Chapter 26 Nursing Care of Patients with Heart Failure

Answers CHAPTER 26 NURSING CARE OF PATIENTS WITH HEART FAILURE FLUID ACCUMULATION PATTERNS Left-Sided HF Left ventricle → left atrium → pulmonary veins → lungs AUDIO CASE STUDY Mrs. Sims and Heart Failure 1. Mrs. Sims gained 3 pounds in 2 weeks. Her ankles are swollen, and her shoes are tight. She is short of breath, has neck (jugular) vein distention, tires easily, and gets up to go to the bathroom as soon as she falls asleep. She awakened feeling as if she were suffocating. 2. Oxygen on at 2 L by cannula, intravenous (IV) diuretic. 3. Acute heart failure (HF) known as pulmonary edema. 4. Mrs. Sims was placed into the Fowler position so her lungs could expand more easily. Her oxygen was changed to a mask to provide higher oxygen amounts. Endotracheal intubation and mechanical ventilation were ordered on standby in case they were needed. Morphine was given via IV to quickly reduce anxiety, relax airways, and decrease preload. A diuretic was also given at an increased dose to reduce fluid congestion. A vasodilator was given to reduce hypertension and afterload, thus easing the heart’s workload. A urinary catheter was inserted. VOCABULARY 1. Pulmonary edema (acute heart failure) 2. Cor pulmonale 3. splenomegaly, hepatomegaly 4. peripheral vascular resistance 5. Paroxysmal nocturnal dyspnea 6. preload 7. afterload 8. Orthopnea 1 2 Chapter 26 Answers Right-Sided HF Right ventricle → right atrium → vena cava → jugular vein distention → hepatomegaly → splenomegaly → peripheral edema (2) Provides greater availability of oxygen in inhaled air. (3) Potent diuretic that, when given via an intravenous push (IVP), has a quicker onset of action to reduce the amount of fluid congestion and fluid returning to the heart to improve cardiac output. (4) Decreases preload, which reduces cardiac workload. 6. Possible priority nursing diagnoses include the following: Excess Fluid Volume related to pump failure; clear breath sounds and free of edema. Impaired Gas Exchange related to pump failure; maintains clear lung fields. Activity Intolerance related to fatigue; tolerates activity with appropriate increases in heart rate, blood pressure, and respirations. Disturbed Sleep Pattern related to nocturnal dyspnea; awakens refreshed and is less fatigued during day. 7. Signs and symptoms of HF; medications; purpose, monitoring (heart rate, potassium); side effects; diet; energy conservation; daily weights. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. SIGNS AND SYMPTOMS OF HEART FAILURE 1. (1) 2. (2) 3. (1) 4. (2) 5. (2) 6. (1) 7. (2) 8. (1) CRITICAL THINKING 1. Left-sided HF leading to backward fluid accumulation in lung tissues and decreased cardiac output. 2. Left: dyspnea, cough, crackles, orthopnea. Right: jugular vein distention, peripheral edema. 3. (1) Furosemide (Lasix) is a potent diuretic to reduce fluid congestion and fluid returning to the heart (preload) to improve cardiac output. (2) Lisinopril (Zestril) decreases afterload and cardiac hypertrophy. (3) Restricting sodium may reduce fluid volume and aid in reducing edema. (4) Oxygen administration provides greater availability of oxygen to the tissues by increasing the percentage of oxygen in inhaled air. 4. Mr. Donner is experiencing acute HF (pulmonary edema). Fluid accumulation in his lungs is severe and requires immediate treatment. 5. (1) Decreases fluid returning to the heart (preload) to ease the heart’s workload and improve cardiac output. 1. (3, 4) are correct. 0.125 mg by mouth (older adult) and 0.25 mg are within the normal adult daily dosage range for digoxin (Lanoxin). (1, 2) are less than the usual daily dose of Lanoxin. (5, 6) are greater than the usual daily dose of Lanoxin. 2. (1) is correct. Hypokalemia may predispose to digoxin (Lanoxin) toxicity. (2, 3, 4) do not predispose to digoxin (Lanoxin) toxicity. 3. (4) is correct. The right ventricle enlarges from the extra workload that occurs from the increased pulmonary pressures while ejecting blood into the pulmonary artery. (1, 2, 3) are not directly affected by pulmonary pressures. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 4. (2) is correct. Decreased cardiac output occurs with heart failure, leading to reduced oxygenation of the tissues and therefore fatigue. (1, 3, 4) all result from heart failure, as does fatigue. They do not cause the fatigue. 5. (4) is correct. The heart is failing as a pump to move blood forward. (1) occurs in cardiac arrest, (2) occurs in a myocardial infarction, and (3) is the opposite of what occurs with heart failure. 6. (3) is correct. Fluid in the lungs is heard as crackles. (1, 2, 4) are related to right-sided heart failure. 7. (1) is correct. If fluid accumulates from heart failure, weight will increase and is detectable by daily weights. (2) would be monitored for problems with an adequate caloric intake, not a fluid problem. (3) would be monitored for the effects of digitalis toxicity. (4) would be monitored for ascites development. 8. (2) is correct. Digoxin (Lanoxin) increases the strength of the heart’s contraction. This allows better emptying of the ventricle, which improves cardiac output and Chapter 26 increases blood flow to the kidneys, so increased urine output occurs. (1) is incorrect. If urine output decreases, digoxin has not improved cardiac output to increase blood flow to the kidneys. (3) is incorrect. Digoxin slows the heart rate. A rapid heart rate occurs to compensate for reduced cardiac output. (4) is incorrect. A slow heart rate is expected with digoxin, but below 50 beats per minute is slower than desired for effectiveness. 9. (1, 5, 6) are correct. Poor appetite as well as bradycardia and yellow lights are common signs of digoxin (Lanoxin) toxicity. (2) is incorrect. Diarrhea is a side effect of digoxin. (3) is incorrect. Yellow lights, not halos, are a sign of toxicity. (4) is incorrect. Apnea is not a specific sign of digoxin toxicity. 10. (4) is correct. Furosemide (Lasix) is a loop diuretic that may deplete electrolytes, especially potassium, so ongoing monitoring of potassium is necessary. (1, 2, 3) are not affected directly by furosemide and are not monitored for this therapy. 11. (1, 3, 5) are correct. Daily weights are essential to monitor the need for treatment if weight gain occurs. Edema indicates the need for treatment. Fresh vegetables do not contain salt to reduce salt intake in the diet. (2) is incorrect. A low sodium diet should be used, which would not include cooking with salt. (4) is incorrect. Diuretics are given to prevent edema, so they should be taken daily as prescribed, not just when edema occurs. 12. (3) is a common sign of pulmonary edema. (1, 2) are associated with right-sided heart failure, not acute heart failure. (4) is incorrect. Tachycardia occurs in pulmonary edema as a compensatory mechanism. 13. (4) is correct. Inotropic agents strengthen the heart’s contractions. (1) is incorrect. An agent that slows the heart rate is a chronotropic agent. (2) is incorrect. An inotropic agent does not increase heart rate. Answers 3 (3) is incorrect. Conduction time is not affected by the inotropic property of a medication. 14. (1) is correct. Furosemide is a potent diuretic that works quickly when given intravenously to increase urine output and subsequently pull fluid from extravascular spaces. It thereby reduces fluid in the lungs so bilateral crackles will diminish. (2, 3, 4) are not the reasons a diuretic is given. 15. (2) is correct. An anxious patient is comforted by the presence of the nurse and does not want to be left alone. (1) would increase oxygen needs and increase dyspnea and anxiety. (3, 4) could make the dyspneic patient feel more confined, increasing dyspnea and anxiety. 16. The area where congestion occurs from blood backup caused by left-sided heart failure. 4 Chapter 26 Answers 17. The area where the nurse would monitor for peripheral edema that occurs in right-sided heart failure. 18. The area where the nurse would auscultate for congestion occurring in acute heart failure.