The Patient With Heart Failure PDF

10/18/23, 3:02 AM Realizeit for Student The Patient With Heart Failure Despite advances in treatment of HF, morbidity and mortality remain high. Nurses have a major impact on outcomes for patients with HF, especially in the areas of patient education and monitoring. Assessment Nursing assessment f...

10/18/23, 3:02 AM Realizeit for Student The Patient With Heart Failure Despite advances in treatment of HF, morbidity and mortality remain high. Nurses have a major impact on outcomes for patients with HF, especially in the areas of patient education and monitoring. Assessment Nursing assessment for the patient with HF focuses on observing for effectiveness of therapy and for the patient’s ability to understand and implement self-care management strategies. Signs and symptoms of worsening HF are analyzed and reported to the patient’s provider so that therapy can be adjusted. The nurse also explores the patient’s emotional response to the diagnosis of HF, because it is a chronic and often progressive condition that is commonly associated with depression and other psychosocial issues (Jiang, Shorey, Seah, et al., 2018). HEALTH HISTORY The health history focuses on the signs and symptoms of HF, such as dyspnea, fatigue, and edema. Sleep disturbances, particularly sleep suddenly interrupted by shortness of breath, may be reported. Patients are asked about the number of pillows needed for sleep, edema, abdominal symptoms, altered mental status, activities of daily living, and the activities that cause fatigue. Nurses need to be aware of the variety of clinical manifestations that may indicate worsening HF and assess the patient accordingly. While obtaining the patient’s history, the nurse assesses the patient’s understanding of HF, self-care management strategies, and the patient’s ability and willingness to adhere to those strategies. PHYSICAL EXAMINATION The patient is observed for restlessness and anxiety that might suggest hypoxia from pulmonary congestion. The patient’s level of consciousness is also evaluated for any changes, as low CO can decrease the flow of oxygen to the brain. The rate and depth of respirations are assessed along with the effort required for breathing. The lungs are auscultated to detect crackles and wheezes (Meyer, 2019a). Crackles are produced by the sudden opening of edematous narrowed airways and alveoli. They may be heard at the end of inspiration and are not cleared with coughing. Wheezing may also be heard in some patients who have bronchospasm along with pulmonary congestion. The blood pressure is carefully evaluated, because patients with HF may present with hypotension or hypertension. Patients may be assessed for orthostatic hypotension, especially if they report lightheadedness, dizziness, or syncope. The heart is auscultated for an S3 heart sound, which is an early sign that increased blood volume fills the ventricle with each beat. Heart rate and rhythm are also documented, and patients are often placed on continuous ECG monitoring in the hospital setting. When the heart rate is rapid or very slow, the CO decreases and potentially worsens the HF. JVD is https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IYH%2fMiUZkmGn1VrFXwQeG%2fpUCxJZEI1Lebfhwo2Y… 1/5 10/18/23, 3:02 AM Realizeit for Student assessed with the patient sitting at a 45-degree angle; distention greater than 4 cm above the sternal angle is considered abnormal and indicative of right ventricular failure (Bickley, 2017). This is an estimate, not a precise measurement, of high central venous pressure. The nurse assesses peripheral pulses and rates their volume on a scale from 0 (not palpable) to 3+ (bounding). The skin is also assessed for color and temperature. With significant decreases in SV, there is a decrease in perfusion to the periphery, decreasing the volume of pulses and causing the skin to feel cool and appear pale or cyanotic. The feet and lower legs are examined for edema; if the patient is supine in bed, the sacrum and back are also assessed for edema. The upper extremities may also become edematous in some patients. Edema is typically rated on a scale from 0 (no edema) to 4+ (severe pitting edema). The abdomen is examined for tenderness and hepatomegaly. The presence of firmness, distention, and possible ascites is noted. The liver may be assessed for hepatojugular reflux. The patient is asked to breathe normally while manual pressure is applied over the right upper quadrant of the abdomen for 30–60 s. If neck vein distention increases more than 1 cm, the finding is positive for increased venous pressure. If the patient is hospitalized, the nurse measures urinary output and evaluates it in terms of diuretic use. Intake and output records are rigorously maintained and analyzed. It is important to track whether the patient has excreted excessive volume (i.e., negative fluid balance is generally the goal). The intake and output is then compared with changes in weight. Although diuresis is expected, the patient with HF must also be monitored for oliguria (diminished urine output, less than 0.5 mL/kg/h for at least 6 h or <400 mL/24 h) or anuria (urine output of less than 50 mL/24 h) because of the risk of renal dysfunction. The patient is weighed daily in the hospital or at home, at the same time of day, with the same type of clothing, and on the same scale. If there is a significant change in weight (i.e., 2–3-lb increase in a day or 5-lb increase in a wk), the primary provider is notified and medications are adjusted (e.g., the diuretic dose is increased). Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Activity intolerance associated with decreased CO Hypervolaemia associated with the HF syndrome Anxiety associated with clinical manifestations of HF Powerlessness associated with chronic illness and hospitalizations Impaired family ability to manage regime MONITORING AND MANAGING POTENTIAL COMPLICATIONS https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IYH%2fMiUZkmGn1VrFXwQeG%2fpUCxJZEI1Lebfhwo2Y… 2/5 10/18/23, 3:02 AM Realizeit for Student Because HF is a complex and progressive condition, patients are at risk for many complications, including acute decompensated HF and pulmonary edema; hypotension and cardiogenic shock; arrhythmias; thromboembolism formation; and pericardial effusion. Pulmonary Edema. As described previously, pulmonary edema is associated with acute decompensated HF that can lead to acute respiratory failure and death. If it is recognized early, pulmonary edema may be alleviated by increasing dosages of diuretics and by implementing other interventions to decrease preload. For instance, placing the patient in an upright position with the feet and legs dependent reduces left ventricular workload. The treatment regimen and the patient’s understanding of and adherence to it are assessed. The long-range approach for preventing pulmonary edema must be directed at identifying and managing its precipitating factors. Clinical management of a patient with acute pulmonary edema due to left ventricular failure is directed toward reducing volume overload, improving ventricular function, and increasing oxygenation. These goals are accomplished through a combination of oxygen and ventilatory support, IV medication, and nursing assessment and interventions. The patient’s airway and breathing are assessed to determine the severity of respiratory distress, along with vital signs. The patient is placed on pulse oximetry, a cardiac monitor, and IV access is confirmed or established for administration of medications. Laboratory tests are obtained, including arterial blood gases, electrolytes, BUN, and creatinine; other laboratory tests that may be indicated include a complete blood cell count (CBC), BNP, or a serum troponin-I. A chest x-ray or an ultrasound of the lungs may be obtained to confirm the extent of pulmonary edema (Meyer, 2019a). Oxygen is given in concentrations adequate to relieve hypoxemia and dyspnea; a non-rebreathing mask may be used initially. If respiratory failure is severe or persists, noninvasive positive-pressure ventilation is the preferred mode of assisted ventilation (Colucci, 2019). For some patients, endotracheal (ET) intubation and mechanical ventilation are required. The ventilator can provide positive end-expiratory pressure (PEEP), which is effective in reducing venous return, decreasing fluid movement from the pulmonary capillaries to the alveoli, and improving oxygenation. Oxygenation is monitored by pulse oximetry and by measurement of arterial blood gases. The patient who is experiencing pulmonary edema is likely going to be highly anxious, as are the patient’s family members. As the ability to breathe decreases, the patient’s fear and anxiety rise proportionately, making the condition more severe. Reassuring the patient and family and providing skillful anticipatory nursing care are integral parts of the therapy. Because the patient is in an unstable condition, the nurse must remain with the patient. The nurse gives the patient simple, concise information in a reassuring voice about what is being done to treat the condition and the expected results. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IYH%2fMiUZkmGn1VrFXwQeG%2fpUCxJZEI1Lebfhwo2Y… 3/5 10/18/23, 3:02 AM Realizeit for Student Vasodilators such as IV nitroglycerin or nitroprusside may enhance symptom relief in pulmonary edema, as previously described (Meyer, 2019a). Blood pressure is continually assessed in patients receiving IV vasodilator infusions. Furosemide or another loop diuretic is given by IV push or as a continuous infusion to produce a rapid diuretic effect. The blood pressure is closely monitored as the urine output increases, because it is possible for the patient to become hypotensive as intravascular volume decreases. The patient receiving diuretic therapy may excrete a large volume of urine within minutes after a potent diuretic is given. A bedside commode may be used to decrease the energy required by the patient and to reduce the resultant increase in cardiac workload induced by getting on and off a bedpan. If necessary, in order to carefully monitor urine output, an indwelling urinary catheter may be inserted. Once the patient is stable, they may transition to oral diuretics; intake and output, daily weights, serum electrolytes, and creatinine are carefully monitored. Many potential problems associated with HF therapy relate to the use of diuretics. These problems require ongoing nursing assessment and collaborative intervention: Excessive and repeated diuresis can lead to hypokalemia (i.e., potassium depletion). Signs include ventricular arrhythmias, hypotension, muscle weakness, and generalized weakness. In patients receiving digoxin, hypokalemia can lead to digitalis toxicity, which increases the likelihood of dangerous arrhythmias. Patients with HF may also develop low levels of magnesium, which can add to the risk of arrhythmias. Hyperkalemia may occur, especially with the use of ACE inhibitors, ARBs, or spironolactone. Hyperkalemia can also lead to profound bradycardia and other arrhythmias. Prolonged diuretic therapy may produce hyponatremia (deficiency of sodium in the blood), which can result in disorientation, weakness, muscle cramps, and anorexia. Volume depletion from excessive fluid loss may lead to dehydration and hypotension. ACE inhibitors and beta-blockers may contribute to the hypotension. Other problems associated with diuretics include increased serum creatinine (indicative of renal dysfunction) and hyperuricemia (excessive uric acid in the blood), which leads to gout. Educating Patients About Self-Care The nurse provides patient education and involves the patient and family in the therapeutic regimen to promote understanding and adherence to the plan. When the patient recognizes that the diagnosis of HF can be successfully managed with lifestyle changes and medications, recurrences of acute HF lessen, unnecessary hospitalizations decrease, and life expectancy increases. Nurses play a key role in educating patients and their families about medication management, a low sodium diet, moderate alcohol consumption, activity and exercise recommendations, smoking cessation, how to recognize the signs and symptoms of worsening HF, and when to contact the primary provider (Jones et al., 2017). Use of the teach-back technique to assess the patient’s comprehension of the instructions can increase education effectiveness and prevent rehospitalization (Esquivel, White, Carroll, et al., 2018). In order for teach-back to be effective, the nurse must ensure adequate time is dedicated to ensuring that patient learning occurs (Esquivel et al., 2018). The patient should receive a written copy of the instructions. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IYH%2fMiUZkmGn1VrFXwQeG%2fpUCxJZEI1Lebfhwo2Y… 4/5 10/18/23, 3:02 AM Realizeit for Student The patient’s readiness to learn and potential barriers to learning are assessed. Patients with HF may have temporary or ongoing cognitive impairment due to their illness or other factors, increasing the need to rely on an identified caretaker (Hodson et al., 2019). An effective treatment plan incorporates both the patient’s goals and those of the health care providers. The nurse must consider cultural factors and adapt the education plan accordingly. Patients and families need to understand that effective HF management is influenced by choices made about treatment options and their ability to follow the treatment plan. They also need to be informed that health care providers are available to assist them in reaching their health care goals. Continuing and Transitional Care Successful management of HF requires adherence to a complex medical regimen that includes multiple lifestyle changes for most patients. Assistance may be provided through a number of options that optimize evidence-based recommendations for effective management of HF. Depending on the patient’s physical status and the availability of family assistance, a home care referral or another type of disease management program may be indicated for a patient who has been hospitalized. Transitional care programs (hospital to home) that include telephone contact along with home visits have been shown to decrease rehospitalizations and increase patient quality of life (Cyrille & Patel, 2017; Jones et al., 2017). Home visits by nurses who are specially trained in managing patients with HF provide assessment and management tailored to specific individualized patient needs. Older patients and those who have long-standing heart disease with compromised physical stamina often require assistance with the transition to home after hospitalization for an acute episode of HF. The home health nurse assesses the physical environment of the home and makes suggestions for adapting the home environment to meet the patient’s activity limitations. If stairs are a concern, the patient can plan the day’s activities so that stair-climbing is minimized; for some patients, a temporary bedroom may be set up on the main level of the home. The home health nurse works with the patient and family to maximize the benefits of these changes. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IYH%2fMiUZkmGn1VrFXwQeG%2fpUCxJZEI1Lebfhwo2Y… 5/5