HF Management of Care
What document outlines the clients care goals and priorities for that shift?
Care Plan
What is the priority position for a client with dyspnea?
High Fowlers
What is the most common visible sign of R sided HF
Edema/ Swelling
What is the most common lung sound head in Left sided HF
Crackles
What medication class is required at discharge (unless contraindicated) to help improve HR survival rates?
ACE inhibitors or ARBs
What task requires clinical judgment and can not be delegated to a UAP?
Assessment
What is the best method to evaluate medication understanding at discharge?
Teach back method
What is the clinical term for abdominal swelling from fluid back up?
Ascites
What is the clinical term for low oxygen perfusion which causes the skin to turn blue?
Cyanosis
What vaccine should a HF patient receive before discharge?
Flu and/or Pneumococcal
What safety checks are used before medication administration?
The 6 Rights of Med Pass
What is the priority assessment after giving IV Furosemide?
Monitor urine output
What assessment finding in the neck indicates increased venous pressure?
JVD
What condition is breathlessness when lying flat?
Orthopnea
What dietary education is required at discharge to reduce fluid volume overload?
Sodium Restriction
What is the priority action if a HF client suddenly becomes confused and anxious/restless?
Administer Oxygen
What safety assessment is most important to assess before giving Lisinopril?
Check the patients BP
What term means low urine output from poor kidney perfusion?
Oliguria
What is usually the first sign of poor cerebral perfusion?
Confusion
What daily self monitoring method should be taught at discharge?
Daily weight monitoring
What is the suspected medication toxicity if a HF patient reports yellow halos and nausea?
Digoxin
What assessment finding of fluid volume overload should the nurse report to the provider?
A weight gain of 2-3lbs in 24 hours
What is the definition of Right sided HF
The right side of the heart cant pump blood effectively to the the lungs, causing blood to back up into the veins.
What is the definition of Left sided HF
The left ventricle does not pump blood effectively to the body causing a blood to back up into the lungs.
What is the calculation for MAP
(Diastolic x2)+Systolic /3