Week 2(Stacy) Chapter 25 : Management of Patients with Complications from Heart Disease

Question 1

Heart Failure #1

Answer 1

Cardiovascular disease is the leading cause of death
in the United States
Heart disease remains a chronic and often
progressive condition, associated with serious
comorbidities, such as heart failure
Heart failure (HF) is a clinical syndrome resulting
from structural or functional cardiac disorders that
impair the ability of a ventricle to fill or eject blood;
the heart is unable to pump enough blood to meet
the body’s metabolic demands or needs

Question 2

Heart Failure #2

Answer 2

The term heart failure indicates myocardial disease,
in which there is a problem with the contraction of
the heart (systolic dysfunction) or filling of the heart
(diastolic dysfunction) may cause pulmonary or
systemic congestion
Some cases are reversible depending on the cause
Most HF is a chronic, progressive condition managed
with lifestyle changes and medications

Question 3

Chronic Heart Failure

Answer 3

The incidence of HF increases with age
Approximately 6 million people in the United States
have HF, and 870,000 new cases are diagnosed each
year
Most common reason for hospitalization of people
older than 65 years and the second most common
reason for visits to a provider’s office
Approximately 20% of patients discharged after
treatment for HF are readmitted to the hospital
within 30 days and nearly 50% are readmitted to
the hospital within 6 months

Question 4

Right Sided HF

Answer 4

Viscera and peripheral
congestion
Jugular venous
distention (JVD)
Dependent edema
Hepatomegaly
Ascites
Weight gai

Question 5

Left Sided HF

Answer 5

Pulmonary congestion,
crackles
S3 or “ventricular gallop”
Dyspnea on exertion
(DOE)
Low O2 sat
Dry, nonproductive
cough initially
Oliguria

Question 6

Medical Management of the Patient with
Heart Failure


Answer 6

Vary according to the severity of the patient’s
condition, comorbidities, and cause
Treatment may include
o Oral and IV medications
o Lifestyle modifications
o Supplemental O2
o Surgical interventions: ICD and heart transplant
Comprehensive education and counseling to patient
and family is needed

Question 7

Medications Used to Treat HF #1

Answer 7

Diuretics: decreases fluid volume, monitor serum
electrolytes
Angiotensin-converting enzyme (ACE) inhibitors:
vasodilation; diuresis; decreases afterload; monitor
for hypotension, hyperkalemia, and altered renal
function; cough
Angiotensin II receptor blockers: prescribed as an
alternative to ACE inhibitors; work similarly
Beta-blockers: prescribed in addition to ACE
inhibitors; may be several weeks before effects
seen; use with caution in patients with asthma

Question 8

Medications Used to Treat HF #2

Answer 8

Ivabradine: decreases rate of conduction through
the SA node; observe for decrease HR and BP
Hydralazine and isosorbide dinitrate: alternative to
ACE inhibitors; observe for decreased BP
Digitalis: improves contractility; monitor for digitalis
toxicity especially if patient is hypokalemic

Question 9

Medications Used to Treat HF #3

Answer 9

IV medications: indicated for hospitalized patients
admitted for acute decompensated HF
o Dopamine: vasopressor to increase BP and
myocardial contractility; adjunct with loop diuretics
o Dobutamine: used for patients with left ventricular
dysfunction; increases cardiac contractility and renal
perfusion
o Milrinone: decreases preload and afterload; causes
hypotension and increased risk of dysrhythmias
o Vasodilators: IV nitro, nitroprusside, nesiritide;
enhance symptom relief

Question 10

Gerontologic Considerations

Answer 10

May present with atypical signs and symptoms such
as fatigue, weakness, and somnolence
Decreased renal function can make older patients
resistant to diuretics and more sensitive to changes
in volume
Administration of diuretics to older men requires
nursing surveillance for bladder distention caused by
urethral obstruction from an enlarged prostate gland

Question 11

Assessment of the Patient with Heart
Failure

Answer 11

Focus
o Effectiveness of therapy
o Patient’s self-management
o S&S of increased HF
o Emotional or psychosocial response
Health history
PE
o Mental status; lung sounds: crackles and wheezes;
heart sounds: S3; fluid status or signs of fluid
overload; daily weight and I&O; asess responses to
medications

Question 12

Collaborative Problems and Potential Complications of the Patient with HF

Answer 12

Pulmonary edema
Hypotension, poor perfusion, and cardiogenic shock
(see Chapter 11)
Arrhythmias (see Chapter 22)
Thromboembolism (see Chapter 26)
Pericardial effusion

Question 13

Planning and Goals for the Patient With
Heart Failure

Answer 13

Goals
o Promote activity and reduce fatigue
o Relieve fluid overload symptoms
o Decrease anxiety or increase the patient’s ability
to manage anxiety
o Encourage the patient to verbalize his or her
ability to make decisions and influence outcomes
o Educate the patient and family about
management of the therapeutic regimen

Question 14

Nursing Interventions for the Patient with
Heart Failure #1

Answer 14

Promote activity tolerance
o Bed rest for acute exacerbations
o Encourage regular physical activity; build up to about
30 minutes daily
o Exercise training
o Pacing of activities; wait 2 hours after eating for
physical activity
o Avoid activities in extreme hot, cold, or humid
weather
o Modify activities to conserve energy
o Positioning; elevation of the head of bed to facilitate
breathing and rest, support of arms

Question 15

Nursing Interventions for the Patient with
Heart Failure #2

Answer 15

Manage fluid volume
o Assess for symptoms of fluid overload
o Daily weight
o I&O
o Diuretic therapy; timing of meds
o Fluid intake; fluid restriction
o Maintenance of sodium restriction

Question 16

Patient Education for the Patient with
Heart Failure

Answer 16

Medications
Diet: low-sodium diet and fluid restriction
Monitor for signs of excess fluid, hypotension, and
symptoms of disease exacerbation, including daily
weight
Exercise and activity program
Stress management
Prevention of infection
Know how and when to contact health care provider
Include family in education

Question 17

Pulmonary Edema

Answer 17

Acute event reflecting a breakdown of physiologic
compensatory mechanisms
As LV begins to fail, blood backs up into the
pulmonary circulation, causing pulmonary interstitial
edema
Results in hypoxemia, often severe
Clinical manifestations: restlessness, anxiety,
tachypnea, dyspnea, cool and clammy skin,
cyanosis, weak and rapid pulse, cough, lung
congestion (moist, noisy respirations), increased
sputum production (sputum may be frothy and
blood tinged), decreased level of consciousness

Question 18

Management of Pulmonary Edema

Answer 18

Easier to prevent than to treat
Early recognition: monitor lung sounds and for signs
of decreased activity tolerance and increased fluid
retention
Minimize exertion and stress
Oxygen; nonrebreather
Medications
o Diuretics (furosemide), vasodilators
(nitroglycerin)

Question 19

Nursing Interventions for the Patient with
Pulmonary Edema

Answer 19

Positioning the patient to promote circulation
o Positioned upright with legs dangling
Providing psychological support
o Reassure patient and provide anticipatory care
Monitoring medications
o I&O

Question 20

End-of-Life Considerations

Answer 20

HF is a chronic and often progressive condition
o Need to consider issues related to the end of life
o When palliative or hospice care should be
considered

Question 21

Cardiogenic Shock

Answer 21

A life-threatening condition with a high mortality
rate
Decreased CO leads to inadequate tissue perfusion
and initiation of shock syndrome
Commonly occurs following acute MI when a large
area of myocardium becomes ischemic and
hypokinetic
Can occur as a result of end-stage HF, cardiac
tamponade, pulmonary embolism (PE),
cardiomyopathy, and arrhythmias

Question 22

Thromboembolism

Answer 22

Patients with cardiovascular disorders are at risk for
the development of arterial thromboemboli and
venous thromboemboli (VTE)
Decreased mobility and circulation increase the risk
for thromboembolism in patients with cardiac
disorders, including those with HF
Intracardiac thrombi can form in patients with atrial
fibrillation because the atria do not contract
forcefully, and increasing the likelihood of thrombus
formation
Pulmonary embolism: blood clot from the legs
moves to obstruct the pulmonary vessel

Question 23

Pericardial Effusion and Cardiac
Tamponade

Answer 23

Pericardial effusion is the accumulation of fluid in the
pericardial sac
Cardiac tamponade is the restriction of heart
function because of this fluid, resulting in decreased
venous return and decreased CO
Clinical manifestations: ill-defined chest pain or
fullness, pulsus paradoxus, engorged neck veins,
labile or low BP, shortness of breath
Cardinal signs of cardiac tamponade: falling systolic
BP, narrowing pulse pressure, rising venous
pressure, distant heart sounds

Question 24

Medical Management of Pericardial
Effusion and Cardiac Tamponade

Answer 24

Pericardiocentesis
o Puncture of the pericardial sac to aspirate
pericardial fluid
Pericardiotomy
o Under general anesthesia, a portion of the
pericardium is excised to permit the exudative
pericardial fluid to drain into the lymphatic
system