NR 224 HEART FAILURE (HF) OR CONGESTIVE HEART FAILURENR 224 HEART FAILURE (HF) OR CONGEST, Exams of Nursing

Download NR 224 HEART FAILURE (HF) OR CONGESTIVE HEART FAILURENR 224 HEART FAILURE (HF) OR CONGEST and more Exams Nursing in PDF only on Docsity! QUESTIONS AND ANSWERS Exam NR 224 HEART FAILURE (HF) OR CONGESTIVE HEART FAILURE TESTED AND CONFIRMED A+ ANSWERS 1 Heart failure (HF) or Congestive Heart Failure (CHF) Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body. Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal bloodvolume or, in absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself, instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion. Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure. Nursing Care Plans Nursing care for patients with heart failure includes support to improve heart pump function by various nursing interventions, prevention and identification of complications, and providing a teaching plan for lifestyle modifications. Here are 16+ nursing care plans (NCP) for patients with Heart Failure: Content 1. Decreased Cardiac Output 2. Activity Intolerance 3. Excess Fluid Volume 4. Risk for Impaired Gas Exchange 5. Risk for Impaired Skin Integrity 6. Deficient Knowledge 7. Decreased Cardiac Output 8. Excess Fluid Volume 9. Acute Pain 10. Ineffective Tissue Perfusion 11. Hyperthermia 12. Ineffective Breathing Pattern 13. Activity Intolerance 14. Ineffective Airway Clearance 15. Impaired Gas Exchange 16. Fatigue 17. Other Nursing Care Plans 4 Nursing Interventions Rationale vasovagal response (straining during defecation, holding breath during position changes). bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function. Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase activity as tolerated. Decreases venous stasis, and may reduce incidence of thrombus or embolusformation. Check for calf tenderness, diminished pedal pulses, swelling, local redness, or pallor of extremity. Reduced cardiac output, venous pooling, and enforced bed rest increases risk of thrombophlebitis. Withhold digitalis preparation as indicated, and notify physician if marked changes occur in cardiac rate or rhythm or signs of digitalis toxicity occur. Incidence of toxicity is high (20%) because of narrow margin between therapeutic and toxic ranges. Digoxin may have to be discontinued in the presence of toxic drug levels, a slow heart rate, or low potassium level. Administer supplemental oxygen as indicated. Increases available oxygen for myocardial uptake to combat effects of hypoxia. Administer medications as indicated: • Diuretics: furosemide (Lasix), ethacrynic acid (Edecrin), bumetanide(Bumex), spironolactone (Aldactone). Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in patients with stages I and II HF. In general, type and dosage of diuretic depend on cause and degree of HF and state of renal function. Preload reduction is most useful in treating patients with a relatively normal cardiac output accompanied by congestive symptoms. Loop diuretics block chloride reabsorption, thus interfering with the reabsorption of sodium and water. • Vasodilators: nitrates (Nitro-Dur, Isordil); • arterial dilators: hydralazine(Apresoline); • combination drugs: prazosin (Minipress); Vasodilators are the mainstay of treatment in HF and are used to increase cardiac output, reducing circulating volume (venodilators) and decreasing SVR, thereby reducing ventricular workload. Note: 5 Nursing Interventions Rationale Parenteral vasodilators(Nitroprusside) are reserved for patients with severe HF or those unable to take oral medications. • ACE inhibitors: benazepril (Lotensin), captopril (Capoten), lisinopril (Prinivil), enalapril (Vasotec), quinapril (Accupril), ramipril (Altace), moexipril (Univasc). ACE inhibitors represent first-line therapy to control heart failure by decreasing ventricular filling pressures and SVR while increasing cardiac output with little or no change in BP and heart rate. • Angiotensin II receptor antagonists: eprosartan (Teveten), irbesartan (Avapro), valsartan (Diovan); Antihypertensive and cardioprotective effects are attributable to selective blockade of AT1(angiotensin II) receptors and angiotensin II synthesis. • Digoxin (Lanoxin) Increases force of myocardial contraction when diminished contractility is the cause of HF, and slows heart rate by decreasing conduction velocity and prolonging refractory period of the atrioventricular (AV) junction to increase cardiac efficiency /output. • Inotropic agents: amrinone (Inocor), milrinone (Primacor), vesnarinone (Arkin-Z); These medications are useful for short- term treatment of HF unresponsive to cardiac glycosides, vasodilators, and diuretics in order to increase myocardial contractility and produce vasodilation. Positive inotropic properties have reduced mortality rates 50% and improved quality of life. • Beta-adrenergic receptor antagonists: carvedilol (Coreg), bisoprolol (Zebeta), metoprolol (Lopressor); Useful in the treatment of HF by blocking the cardiac effects of chronic adrenergic stimulation. Many patients experience improved activity tolerance and ejection fraction. • Morphine sulfate. Decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine 6 Nursing Interventions Rationale release to anxiety. • Antianxiety agents and sedatives. Promote rest, reducing oxygen demand and myocardial workload. • Anticoagulants: low-dose heparin, warfarin (Coumadin). May be used prophylactically to prevent thrombus and embolus formation in presence of risk factors such as venous stasis, enforced bed rest, cardiac dysrhythmias, and history of previous thrombotic episodes. Administer IV solutions, restricting total amount as indicated. Avoid saline solutions. Because of existing elevated left ventricular pressure, patient may not tolerate increased fluid volume (preload). Patients with HF also excrete less sodium, which causes fluid retention and increases myocardial workload. Monitor and replace electrolytes. Fluid shifts and use of diuretics can alter electrolytes (especially potassium and chloride), which affect cardiac rhythm and contractility. Monitor serial ECG and chest x-ray changes. ST segment depression and T wave flattening can develop because of increased myocardial oxygen demand, even if no coronary artery disease is present. Chest x- ray may show enlarged heart and changes of pulmonary congestion. Measure cardiac output and other functional parameters as indicated. Cardiac index, preload, afterload, contractility, and cardiac work can be measured noninvasively by using thoracic electrical bioimpedance (TEB) technique. Useful in determining effectiveness of therapeutic interventions and response to activity. Monitor laboratory studies: • BUN, creatinine. Elevation of BUN or creatinine reflects kidney hypoperfusion. 9 Nursing Interventions Rationale thereby aggravating weakness and fatigue. Assess for other causes of fatigue(treatments, pain, medications). Fatigue is a side effect of some medications (beta- blockers, tranquilizers, and sedatives). Pain and stressful regimens also extract energy and produce fatigue. Evaluate accelerating activity intolerance. May denote increasing cardiac decompensation rather than overactivity. Provide assistance with self-care activities as indicated. Intersperse activity periods with rest periods. Meets patient’s personal care needs without undue myocardial stress and excessive oxygen demand. Implement graded cardiac rehabilitation program. Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption. Assist patient with ROM exercises. Check regularly for calf pain and tenderness. To prevent deep vein thrombosis due to vascular congestion. Excess Fluid Volume Excess Fluid Volume: Increased isotonic fluid retention Nursing Diagnosis • Fluid Volume, excess May be related to • Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention Possibly evidenced by • Orthopnea, S3 heart sound • Oliguria, edema, JVD, positive hepatojugular reflex • Weight gain • Hypertension • Respiratory distress, abnormal breath sounds Desired Outcomes • Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, vital signs within acceptable range, stable weight, and absence of edema. • Verbalize understanding of individual dietary/fluid restrictions. 10 Nursing Interventions Rationale Urine output may be scanty and concentrated Monitor urine output, noting amount and color, as well as (especially during the day) because of reduced renal time of day when diuresis occurs. perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night and/or during bed rest. Monitor and calculate 24-hour intake and output (I&O) balance. Diuretic therapy may result in sudden increase in fluid loss (circulating hypovolemia), even though edema or ascites remains. Maintain chair or bed rest in semi-Fowler’s position during acute phase. Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis. Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care. Ice chips can be part of fluid allotment. Involving patient in therapy regimen may enhance sense of control and cooperation with restrictions. Weigh daily. Frequently monitor blood urea nitrogen, creatinine, and serum potassium, sodium, chloride, and magnesium levels. Documents changes edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in excessive fluid shifts and weight loss. Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema (check for pitting); note presence of generalized body edema (anasarca). Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet and ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually results in systemic tissue edema. Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated. Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility (including bed rest) are cumulative stressors that affect skin integrity and require close supervision/ preventive interventions. Auscultate breath sounds, noting decreased and/or adventitious sounds (crackles, wheezes). Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough. Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute left-sided HF. RHF’s respiratory symptoms (dyspnea, cough, orthopnea) may have 11 Nursing Interventions Rationale slower onset but are more difficult to reverse. Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom. May indicate development of complications (pulmonary edema and/or embolus) and differs from orthopnea paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention. Monitor BP and central venous pressure (CVP) Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, HF. Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation. Visceral congestion (occurring in progressive HF) can alter intestinal function. Provide small, frequent, easily digestible meals. Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/ prevent abdominal discomfort. Measure abdominal girth, as indicated. In progressive RHF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites). Encourage verbalization of feelings regarding limitations. Expression of feelings may decrease anxiety, which is an energy drain that can contribute to feelings of fatigue. Palpate abdomen. Note reports of right upper quadrant pain and tenderness. Advancing HF leads to venous congestion, resulting in abdominal distension, liver engorgement (hepatomegaly), and pain. This can alter liver function and prolong drug metabolism. Administer medications as indicated: Signs of potassium and sodium deficits that may • Diuretics: furosemide (Lasix), bumetanide (Bumex) occur because of fluid shifts and diuretic therapy. Thiazides Increases rate of urine flow and may inhibit reabsorption of sodium/ chloride in the renal tubules. • Diuretics with potassium-sparing agents: spironolactone (Aldactone) Promotes diuresis without excessive potassium losses. • Potassium supplements: K-Dur Replaces potassium that is lost as a common side effect of diuretic therapy, which can adversely affect 14 Nursing Interventions Rationale Institute/instruct patient regarding fluid restrictions as appropriate. This helps reduce extracellular volume. Risk for Impaired Gas Exchange Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. Nursing Diagnosis • Risk for Impaired Gas Exchange Risk factors may include • Alveolar-capillary membrane changes, e.g., fluid collection/shifts into interstitial space/alveoli Possibly evidenced by • [Not applicable] Desired Outcomes • Demonstrate adequate ventilation and oxygenation of tissues by ABGs/oximetry within patient’s normal ranges and free of symptoms of respiratory distress. • Participate in treatment regimen within level of ability/situation. Nursing Interventions Rationale Reveals presence of pulmonary congestion and Auscultate breath sounds, noting crackles, wheezes. collection of secretions, indicating need for further intervention. Instruct patient in effective coughing, deep breathing. Clears airways and facilitates oxygen delivery. Encourage frequent position changes. Helps prevent atelectasis and pneumonia. Maintain chair or bed rest, with head of bed elevated 20–30 degrees, semi-Fowler’s position. Support arms with pillows. Reduces oxygen demands and promotes maximal lung inflation. Place patient in Fowler’s position and give supplemental oxygen. To help patient breath more easily and promote maximum chest expansion. Graph graph serial ABGs, pulse oximetry. Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF. Note: In patients with abnormal cardiac index, research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%. Administer supplemental oxygen as indicated. Increases alveolar oxygen concentration, which may 15 Nursing Interventions Rationale reduce tissue hypoxemia. Administer medications as indicated: • Diuretics: furosemide (Lasix) Reduces alveolar congestion, enhancing gas exchange. • Bronchodilators: aminophylline Increases oxygen delivery by dilating small airways, and exerts mild diuretic effect to aid in reducing pulmonary congestion. Risk for Impaired Skin Integrity Risk for Impaired Skin Integrity: At risk for altered epidermis and/or dermis [The integumentary system is the largest multifunctional organ of the body.] Nursing Diagnosis • Risk for impaired Skin Integrity Risk factors may include • Prolonged bedrest • Edema, decreased tissue perfusion Possibly evidenced by • [Not applicable] Desired Outcomes • Maintain skin integrity. • Demonstrate behaviors/techniques to prevent skin breakdown. Nursing Interventions Rationale Inspect skin, noting skeletal prominences, presence of Skin is at risk because of impaired peripheral edema, areas of altered circulation, or obesity and/or circulation, physical immobility, and alterations in emanciation. nutritional status. Provide gentle massage around reddened or blanched areas. Improves blood flow, minimizing tissue hypoxia. Note: Direct massage of compromised area may cause tissue injury. Encourage frequent position changes, assist with active and passive range of motion (ROM) exercises. Reduces pressure on tissues, improving circulation and reducing time any one area is deprived of full blood flow. Provide frequent skin care: minimize contact with moisture and excretions. Excessive dryness or moisture damages skin and hastens breakdown. 16 Nursing Interventions Rationale Check fit of shoes and slippers and change as needed. Dependent edema may cause shoes to fit poorly, increasing risk of pressure and skin breakdown on feet. Avoid intramuscular route for medication. Interstitial edema and impaired circulation impede drug absorption and predispose to tissue breakdown and development of infection. Provide alternating pressure, egg-crate mattress, sheepskin elbow and heel protectors. Reduces pressure to skin, may improve circulation. Deficient Knowledge Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic. Nursing Diagnosis • Knowledge deficient [Learning Need] regarding condition, treatment regimen, self care, and discharge needs May be related to • Lack of understanding/misconceptions about interrelatedness of cardiac function/disease/failure Possibly evidenced by • Questioning • Statements of concern/misconceptions • Recurrent, preventable episodes of HF Desired Outcomes • Identify relationship of ongoing therapies (treatment program) to reduction of recurrent episodes and prevention of complications. • List signs/symptoms that require immediate intervention. • Identify own stress/risk factors and some techniques for handling. • Initiate necessary lifestyle/behavioral changes. Nursing Interventions Rationale Discuss normal heart function. Include information Knowledge of disease process and expectations can regarding patient’s variance from normal function. facilitate adherence to prescribed treatment regimen. Explain difference between heart attack and HF. Reinforce treatment rationale. Include SOs in teaching as appropriate, especially for complicated regimens such as dobutamine infusion home therapy when patient does not respond to customary combination therapy or cannot be weaned from dobutamine, or those awaiting heart transplant. Patient may believe it is acceptable to alter postdischarge regimen when feeling well and symptom- free or when feeling below par, which can increase the risk of exacerbation of symptoms. Understanding of regimen, medications, and restrictions may augment 19 Nursing Interventions Rationale care providers. significant worsening of symptoms. If patient chooses to refuse life-support measures, an alternative contact person (rather than 911) needs to be designated, should cardiac arrest occur. Decreased Cardiac Output Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands of the body. The heat fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased therefore decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness Assessment The patient may manifest the following: • Pale conjunctiva, nail beds, and buccal mucosa • irregular rhythm of pulse • bradycardia • generalized weakness Diagnosis • Decreased cardiac output r/t [altered heart rate and rhythm] AEB [bradycardia] Planning • Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart. • Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability. Nursing Interventions Rationale Allows detection of left-sided heart failure that may Assess for abnormal heart and lung sounds. occur with chronic renal failurepatients due to fluid volume excess as the diseased kidneys are unable to excrete water. Monitor blood pressure and pulse. Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the renin-angiotensin mechanism. Assess mental status and level of consciousness. The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness. 20 Nursing Interventions Rationale Assess patient’s skin temperature and peripheral pulses. Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate. Monitor results of laboratory and diagnostic tests. Results of the test provide clues to the status of the disease and response to treatments. Monitor oxygen saturation and ABGs. Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs. Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance. Implement strategies to treat fluid and electrolyte imbalances. Decreases the risk for development of cardiac output due to imbalances. Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity. Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output. Encourage periods of rest and assist with all activities. Reduces cardiac workload and minimizes myocardial oxygen consumption. Assist the patient in assuming a high Fowler’s position. Allows for better chest expansion, thereby improving pulmonary capacity. Teach patient the pathophysiology of disease, medications Provides the patient with needed information for management of disease and for compliance. Reposition patient every 2 hours To prevent occurrence of bed sores Instruct patient to get adequate bed rest and sleep To promote relaxation to the body Instruct the SO not to leave the client unattended To ensure safety and reduce risk for falls that may lead to injury Evaluation • After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart. • After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability. 21