Nursing Diagnosis in Congestive Heart Failure

Questions and Answers

What is the primary benefit of using Patient-controlled analgesia (PCA) for pain management?

It guarantees immediate relief from all types of pain.

It enables patients to administer their own doses of opioids. (correct)

It allows for continuous intravenous delivery of anesthetics.

It completely eliminates the need for any nursing oversight.

Which statement about the delegation of PCA administration is correct?

Nursing assistants should notify nurses of any changes in patient status. (correct)

Nurses can delegate PCA administration to licensed practical nurses.

Nursing assistants can independently manage PCA devices.

Delegation to assistive personnel is acceptable in all scenarios.

What should a nurse advise a patient about their PCA device?

The device only works when plugged into a power source.

They can press the button whenever they feel pain. (correct)

They should wait for a nurse to administer any doses.

It is safe to allow family members to administer doses.

Which of the following steps is NOT part of the ABCs when prioritizing a patient in pain?

Pain assessment Signup and view all the answers

What is a significant risk associated with Patient-controlled analgesia (PCA)?

Uncontrolled dosage escalation. Signup and view all the answers

In the case of patient unresponsiveness while using PCA, what is the nurse's most appropriate action?

Notify the physician and monitor vitals. Signup and view all the answers

What is a primary goal when using PCA for pain management?

To maintain consistent plasma levels of analgesics. Signup and view all the answers

What should a nurse emphasize regarding the PCA device in terms of patient control?

The device allows patients to control their own pain relief. Signup and view all the answers

Which aspect of nursing care is essential while managing a PCA patient?

Monitoring the patient for any signs of overdose or adverse effects. Signup and view all the answers

Study Notes

Decreased Cardiac Output

Characterized by alteration in stroke volume due to congestive heart failure.
Indicators include cyanosis, crackles in lung fields, dyspnea, and decreased ejection fraction (EF).

Medical Diagnosis vs. Nursing Diagnosis

Medical diagnosis identifies specific diseases based on signs and symptoms, medical history, and diagnostic tests.
Nursing diagnosis focuses on patient responses to medical conditions, such as acute pain and impaired mobility.
Nursing care aims to prevent complications rather than solely address the primary medical issue (e.g., post-appendectomy care for infection, pain management).

Nursing Diagnostic Statements

Impaired physical mobility relates to cerebral damage from a right CVA, indicated by paralysis on the left side.
Evaluation of interventions is crucial when outcomes aren't fully met; requires consideration of intervention appropriateness and outcome attainability.
Documentation is essential, noting both positive and negative responses, including input from patients and healthcare providers.

Documentation of Evaluation

Progress evaluation can be challenging with short nursing shifts; consistent nurses find it easier over longer periods.
Outcome measures in documentation include criteria met, unmet, or partially met, along with explanations.

Dysrhythmias

Dysrhythmia refers to deviations from normal sinus rhythm, often presenting as atrial fibrillation or ventricular dysrhythmias.
Atrial fibrillation is marked by multiple pacemaker sites, characterized by an irregular rhythm and normal QRS complex but decreased cardiac output.
Ventricular dysrhythmias arise from ectopic impulse formation, featuring widened QRS complexes and can escalate to life-threatening conditions such as ventricular tachycardia.

Alveolar Responsibilities and Oxygenation

Alveoli facilitate gas exchange (oxygen and carbon dioxide).
Oxygenation involves three processes:
- Ventilation: movement of air into and out of the lungs.
- Perfusion: pumping oxygenated blood to tissues and returning deoxygenated blood to the lungs.
- Diffusion: gas movement across concentration gradients.
Atelectasis refers to alveolar collapse, which is prevented by surfactant maintaining surface tension.

Nursing Interventions

Manage respiratory care by monitoring blood oxygenation and evaluating baseline saturation.
Gastrointestinal (GI) considerations include assessing nutritional status due to risks of delayed gastric emptying and reflux.
Renal care focuses on monitoring urinary output and fluid balance prior to surgeries, especially in patients at risk for shock.

Prioritization in Patient Care

Follow the ABCs (Airway, Breathing, Circulation) alongside pain management and safety.

Patient-Controlled Analgesia (PCA)

PCA allows patients to self-administer opioids, ensuring a consistent plasma level for pain management.
The nurse cannot delegate PCA administration but can direct assistive personnel to report changes in patient status and educate patients about PCA usage.

Description

This quiz explores the differences between medical and nursing diagnoses with a focus on congestive heart failure. It examines essential characteristics of decreased cardiac output and related symptoms such as cyanosis and dyspnea. Test your understanding of the nursing implications in the context of cardiac conditions.