HF
What is heart failure (CHF or HF)? Widely due to what three deficiencies?
1)structural abnormalities
2)myocardial failure (contractility/relaxation of the ventricle is impaired)
3)excessive demands on the heart muscle (sepsis or anemia)
Diagnosing HF based on clinical manifestations (3 groups)
What are the s/sx associated pulmonary congestion?
tachypnea, dyspnea, retractions in infants, flaring nares, exercise intolerance, orthopnea, cough, cyanosis, wheezing, grunting
What are the drugs and interventions used to decrease cardiac demands and lessen workload of the heart?
prevent cold-stress, treat existing infections, reduce effort of breathing (semi-fowlers), provide rest, and decrease stimuli from environment
What can you do as a nurse to lower risk of infection?
limit exposure to individual's w/ infection, promote good pulmonary hygiene (position changes, chest percussion/drainage), prophylactic antibiotics undergoing surgical or dental tx
S/sx of HF can be grouped into 3 categories, what are they?
1)impaired myocardial function
2)pulmonary congestion
3)systemic venous congestion
Diagnosing HF based on clinical manifestations (3 groups)
What are the s/sx associated systemic venous congestion?
weight gain, hepatomegaly, peripheral edema (especially periorbital), ascites, neck vein distention (children)
Digoxin:
Before giving dose, what assessments should you perform, labs/diagnostics should you reviewed?
assessments: heart rate, rhythm, and quality
labs/diagnostics: ECGs throughout IV administration and 6hrs after each dose, monitor electrolytes (magnesium, potassium, and calcium), renal and hepatic function
What can you do as a nurse to lower risk of inadequate nutrition?
offer small frequent meals, use soft nipple to ease stress of sucking, cluster nursing care to allow rest
What is right sided heart failure and how does it affect circulation? How might this manifest in a person?
right ventricle is unable to pump blood effectively into the pulmonary artery
decreased blood flow out of right ventricle will increased pressure in the right atrium and systemic venous circulation
systemic venous hypertension causes hepatosplenomegaly and generalized edema
What are some therapeutic management goals for HF?
improve cardiac function (increase contractility and decrease afterload)
remove accumulated fluid and sodium (decrease preload and minimize fluid overload)
decrease cardiac demands
improve tissue oxygenation and decrease oxygen consumption
Digoxin:
What nursing assessments are associated with a patient receiving digoxin?
Monitor apical pulse for 1 full minute (do NOT give if bpm is below 90-110 in infants, below 70-85 in children, or below 70 in older children)
monitor bp periodically in patients receiving IV dig
observe IV site for redness or infiltration; extravasation can lead to tissue irritability and sloughing
assess for peripheral edema and auscultate lungs for rales/crackles throughout therapy
What can you do as a nurse to lower risk of impaired gas exchange?
maintain clear airway, pulmonary hygiene, monitor electrolytes, monitor I&Os, limit fluids as prescribed, diuretics, limit activity, change position q2h
What is left sided heart failure and how does it affect circulation? How might this manifest in a person?
Left ventricle is unable to pump blood efficiently into the systemic circulation
decreased blood flow out of the left ventricle increases pressure in the left atrium and pulmonary vein
lungs congested with blood results in elevated pulmonary pressure and pulmonary edema
What are the drugs used to enhance myocardial function in HF?
digitalis glycosides (digoxin) = improves contractility; used almost exclusively in children due to rapid onset (dose calculated in micrograms)
Angiotensin-converting enzyme = reduces afterload - easier for heart to pump
beta-blockers (carvedilol; Coreg) = alpha/beta receptors blocked causing decreased heart rate, blood pressure, and vasodilation; used for chronic HF in children
cardiac resynchronization therapy (CRT) = uses biventricular pacing in adults, beginning to be applied to children
Digoxin:
What do you need to know to prevent toxicity and overdose? When do you contact the physician?
Infants are rarely given more than 50 mcg in one dose
IV/IM doses are calculated and divided into 3 doses given over a 12-24hr period. initial dose is 50% of total and the next 2 are 25% of total dose and given at 6 and 12 hr intervals
Therapeutic serum levels range from 0.5-2 mg/mL; serum levels may be drawn at 6-8hrs after a dose is administered
Neonates may have a falsely elevated serum level due to naturally occuring substance chemically similar to digoxin.
in infants and small children, the first s/sx of overdose is usually cardiac dysrhythmias. other s/sx of digoxin toxicity are vomiting and bradycardia. Contact physician immediately and withhold drug
What can you do as a nurse to lower risk of inadequate tissue perfusion?
monitor hemoglobin (newborn 14-24, infant 9.5-13)/hematocrit (~3x hemoglobin), keep child calm, do not allow long periods of crying (?), if hypercyanosis occurs, help child into squatting or knees-to-chest position, administer O2 and MS04 (morphine) during TET spells
Diagnosing HF based on clinical manifestations (3 groups)
What are the s/sx associated impaired myocardial function?
tachycardia, decreased urine output, fatigue, weakness, restlessness, pale, cool extremities, weak peripheral pulses, decreased blood pressure, cardiomegaly
What the drugs and interventions used to remove accumulated fluid and sodium? What is a possible complication of this therapy?
Diuretics (furosemide and thiazide)
fluid and possible sodium restrictions are also applied to remove excess fluid
potassium depletion, supplements or dietary changes to lower risk of hypokalemia
Digoxin:
What teachings should you provide patient and family?
Administer medications on schedule and proper measuring of dose
How to accurately take pulse
Teach parents/caregivers that changes in heart rate (bradycardia), vomiting, and dysrhythmias are signs of dig toxicity in infants and children.
Instruction in apical heart rate assessment and to notify HCP should heart rate fall outside of range set by HCP before administering next dose
What can you do as a nurse to lower risk of decreased cardiac output?
VS, monitor for s/sx of HF, note peripheral edema, daily weights, maintain strict I&Os, diuretics/O2 as ordered, palpate liver (right side failure), administer digoxin as ordered, assess for apical pulse and monitor for bradycardia/arrhythmias