Nursing
Judgement
Judgement
Three assessments you may find with a patient admitted with exacerbation of heart failure
excessive weight gain, orthopnea , rapid or irregular heartbeat, swelling of abdomen (ascites), cough & wheezing, crackles in lungs, edema, SOB, bloody sputum, weakness/fatigue, JVD, cyanosis
what cessation should all heart failure patients practice?
smoking cessation!
You see prolonged capillary refill during your assessment.. good or bad?
BAD!
Rationale:
pallor and prolonged refill time suggest heart failure (blood isn't pumping effectively throughout the body!)
TRUE or FALSE
Patients with left side diastolic dysfunction HF usually have normal ejection fraction
True
ECHO - 50-60% is normal
Anti-coagulants and anti-platelets are used for what?
preventing or treating blood clots
A patient with left sided heart failure is having trouble breathing. What position would you put them in?
high fowlers
rationale: patient might have pulmonary edema. left sided heart failure patients are most at risks for fluid overload and affect the lungs. this position helps with breathing.
priorities: high fowlers, O2, assess lungs sounds
What type of diet should you encourage your heart failure patient to be on?
heart healthy - low sodium (2-3 gm)
extra:
stay away from processed foods, eat plenty of veggies and lean cuts of meat
fluid restriction are also encouraged
Which of the following are typical S&S of left sided heart failure? select all that apply.
A. cough
B. exertional dyspnea
C. Edema in extremities
D. JVD - jugular venous distention
E. Orthopnea
A, B, E
JVD and edema are mostly seen in right sided heart failure
Which of the following is not used to diagnose heart failure?
A. Echo
B. nuclear stress test
C. Right or Left Catheterization
D. ECG/holter monitoring
D. cardiac monitoring is not a way to diagnose heart failure, it just is used to monitor the patients heart rate and rhythm
extra information:
left heart cath: help look at coronary arteries for blockages right hear cath: assess pulmonary pressures and caridac index
True or False:
Diastolic Heart failure involves a low ejection fraction and stiffening of the heart.
FALSE!
Rationale:
Diastolic heart failure does has a stiffening of the heart, but has a normal Ejection fraction.
systolic heart failure: EF is 40% or less and has enlarged/dilated/weak heart
What should be your first priority when checking the MAR and seeing a beta blocker prescribed?
Check MAR for blood pressure and/or heart rate parameters.
extra:
If there are no parameters, call the provider. hold drug until parameters are given.
As a patient with HF.... what should you do first thing in morning after urination?
What will be an expected finding in a patients sputum while in the late stages of left sided HF?
frothy-blood tinged sputum
Will your sodium be high or low in end stage HF?
LOW - confusion and weakness will occur due to low na levels
rationale: normally caused by change sin serum sodium and osmolality due to low cardiac output and blood pressure imbalances.
nocturnal diuresis is a sign of which sided heart failure?
right sided!!
left sided has the paroxysmal nocturnal dyspnea due to fluid in the lungs.
A physician order says to administer 40 mg Lasix IV twice a day. The patients morning labs were: Na+: 140, BNP: 855, K+: 2.2, BUN: 10. What is your priority as the nurse?
hold the dose and notify the physician about the low potassium levels.
Diuretics can lower potassium levels and this patient already has a very low potassium.
Two self management strategies for heart failure patients
follow medication regimen, daily weight, fluid restriction, low sodium diet, MD follow ups, smoking cessation
A client with MI suddenly becomes tachycardic, appears to be struggling for air, and begins coughing up pink sputum. What findings would the nurse anticipate when auscultating breath sounds?
crackles!! - all of the above are signs of pulmonary edema.
Why would you check creatinine labs with heart failure patients?
to determine stress on the kidneys, also assesses fluid status
rationale: when the heart isn't pumping efficiently it becomes congested and causes pressure build up in the veins connected to kidneys
two causes of HF
CAD, a-fib (other arrhythmia's), HTN, myocarditis(inflammation), congenital heart disease, previous Heart attack, heart valve disease, diabetes, HIV, thyroid conditions, buildup or iron/protein
A independent patient states, "talk to my wife about my medication. She's in charge now." What does this indicate about how HF is affecting his daily life?
its impacting his quality of life and ability to engage in self-care activities, role performance issues.
Something to address during admission and discharge, due to HF patients being high risk for contracting viruses...
Vaccination importance!
Most at risk for confusion in heart failure
older adults
anyone with HF is at risk but older adults are MOST at risk due to decreased functional reserves.
What value would you expect in a patient with heart failure?
A. sodium of 160
B. potassium of 6.5
C. BNP 50
High BNP (100-400), low NA (below 135), high K (above 5.1)
two factors that can cause readmission for a patient with HF
dietary non-compliance, not taking medication, not attending MD follow-ups (can be due to transportation, affordability, location of appointments), unavoidable progression of disease