into what two sub-categories?

Systolic HF with reduced Ejection Fraction (Forward Failure) Diastolic HF with preserved left ventricular function

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)?

Troponin.

What is the biggest cause of HF?

Untreated HTN-screening is most important in preventing HF

Why will urinary output be decreased in a PT with HF?

decreased renal perfusion

Normal BNP Range:

less than 100 pg/mL

How will the H&H be affected in a PT with a HF exacerbation?

low with fluid overload

Why might a PT with a HF exacerbation have a high BUN?

may have high bnp because of ventricular stretch (due to fluid overload in the ventricles).

What should you do before giving Digoxin?

need to listen to the apical pulse for a full minute to ensure it is not <60 BPM -Provide education about checking pulse at home to prevent OD

How does HF impact Afterload?

ventricular wall tension; afterload increases and stroke volume decreases

What are the signs and symptoms of HF related to?

weakened cardiac contraction, decreased cardiac output, back up of blood, poor peripheral perfusion

Common Risk Factors for HF:

• Dysrhythmias • Diabetes mellitus • Smoking/tobacco use • Family history • Obesity • Severe lung disease • Sleep apnea • Hyperkinetic conditions (e.g., hyperthyroidism)

Common Causes of HF:

• Hypertension • Coronary artery disease • Cardiomyopathy • Substance abuse (alcohol and illicit/prescribed drugs) • Valvular disease • Congenital defects • Cardiac infections and inflammation

Normal EF:

•60-65% of Blood in the ventricle.

Ventricular assist devices-LVAD

•Acts as the left ventricle and pumps blood into the aorta and out into the body

Imaging assessments for HF

•CXR looking for cardiomegaly •Echocardiography (Ejection fraction calculation) •Trans-esophageal scan—helps diagnose EF •Radio-nucleotide studies •MUGA

What new or worsening symptoms related to HF should the patient immediately notify the provider of?

•Decrease in exercise tolerance lasting 2-3 days •Excessive awakening at night to urinate •SOB, chest pain at rest •Increased swelling in feet, ankles or hands •Cold symptoms lasting >3-5 days

Treatments to decrease RAAS and SNS response:

•Decreasing constriction as compensatory mechanism to improve blood flow •These meds prevent this: •ACEI/ARBS (more common that digoxin), Beta-blockers

Hemodynamic monitoring for HF involves what?

•Direct assessment of cardiac function and volume status

Treatment to decrease preload and afterload:

•Diuretics: decrease fluid overload (lasix) •Nitrates: vasodilation •ACEI/ARB: decrease fluid volume and sympathetic response •Beta-blockers: decrease sympathetic response

What is HF?

•Inability of the heart to pump enough blood to meet the metabolic demands of the body, no oxygen to organs

Treatment to increased contractility

•Inotropic drugs: digoxin, Milrinone (Primacor) •Before giving Digoxin, need to listen to the apical pulse for a full minute to ensure it is not <60 BPM •Need to make sure that education is provided about checking pulse at home to prevent overdose •Side effects: halos, N/V

Causes of LT sided HF (systolic and diastolic):

•Left ventricular •Pulmonary hypertension (not curable) •Right ventricle cannot empty completely •Increased volume and pressure in venous system and peripheral edema •Peds treated with Viagra

What education should be given to the patient about diet for HF management?

•Limit daily sodium intake to 2g/day •No evidence that doing less will be any more beneficial than 2g/day •Limit daily fluid intake to 2 liters

Life-threatening manifestation associated with LT-Sided HF:

•Pink tinged, frothy sputum •Indicates pressure and fluid in the alveoli

What labs should be drawn for HF?

•Serum electrolytes •Sodium could be low and potassium could be high •Hemoglobin and hematocrit low with fluid overload •BNP •BUN, Creatinine, urine studies •ABGs

What education should be given to the patient about activity for HF management?

•Stay active •Alternate rest and activity periods •Know your limits •be able to carry on conversation while exercising

What education should be given to the patient about medications for HF management?

•Take medication as prescribed, do not stop abruptly •Know purpose and side effects of each drug •Have family member watch them to ensure they are taking correct meds •Avoid NSAIDs to prevent sodium and fluid retention

What education should be given to the patient about weight for HF management?

•Weigh yourself each day at same time •Notify provider for 2-3lb weight gain in 1 day or 5 lbs in 1 week

High rates of depression and anxiety in HF patients can impact what?

•self-management