NR 324 EXAM 2 MEDICAL SURGICAL STUDY GUIDE
HEART FAILURE
Assessment of left and right
CAD: lab test Hct and LDL
Left Sided Heart Failure (think about s/s of Pulmonary
• Most common disorders)
• Prevents normal forward flowing blood
• Blood backs up into the left atrium, and then to the pulmonary vein
o Pressure increases, fluid leaks from the pulmonary capillary bed into the interstitium and then the
alveoli
o Results in pulmonary congestion and edema
• Signs
o LV heaves o Pleural effusion
o Alternating pulses (strong, weak): o Changes in mental status,
o Increased HR restlessness, confusion
o Decreased PaO2, slight increase o Orthopnea, shallow respirations, dry
PaCO2 (result poor oxygen hacking cough
exchange) o Nocturia
o Crackles (pulmonary edema) o **Frothy, pink-tinged sputum
o S3/S4 sounds (advanced pulmonary edema)
Right Sided Heart Failure
• RV fails to contract effectively
• Backup of blood into the right atrium, and then venous circulation
• Venous congestion in systemic circulation results in
o JVD
o Hepatomegaly
o Splenomegaly
o Vascular congestion of GI tract
o Peripheral edema: blood returning is blocked/backed up
• Can result from acute conditions such as RIGHT VENTRICULAR INFARCTION or P.E.
• CorPulmonale: right ventricular dilation and hypertrophy caused by pulmonary disease
• Primary cause: Left-sided HF
o Left side HF results in pulmonary congestion, increased pressure in the blood vessels of
lungs (pulmonary HTN)
o Chronic pulmonary HTN puts increased right ventricular afterload and results in right-sided
hypertrophy and HF
• Signs/Symptoms
o RV heaves, murmurs o Ascites: abdomen
o JVD: 30-45 degree angle to be able o Anasarca (massive generalized body
to see edema): 2+ everywhere
o Edema (pedal, scrotum, sacrum) o Hepatomegaly (liver enlargement):
o Weight gain o RUQ pain, anorexia, GI bloating
o Increased HR
1
, o
o
o Effect on organ perfusion
• Fatigue: earliest symptoms of chronic HF, caused by decreased CO, impaired perfusion to vital
organs, decreased oxygenation to the tissues, and anemia
• Dyspnea: Paroxysmal nocturnal dyspnea: reabsorption of fluid from dependent body areas when patient
is flat
• Tachycardia: body trying to compensate
• Edema
o Occur in dependent body areas (Peripheral), liver (hepatomegaly), abdominal cavity (acities) and
lungs (pulmonary edema and pleural effusion)
• Nocturia
o Decreased CO will have impaired renal perfusion and decreased urine output during the day
o When they lie down at night, fluid moves back into circulatory system
• Skin
o Tissue capillary oxygen extraction is increased, skin may appear dusky
o Lower extremities shiny and swollen, diminished or absent hair growth
o Chronic swelling brown areas
• Behavioral Changes
o Decreased cerebral perfusion leads to restlessness, confusion, decreased attention span or
memory
o Seen in late stages
• Chest Pain
o Decreased coronary artery perfusion from decreased CO and increased myocardial work
• Weight Changes
o Fluid retention
o Renal failure and fluid rentetion
o Ascities, hepatomegaly causes anorexia and vomiting
o Cachexia: muscle wasting and fat loss
• Renal insufficiency and failure
• Liver cells die, fibrosis occurs, and cirrhosis can develop
o
o Nursing care in hospital: Table 35-6
• Goals: Decrease in symptoms, decrease in peripheral edema, increase in exercise tolerance, adherence
with medical regimen, no complications
• Measures to manage BP or cholesterol with medication, diet, and exercise
• Valvular disease: have valve replacement planned before lung congestion develops
• CAD patients should consider coronary revascularization procedures
• Dysrythmias: antidysrhythmic drugs or pacing therapy
• Vaccinations against flu and pneumonia
• Treatment and quality of life goals
• Symptom management controlled by self management tools: daily weights, drug regimens, diet, exercise
• Salt and sometimes water must be restricted
• Conserve energy
• Support systems
2
, • Focus on reduction of anxiety (it stimulates the SNS response and increases workload), this is done by
nursing interventions and the use of sedatives
• Nursing responsibilities
o Teaching the patient about changes that have occurred
o Helping the patient to adapt to physiologic and psychological changes
o Integrate the patient and caregiver in the overall plan
o Provide a clear plan if s/s of HF occur
o Emphasize they can live a productive life
o Emphasize medication must be continued to keep HF under control even if they feel better
o Teach action of the drugs and signs of drug toxicity
o How to take a pulse rate (1 minute) if <50 withhold B-adrenergic blocker drugs.
Provide information when these drugs should be held and when a provider should call
o Teach s/s of hypo/per kalemia if diuretics are ordered
o Give supplemental potassium to those taking thiazide or loop
diuretics
• Consult with physical/occupational therapist on energy conserving techniques
• Exercise training (cardiac rehabilitation). Exercise is safe, help patient explore alternative activities that
cause less physical stress
o
o Lab test: BNP B-typye Natriuretic Perptide- hallmark of heart failure
o Table 35-6
• O2 therapy 2-6 L/min by nasal cannula
• Rest-activity periods
• Cardiac Rehabilitation
• Home health nursing care (telehealth monitoring)
• Drug therapy
• Cardiac resynchronization therapy with biventricular pacing and internal cardioverter-defibrillator
• LVAD
• Cardiac transplantation
• Palliative and end-of-life care
o
o Drugs
• Diuretics: Furosemide [Lasix], bumetanide [Bumex]
o Be careful may lose to much potassium
o Spironolactone: Aldactone: Potassium sparring
• Sodium Nitroprusside [Nipride]
o IV vasodilatory reduces preload/afterload
o Improves contraction, increases CO, and reduce pulmonary congestion
o Complications
▪ Hypotension
▪ Thiocyanate Toxicity (after 48 hrs of use)
• Dopamine:
o Look at IV site for extravasation
o Tissue necrosis w/ sloughing
o High dosages may produce ventricular dysrhythmias
o
3
HEART FAILURE
Assessment of left and right
CAD: lab test Hct and LDL
Left Sided Heart Failure (think about s/s of Pulmonary
• Most common disorders)
• Prevents normal forward flowing blood
• Blood backs up into the left atrium, and then to the pulmonary vein
o Pressure increases, fluid leaks from the pulmonary capillary bed into the interstitium and then the
alveoli
o Results in pulmonary congestion and edema
• Signs
o LV heaves o Pleural effusion
o Alternating pulses (strong, weak): o Changes in mental status,
o Increased HR restlessness, confusion
o Decreased PaO2, slight increase o Orthopnea, shallow respirations, dry
PaCO2 (result poor oxygen hacking cough
exchange) o Nocturia
o Crackles (pulmonary edema) o **Frothy, pink-tinged sputum
o S3/S4 sounds (advanced pulmonary edema)
Right Sided Heart Failure
• RV fails to contract effectively
• Backup of blood into the right atrium, and then venous circulation
• Venous congestion in systemic circulation results in
o JVD
o Hepatomegaly
o Splenomegaly
o Vascular congestion of GI tract
o Peripheral edema: blood returning is blocked/backed up
• Can result from acute conditions such as RIGHT VENTRICULAR INFARCTION or P.E.
• CorPulmonale: right ventricular dilation and hypertrophy caused by pulmonary disease
• Primary cause: Left-sided HF
o Left side HF results in pulmonary congestion, increased pressure in the blood vessels of
lungs (pulmonary HTN)
o Chronic pulmonary HTN puts increased right ventricular afterload and results in right-sided
hypertrophy and HF
• Signs/Symptoms
o RV heaves, murmurs o Ascites: abdomen
o JVD: 30-45 degree angle to be able o Anasarca (massive generalized body
to see edema): 2+ everywhere
o Edema (pedal, scrotum, sacrum) o Hepatomegaly (liver enlargement):
o Weight gain o RUQ pain, anorexia, GI bloating
o Increased HR
1
, o
o
o Effect on organ perfusion
• Fatigue: earliest symptoms of chronic HF, caused by decreased CO, impaired perfusion to vital
organs, decreased oxygenation to the tissues, and anemia
• Dyspnea: Paroxysmal nocturnal dyspnea: reabsorption of fluid from dependent body areas when patient
is flat
• Tachycardia: body trying to compensate
• Edema
o Occur in dependent body areas (Peripheral), liver (hepatomegaly), abdominal cavity (acities) and
lungs (pulmonary edema and pleural effusion)
• Nocturia
o Decreased CO will have impaired renal perfusion and decreased urine output during the day
o When they lie down at night, fluid moves back into circulatory system
• Skin
o Tissue capillary oxygen extraction is increased, skin may appear dusky
o Lower extremities shiny and swollen, diminished or absent hair growth
o Chronic swelling brown areas
• Behavioral Changes
o Decreased cerebral perfusion leads to restlessness, confusion, decreased attention span or
memory
o Seen in late stages
• Chest Pain
o Decreased coronary artery perfusion from decreased CO and increased myocardial work
• Weight Changes
o Fluid retention
o Renal failure and fluid rentetion
o Ascities, hepatomegaly causes anorexia and vomiting
o Cachexia: muscle wasting and fat loss
• Renal insufficiency and failure
• Liver cells die, fibrosis occurs, and cirrhosis can develop
o
o Nursing care in hospital: Table 35-6
• Goals: Decrease in symptoms, decrease in peripheral edema, increase in exercise tolerance, adherence
with medical regimen, no complications
• Measures to manage BP or cholesterol with medication, diet, and exercise
• Valvular disease: have valve replacement planned before lung congestion develops
• CAD patients should consider coronary revascularization procedures
• Dysrythmias: antidysrhythmic drugs or pacing therapy
• Vaccinations against flu and pneumonia
• Treatment and quality of life goals
• Symptom management controlled by self management tools: daily weights, drug regimens, diet, exercise
• Salt and sometimes water must be restricted
• Conserve energy
• Support systems
2
, • Focus on reduction of anxiety (it stimulates the SNS response and increases workload), this is done by
nursing interventions and the use of sedatives
• Nursing responsibilities
o Teaching the patient about changes that have occurred
o Helping the patient to adapt to physiologic and psychological changes
o Integrate the patient and caregiver in the overall plan
o Provide a clear plan if s/s of HF occur
o Emphasize they can live a productive life
o Emphasize medication must be continued to keep HF under control even if they feel better
o Teach action of the drugs and signs of drug toxicity
o How to take a pulse rate (1 minute) if <50 withhold B-adrenergic blocker drugs.
Provide information when these drugs should be held and when a provider should call
o Teach s/s of hypo/per kalemia if diuretics are ordered
o Give supplemental potassium to those taking thiazide or loop
diuretics
• Consult with physical/occupational therapist on energy conserving techniques
• Exercise training (cardiac rehabilitation). Exercise is safe, help patient explore alternative activities that
cause less physical stress
o
o Lab test: BNP B-typye Natriuretic Perptide- hallmark of heart failure
o Table 35-6
• O2 therapy 2-6 L/min by nasal cannula
• Rest-activity periods
• Cardiac Rehabilitation
• Home health nursing care (telehealth monitoring)
• Drug therapy
• Cardiac resynchronization therapy with biventricular pacing and internal cardioverter-defibrillator
• LVAD
• Cardiac transplantation
• Palliative and end-of-life care
o
o Drugs
• Diuretics: Furosemide [Lasix], bumetanide [Bumex]
o Be careful may lose to much potassium
o Spironolactone: Aldactone: Potassium sparring
• Sodium Nitroprusside [Nipride]
o IV vasodilatory reduces preload/afterload
o Improves contraction, increases CO, and reduce pulmonary congestion
o Complications
▪ Hypotension
▪ Thiocyanate Toxicity (after 48 hrs of use)
• Dopamine:
o Look at IV site for extravasation
o Tissue necrosis w/ sloughing
o High dosages may produce ventricular dysrhythmias
o
3
