Chapter 28: Caring for Clients with Heart Failure

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing action?

Assess oxygen saturation The nurse's priority action is to assess oxygen saturation to determine the severity of the exacerbation. It is important to assess the oxygen saturation in a client with heart failure because below-normal oxygen saturation can be life-threatening. Treatment options vary according to the severity of the client's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve symptoms and reduce the workload on the heart by reducing afterload and preload.

A patient has been admitted to the hospital with exacerbation of heart failure (HF) that has resulted in pulmonary and peripheral edema. The nurse has been carefully monitoring the trajectory of the patient's signs and symptoms of HF. How can the nurse best monitor the patient's fluid balance?

By performing daily weights at the same time each day Changes in fluid balance can be identified by monitoring the patient's weight on a daily basis. This assessment is more accurate than assessing skin turgor. Intake must be considered in combination with output. BUN and creatinine levels provide important data, but these do not convey the patient's fluid balance when considered in isolation.

The client with cardiac failure is taught to report which symptom to the health care provider 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.

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?

Call for a chest x-ray. A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.

Why does a client with left-sided heart failure require careful monitoring?

Right-sided heart failure is a risk. Left-sided heart failure is a major cause of right-sided heart failure.

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?

An echocardiogram Increasing shortness of breath (dyspnea) and fatigue are common signs of left-sided heart failure (HF). However, some of the physical signs that suggest HF may also occur with other diseases, such as renal failure and chronic obstructive pulmonary disease; therefore, diagnostic testing is essential to confirm a diagnosis of HF. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, and confirm the diagnosis of HF.

The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis?

Distended neck veins Right-sided heart failure may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers are not characteristic signs of right-sided heart failure.

A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client?

In a high Fowler position Proper positioning can help reduce venous return to the heart. The client is positioned upright. If the client is unable to sit with the lower extremities dependent, the client may be placed in an upright position in bed. The supine and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment information?

Potassium level The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.

An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing diagnosis should be identified?

Risk for falls related to hypotension The combination of low BP, diuretic use, and ACE inhibitor use constitutes a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The client's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all clients with heart failure, but this is not in evidence for this client at this time.

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 heart failure has been admitted to the cardiac clinic. What steps should the nurse take to ensure a proper assessment? Select all that apply.

Obtain an admission weight and thereafter weigh the client daily on the same scale, at about the same time of day, with the client wearing similar clothing. Note respiratory difficulties during activity and rest. The nurse should be aware of the complete checklist for doing a proper assessment on a patient with heart failure. Weigh the client at admission and thereafter weigh the client daily on the same scale, at about the same time of day, with the client wearing similar clothing. Include questions about respiratory difficulties during activity and rest. Checking sodium levels and questions about smoking are not on this checklist.

The client asks the nurse why a stress test is needed. What statement best explains the rationale for the health care provider to order a cardiac stress test?

The health care provider wants to identify if the heart failure is from coronary artery disease. Cardiac stress testing or cardiac catheterization is performed to determine whether the coronary artery disease and cardiac ischemia are causing the heart failure. The nurse is generalizing when saying everything is being evaluated. Explaining that heart failure is causing weakness and fatigue does not answer the need for the stress test. The stress test does not diagnose the client's stage of heart failure.

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.

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home?

"I'm having trouble going up the steps during the day." Difficulty with activities like climbing stairs is an indication of a lessened ability to exercise. Eating small meals and not using salt are usually indicated for clients with heart failure. The client's assertion about morning being the best time of day is a vague statement.

A patient is being discharged to home. The nurse must emphasize the importance of being weighed daily. Which significant weight change would need to be reported to the patient's health care provider?

A weight gain of 2½ pounds in a day If there is a significant change in weight (2 to 3 pounds increase in a day or a 5 pound increase in a week), the patient should be instructed to notify his provider or to adjust medications per provider's directions.

A client with heart failure has met with his primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse should prioritize what assessment?

Blood pressure Clients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in clients with heart failure, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Heart failure A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.

Which New York Heart Association classification of heart failure (HF) has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV Symptoms of cardiac insufficiency at rest are classified as IV according to the New York Heart Association Classification of HF. In Class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In Class II, there is a slight limitation of ADLs. In Class III, there is marked limitation of activities of daily living (ADLs).

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.

The nurse identifies which symptom as a characteristic of right-sided heart failure?

Jugular vein distention (JVD) 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) Although a low EF is a hallmark of heart failure (HF), the severity of HF is frequently classified according to the client's symptoms. Pulmonary congestion, limitation of ADLs, and basilar crackles are all symptoms of HF.

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

Preload Preload is the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.

A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?

acute pulmonary edema. Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.

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 nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?

heart rate of 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 transplant 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.

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 triage nurse in the ED is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, what is a potential primary cause of the client's heart failure?

Atherosclerosis Atherosclerosis of the coronary arteries is the primary cause of heart failure. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of heart failure.

The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

Avoid positioning the client supine. Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of heart failure and, consequently, the nurse should avoid positioning the client supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.

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 heart's 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 of the following describes difficulty breathing when lying flat?

Orthopnea Orthopnea occurs when the patient is having difficulty breathing when laying 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 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 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).

The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?

The woman may be experiencing an exacerbation of right-sided HF. Increased JVP is associated with right-sided HF. Dyspnea may or may not be present, but is more closely associated with left-sided HF. Increased JVP is not necessarily indicative of impending shock.

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 is caring for an older adult client who has just returned from the OR after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery and the nurse recognizes that the client is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?

Bibasilar fine crackles Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?

Check the client's potassium level. The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the health care provider. Because the client is taking furosemide, a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the health care provider with a more complete database. The health care provider will need to be notified after the nurse checks the latest potassium level. The intake and output will not change the heart rhythm. Administering potassium requires a health care provider's order.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-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 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 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.

The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition?

Crackles are audible on chest auscultation. Patients with HF often exhibit crackles, which are produced by the sudden opening of edematous small airways and alveoli that have adhered together by exudate. These may be heard at the end of inspiration and are not cleared with coughing. A widened pulse pressure, increased BP, and production of dilute urine are not characteristic of HF. Changes in blood glucose levels are not normally symptomatic of HF.