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The nurse's initial assessment should focus on identifying symptoms of life-threatening conditions. For this client, the most concerning findings include: Hypoxemia: Decreased oxygen saturation is a sign of inadequate gas exchange. This is most likely related to pulmonary edema from he...

The nurse's initial assessment should focus on identifying symptoms of life-threatening conditions. For this client, the most concerning findings include: Hypoxemia: Decreased oxygen saturation is a sign of inadequate gas exchange. This is most likely related to pulmonary edema from heart failure (HF) exacerbation. Crackles with auscultation: Crackles are a manifestation of pulmonary edema caused by fluid in the alveoli. Pulmonary edema is concerning for worsening HF and impaired gas exchange. Abnormal heart tones: An S3 heart tone (eg, ventricular gallop) is characteristic of HF and occurs during early diastole when blood from the atria rapidly enters the ventricle and hits the less compliant (stiff) ventricular wall, creating an audible vibration. Hypertension: Elevated blood pressure (eg, afterload) increases cardiac workload. This is especially concerning in a client with HF because the heart muscle is already weak and cannot withstand additional afterload. Peripheral edema: Bilateral lower extremity pitting edema in a client with HF is concerning for fluid volume overload. hypertension, extra heart tones, peripheral edema, dyspnea, crackles, tachypnea, and decreased oxygen saturation require further investigation due to concern for fluid overload and impaired gas exchange. An exacerbation of HF is identified by worsening symptoms, including: Crackles with auscultation and decreased capillary oxygen saturation: In clients with HF, blood backs up into the lungs (pulmonary edema) due to a failing left ventricle, producing crackles with auscultation and impairing alveolar gas exchange (Options 1 and 2). Elevated b-type natriuretic peptide (BNP): BNP is a hormone that produces natriuresis (ie, sodium elimination in urine) to compensate for fluid volume overload associated with HF. BNP is released in response to increased intraventricular volume and stretch (Option 3). Low left ventricular ejection fraction (EF) (ie, worsen respiratory distress by promoting displacement of venous air emboli into pulmonary circulation (upright position can allow air bubbles that have entered the blood circulation to migrate toward the brain or the heart due to gravity. In the case of a venous air embolism, air bubbles that are in the right atrium may move into the right ventricle and then into the pulmonary artery, potentially causing serious complications like a pulmonary embolism) left lateral decubitus position (lying on the left side) and in a trendelenburg position (where the body is laid flat on the back with the legs elevated). This positioning helps trap any air bubbles in a less dangerous area and facilitates the best possible blood flow and oxygenation. Femoral cardiac catheterization is a procedure in which a large catheter is inserted through a sheath in a femoral vessel and threaded to coronary vessels to diagnose and treat cardiac disorders. Immediately following cardiac catheterization, clients must remain supine with the head of the bed at ≤30 degrees. This prevents hip flexion, which could disrupt clot formation at the insertion site and cause bleeding. Because of this, the nurse should intervene if a staff member is assisting the client to sit on the side of the bed (also prevent movement for 24 hrs to prevent dislodge of clot) (Option 1) It is important to verify adequate perfusion to the affected extremity by frequently palpating the pedal pulses. Pulses should be palpated bilaterally for comparison. (Option 2) A small amount of bleeding can be expected after the catheter is removed. If bleeding occurs, it is appropriate to apply direct pressure over the insertion site. (Option 4) Chest pain after cardiac catheterization may be due to cardiac muscle damage but could also be caused by cardiac ischemia. This should be reported immediately to the health care provider. Deep venous thrombosis (DVT) occurs when a blood clot (ie, thrombus) becomes lodged in a vein and blocks circulation, most often in the deep veins of the lower extremities. Risk for DVT increases with age (>65), immobility, obesity, and oral contraceptive use. Early recognition of DVT is essential because thrombus can quickly dislodge from the vessel and cause life-threatening complications (eg, pulmonary embolism). Although clients may not experience symptoms, typical signs and symptoms of DVT include edema, localized pain (eg, calf pain) or tenderness, warmth, and erythema of the affected extremity (Options 2, 3, and 4). (Option 1) Dry, shiny, hairless skin that feels cool to touch can occur in chronic peripheral arterial disease. These manifestations occur from long-term impairment of blood flow to the extremity. (blood cant go to lower extremities; no oxygen so hair cant grow, toes will become cyanotic/gangrene; intermittent claudication d/t ischemic muscle pain) (Option 5) Cyanotic digits (eg, fingers, toes) with loss of sensation can occur in Raynaud phenomenon as a result of temporary vasospasm. When perfusion returns, the skin becomes red, throbbing, and often painful. Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated. If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade (Option 1) and if no such signs are present should troubleshoot other possible causes of chest tube occlusion. (Option 2) The health care provider should be notified after relevant assessment data has been gathered and troubleshooting has been performed. (Option 3) The chest tube should be kept free of dependent loops and kinks. This assists with proper drainage and prevents fluid from accumulating and backflowing into the mediastinum. (Option 4) Stripping (or milking) a chest tube should not be performed, unless specifically prescribed, as it can exert excessively high negative pressure and traumatize tissues within the mediastinum. Educational objective: A marked decrease in mediastinal chest tube drainage warrants immediate assessment for signs of cardiac tamponade (eg, muffled heart tones, pulsus paradoxus, hypotension). If there are no signs of tamponade, the nurse should troubleshoot other possible causes of chest tube occlusion and contact the health care provider. Complete heart block (third-degree atrioventricular block) is characterized by dissociated atrial and ventricular rhythms. Pulseless electrical activity is characterized by organized electrical activity on the ECG but no discernible pulse Asystole is characterized by complete absence of electrical activity on the ECG. The client will have no pulse or respirations, and will be unresponsive. The nurse should immediately initiate cardiopulmonary resuscitation Client teaching for heart failure Weight Measure & record daily weights (same amount of clothing, before monitoring breakfast but after voiding, same scale) Diet Sodium restriction to decrease fluid overload Examine over-the-counter drugs such as laxatives, cough medicines & antacids for sodium content Increase food rich in potassium if taking potassium-losing diuretics; restrict potassium if taking potassium-sparing diuretics Medication Take own pulse for 1 minute if taking digoxin or beta blockers. regimen Notify health care provider if 120/min. Know signs & symptoms of orthostatic hypotension & ways to prevent it Take blood pressure & keep a record of it Activity Increase walking or other activities gradually Plan for rest periods Consider a cardiac rehabilitation program Avoid extremes of heat & cold Symptoms to Weight gain of 3 lb (1.36 kg) in 2 days or 3-5 lb (1.36-2.27 kg) in a report week Difficulty breathing, especially with exertion or when lying flat Waking up breathless at night Frequent dry, hacking cough, especially when lying down Fatigue, dizziness, fainting Swelling of ankles, feet, abdomen, or face This client with heart failure would need to measure weight daily, restrict sodium and fluid intake, and know how to take a pulse. (Option 3) This client is not taking warfarin, so monthly testing of INR is not indicated. (Option 4) Spironolactone is a potassium-sparing diuretic, and so increasing dietary potassium is not necessary. Angiotensin-converting enzyme inhibitors such as captopril can cause hyperkalemia. (Option 6) The client's SpO2 was 96% on room air and home oxygen has not been prescribed. High potassium levels (hyperkalemia) can reduce the effectiveness of digoxin. In contrast, low potassium levels (hypokalemia) can increase the risk of digoxin toxicity. Sodium nitroprusside is a potent vasodilator that begins exhibiting effects within 1 minute and can produce a sudden and drastic decrease in blood pressure (symptomatic hypotension- light-headedness; cool, clammy skin). Therefore, the client's blood pressure should be monitored closely (ie, every 2-5 min). (Option 1) Capillary refill should be checked because it gives the nurse information about peripheral perfusion status, but it can be safely delayed until after BP is measured. (Option 2) The ECG monitor should be reviewed because the client is at risk for cardiac dysrhythmias; however, because hypotension is the main adverse effect of sodium nitroprusside, obtaining the client's BP is the priority. (Option 4) Breath sounds should be frequently assessed for clients with heart failure. However, light-headedness and cool, clammy skin are manifestations of hypotension, and obtaining the client's BP is the priority. Continuous cardiac monitoring may be accomplished via a portable unit (eg, Holter monitor) that can be carried in a pocket to allow for client mobility. The electrodes are placed on the client's torso, avoiding irritated skin, scars, or implantable devices (eg, pacemakers). The electrodes are not placed on the limbs because movement (eg, ambulation) causes artifact on the monitor (Option 4). For a 12-lead ECG, the leads are placed on the limbs because the test is completed within a few minutes while the client is stationary. nurse should verify that gel is present and moist on the back of each electrode to ensure appropriate conduction; the gel should not be dry and should not be removed. For clarity of recording, the skin should be clean, dry, and free of lotion. Hair can be clipped for better contact with skin if necessary. Shaving should be avoided because it can cause nicks in the skin, increasing the risk for infection.