Heart Failure: Diagnosis and Management

Week 5: Heart Failure

• Heart failure (HF) is classified as left vs. right and systolic vs. diastolic
• Risk factors mirror those of Coronary Artery Disease
• HF can cause kidney failure and atrial fibrillation
• HF causes typically involve excessive preload or afterload
• Treatment focuses on managing volume and systemic vascular resistance
• Evaluation involves BNP level and echocardiogram
• Medical management includes inotropes (digitalis), diuretics, and vasodilators (nitroglycerin)
• Patient education emphasizes medication adherence, daily weight monitoring, output and BP tracking, regular follow-up, and exercise
• BNP of 1,229 pg/mL indicates severe HF exacerbation
• EF of 37% signifies HFrEF, or systolic heart failure
• Bibasilar crackles, edema, weight gain, and S3 gallop are classic signs of both LHF and RHF
• High INR + warfarin + co-trimoxazole increases bleeding risk, hold warfarin, give Vitamin K
• Be aware of BNP thresholds
• Monitor for digoxin toxicity (N/V, halos, confusion)
• Assess for fluid overload by monitoring daily weights, crackles, and I&O
• Avoid prescribing co-trimoxazole with warfarin
• BNP levels: <100 normal, 100-400 probable CHF, >400 very likely CHF
• Normal ejection fraction: 55–65%; <55% indicates heart failure
• Preload and Afterload are both elevated in HF; the key treatment goal is reducing them
• 'Pee it, Pump it, Pool it' is a framework for managing volume, contractility, and resistance
• Daily weight monitoring: >3 lbs in 2 days or >5 lbs in a week signifies a red flag
• Always prioritize positioning (e.g., raise HOB for SOB)
• S3 heart sound may indicate HF, requires note in assessments
• Crackles + IV Fluids + High BNP indicates stop fluids and notify provider immediately
• Digoxin toxicity signs: N/V, yellow halos, bradycardia, confusion
• Electrolyte monitoring (especially K+) is important with digoxin or diuretics
• Atypical signs include fatigue or confusion in elderly patients

Week 6: Breast/Prostate Reproductive Problems

• Breast cancer is prevalent in US women, and second leading cause after lung cancer
• Screening & early treatment are survival keys
• Benign breast lesions might need evaluation if infected/inflamed
• History involves reviewing multifactorial risks for breast cancer
• Tamoxifen, an anti-estrogen treats breast cancer, may cause menopause-like reactions
• Post-mastectomy include care of drains, prevention of infection, mastectomy exercise & lymphedema prevention after node dissection
• PSA-based screening is no longer recommended
• Erectile dysfunction can be psychogenic or physiologic
• TURP is a surgery cutting prostate section
• Prostatectomy can cause incontinence
• Female nurses use gloves for finasteride
• Tamoxifen for breast cancer can cause menopause
• Hormone Receptor Positive Breast CA responds to Tamoxifen (anti-estrogen)
• Post-mastectomy risk = Lymphedema, avoid BP/IV in affected arm
• Surgical drains (JP) are monitored for output & signs of infection
• Neutropenia + Fever = Emergency, sepsis risk post-chemo
• PSA > 4 ng/mL + LUTS symptoms (urgency, hesitancy) possibly BPH/cancer workup
• Flomax (Tamsulosin) side effect is orthostatic hypotension, dizziness
• Know post-op mastectomy care
• Report fever + ↓ WBC in cancer patient
• Manage TURP/CBI, prevent clots, monitor flow, watch for bladder spasms
• Fibrocystic breast changes are key
• Hormone receptor status (estrogen/progesterone), HER2, treatment implications
• Be aware of guidelines for ACS screening
• Understand breast cancer risks
• Estrogen link to breast cancer and fibroadenoma
• Lymphedema is a complication after node removal
• Know Jackson-Pratt drainage threshold for removal
• Lymphedema care & prevention are important
• Fibroadenoma vs Fibrocystic Breast Disease are compared & contrasted
• Triple-negative breast cancer is considered “Very aggressive"
• Difference & risk implications matter for BRCA1/2 mutations
• Hormone receptor positive tumors are easier to treat
• Note ACS mammogram guidelines as primary source, not USPSTF

Week 7: Renal & Urinary Notes

• E. coli commonly causes UTI, risk increases as women age
• Key kidney functions: strong bones, waste excretion, Na/H2O balance, RBC production & BP control
• ASO (antistreptolysin O) titers are produced from streptococcus throat infection for glomerulonephritis
• Upper tract UTIs (pyelonephritis) have higher symptom compared to lower
• Flank pain & fever indicate ascending UTI possibly causing AKI
• Sulfa drugs are common for uncomplicated UTIs
• Proteinuria is a glomerulonephritis (GN) manifestation, causing AKI
• Increased fluid intake can prevent kidney stones
• Painless hematuria is a common sign for bladder cancer
• Cystectomy patients may require different urinary diversions (may need stoma)
• Monitor bleeding & integrity for patients with stoma
• Quality stoma care/education are assisting keys
• For chronic kidney disease, monitor complete blood count to check for anemia
• Dialysis patients require evaluation of skin color, dialysis access site, vital indicators, cardiac & respiratory system, electrolytes
• Peritoneal dialysis drainage (effluent/outflow) should be clear/pale yellow
• Electrolytes need monitoring (K, Mg, and Na)
• Prioritize assessments include:
  • Vital signs every 4 hours
  • Daily weights
  • I/O monitoring
  • Mental status/LOC
  • Lung sounds (crackles) for fluid overload
  • Electrolyte monitoring
• Electrolyte imbalances may show hyperkalemia (peaked T-waves)
• Diagnostics: Ultrasound first (less harmful than CT)
• CT/MRI is used with caution, due to radiation/contrast toxicity
• Need to know the timing of dialysis before medication
• "Will Epic let you give a med? Yes. Should you always? No. You need to think—will it be dialyzed out?"
• A patient is scheduled for hemodialysis at 9 AM. Which of the following medications should the nurse hold?"
• The answer will likely be a BP med, water-soluble vitamin, or certain antibiotics depending on context
• HD: CBC monitor & fluid restrictions 1 L/day
• Risk of urinary diversion

Week 8: Upper GI, Hepatic Complications, and Blood Transfusions

• Heartburn, a GERD symptom, can mimic angina
• GERD patient teaching includes lifestyle adjustments: diet, avoiding trigger foods, no smoking
• Hiatal hernias are often asymptomatic, cause heartburn/GERD symptoms
• If lifestyle changes & drugs (PPIs, H2 blockers, antacids) fail, hiatal hernia/GERD patients might need surgery (Nissen fundoplication)
• Gastric ulcer (pain: 1-2 hours after meals), duodenal ulcer (pain: 4-5 hours after meals)
• PUD causes dull/burning pain between sternum/belly button (epigastric pain)
• Hospitalization causes stress ulcers, patients can have prophylactic treatment
• Rebound tenderness means gastric perforation
• Dumping syndrome occurs after gastric resection
• Hepatitis A transmits from close contact, sexual contact, contaminated food
• Hepatitis B transmits from contact with infectious blood, semen, other body fluids (birth, sexual contact)
• IV drug user should be tested for hepatitis C
• Hypoalbuminemia causes third spacing/fluid shift
• Blood transfusion best practices: check ID/DOB, stay for 15 minutes, check IV before sending blood, infuse quickly
• Strep viridans endocarditis can follow dental/GI infections
• Splinter hemorrhages, petechiae, new murmur can be classic signs
• Orthostatic hypotension + tachycardia can happen in hypovolemia or sepsis
• Digitalis toxicity (level 2.2): Hold med, notify provider
• VAP prevention involves head of bed elevated, oral care with chlorhexidine, sedation holiday
• Know signs of sepsis deterioration
• Prioritize antibiotics ASAP
• Watch for digitalis toxicity signs
• Remember to ask SATA about actions for preventing sepsis/VAP
• Hepatitis, livers, and cirrhosis are emphasized
• Review general progression
• Serology or blood work screening for Hep B
• New guidelines for hepatitis B, know what AFP is
• ESR indicates indication at its worst
• Vessel dilation anytime inflammation exists
• Know: No alcohol
• Fat-soluble vitamins needed
• Focus on clinical judgements & priorities when monitoring patient
• Check lab values, PT, PTT, INR, and coagulation
• Monitor blood products and FFP/transfusion products/PRBC
• NCLEX will as you: ammonia level + lactulose and what lab test the nurse effectiveness will be: Ammonia
• Involve liver labs and portal hypertension: Ammonia, encephalopathy, ascites, hypoalbuminemia, liver labs (AST, ALT, PT/INR), vitamin K
• Note the difference between Hep A, B, and C - transmission routes, vaccination status, and risk factors
• Know lactulose as treatment for ammonia buildup
• Analyze lab interpretation, bilirubin, albumin, platelets, INR, AST/ALT
• *Always assess for gag reflex before resuming oral intake
• Monitor vital signs (BP, HR)
• Observe for bleeding (coffee ground emesis, melena)
• Take aspiration precautions
• Then gradually advance the diet (clear full soft regular)