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Name: Hoang Tran Sec: 007 CHF Simulation: Preparation Questions 1.

List the risk factors for chronic left-sided heart failure related to coronary artery disease. - Non-modifiable risk factors: Increasing age, gender (men>women until 65 yr of age), ethnicity (whites> African Americans), genetics predisposition and family history of heart disease. - Modifiable risk factors: hypertension, elevated serum lipids, tobacco use, physical inactivity, psychologic state, obesity, diabetes. 2. Explain the cause of the compensations for chronic heart failure. - HF can have an abrupt onset as with acute MI and rapid A-fib, or it can be an insidious process resulting from slow, progressive changes. The overload heart resort to compensatory mechanisms to try to maintain adequate CO. The main compensatory mechanisms include: - Sympathetic Nervous System Activation: First mechanism triggered in low CO states, but it is the least effective one. In response to inadequate stroke volume and CO, there is increased the release of catecholamines (epinephrine and norepinephrine) increase HR increase myocardial contractility and peripheral vasoconstriction. - Neurohormonal response: As CO falls, the blood flow to the kidneys decreases. In response, kidneys release rennin, which converts angiotensinogen to angiotensin I which subsequently convert to angiotensin II. Angiotensin II stimulate the release of aldosterone resulting in sodium and water rentention, vasoconstriction, which increase BP. - Activation of the SNS and the neurohormonal response result in increased cardiac workload , myocardial dysfunction, ventricular remodeling ( ventricles becomes larger and less effective pumps) - Dilation: Enlargement of chambers of the heart. Start as an adaptive mechanism to cope with increasing blood volume. Eventually this mechanism becomes inadequate and can no longer contract effectively thereby decreasing the CO. - Hypertrophy: Increase the muscle mass and cardiac wall thickness in response to overwork and strain. Hypertrophic heart muscles has poor contractility, require more oxygen to perform work and poor coronary artery circulation and is prone to dysrhymias. 3. Describe the manifestations and effects of right-sided and left-sided heart failure. Right-sided HF Left-sided HF - Right ventricle heaves - Left Ventricle heaves - Murmurs - Pulsus alternans (Alternating pulses, strong, - JVD weak) - Edema (pedal, scrotum, sacrum) - Increased HR

- Weight gain - Increased HR - Ascites - Anarsaca ( Massive generalizd body edema) - Hepatomegaly (liver enlargement) - Fatigue - Anxiety and depression - Dependent, bilateral edema - Right upper quadrant pain - Anorexia and GI bloating - Nausea

- Point of maximum displaced inferiorly and posteriorly ( LV hypertrophy) - Decreased PaO2, slight increase PaO2 (poor O2 exchange) - crackles (pulmonary edema) - S3 and S4 heart sound - pleural effusion - Change in mental status - Restlessness, confusion - Weakness, fatigue - Anxiety, depression - Shallow respirations up to 32-40/min - Paroxysmal nocturnal dyspea - Orthopnea ( SOB in recumbent position) - dry, hacking cough - nocturia - frothy, pink-tinged sputum ( advanced pulmonary edema)

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List the goals in the interdisciplinary care of a patient with chronic heart failure Treat underlying cause and contributing factors Maximize CO Provide treatment to alleviate symptoms Improve ventricular function Improve quality of life Preserve target organ function Improve mortality and morbidity risks

5. List the two hormones released by the heart muscle in response to changes in blood volume. - A- type Natriuretic Peptide (ANP) - B-type Natriuretic Peptide (BNP) - Both hormones lower BP by relaxing arterioles, inhibiting the secretion of rennin and aldosterone, inhibiting the reabsoprtion of sodium ions by the kidneys. 6. Explain the nursing implications for the client receiving echocardiography with Doppler flow studies. - Echocardiography- two-dimensional with Doppler flow studies may show ventricular hypertrophy, dilation of chambers and abnormal wall motion. - Place pt in a supine position on left side facing equipment. Instruct pt about procedure and sensations (pressure and mechanical movement from head of transducer). No contraindications to procedure exist. 7. Define refractory heart failure. - Pt with severe symptoms at rest despite maximal medical therapy

8. List the nursing implications and education needs for each of the following categories of medication related to heart failure: a. Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) ACE inhibitors( Captopril [Capoten]): Primary drug choice for blocking the RAAS system. - Implicationss: o Excessive hypotension and hyperkalemia may occur. o Monitor pt for first dose hypotension (first dose syncope) o Skipping dose or discontinuing the drug can result in rebound hypertension o Angioedema (swelling tongue and throat), a rare adverse effect, can develop suddenly and can be life threatening. o Can cause decrease sense of taste and rash in skin. - Education: o Inform pt that this med can cause dry cough o Notify the provider if pt observes a rash or has a decreased sense of taste o Notify the provider if swelling of the face or extremities occurs o Remind pt that BP needs to be monitored every 2hr after the initial dose to detect the hypotension. Angiotensin II Receptor Blockers (Losartan [Cozaar]): For pt who unable tolerate ACE inhibitors. Contraindicated for pt with renal deficiency. b. Beta-adrenergic receptor blockers: block negative effects of the SNS on the failing heart, such as increased HR. Beta- blockers can reduce myocardial contractility. Implication: o Overdosage can produce profound bradycardia, hypotension, bronchospasm and cardiogenic shock. Hold med if pts apical pulse is less than 60/min and notify the provider. o Obtain standing BP 1hr after dosing to assess tolerance. o Abrupt withdrawal may result in sweating, palpitations, and HA. Education: o Encourage pt to sit and lie down slowly o Remind pt to notify the provider immediately if SOB, edema, weight gain or cough occur. c. Diuretics: reduce pulmonary venous pressure and reduce preload. Furosemide (Lasix), bumetanide (Bumex), hydrochlorothiazide (Hydrodiuril), spironolactone (Aldactone). Implication: o Administer furosemide IV no faster than 20mg/min o Loop and thiazide diuretics can cause hypokalemia, and potassium supplementation may be required. Education: o Teach client taking loop or thiazide diuretics to ingest food and drink that are high in potassium to counter the effects of hypokalemia.

d. Positive inotrope agents: Digitalis preparation. Increasee the force of cardiac contraction, thereby increase CO. Decrease conduct speed within the myocardium and slow the HR. Digoxin (Lanoxin), dopamine, dobutamine (Dobutrex), milrinone (Primacor). Implication: o Taking apical HR for 1min. Hold med if apical pulse is less than 60/min and notify the provider o Observe pt for N/V o Dopamine, dobutamine and milrinone are administered via IV. ECG, BP and urine output must be closely monitored. Education: o Report sign of fatigue, muscle weakness, confusion, and loss of appetite. o For digoxin self-admistration: count pulse for 1 min, hold med if pulse is less than 60/min and notify the provider; do not take digoxin at the same time as antacids. e. Sympathomimetic agents: mimic the action of SNS. Dobutamine (Dobutrex), dopamine (Intropine), epinephrine (Adrenalin) Implication: o Administer via central line o Monitor HR, BP o Stop infusion if tachydysrthymias develop f. Phosphodiesterase inhibitors: sidefanil (Revatio). Decreasing pulmonary vascular resistance. Implication: o Pt using nitrates (nitroglycerin for agina) should not take this drug because of severe of hypotension may develop.

9. List the interdisciplinary interventions for each of the following nursing diagnoses related to chronic heart failure. a. Decreased cardiac output: Perform a comprehensive appraisal of peripheral circulation (check pt pulses, edema, capillary refill, color, and temperature of extremity) to determine circulatory status Note signs and symptoms of decreased cardiac output to detect changes in status Monitor for cardiac dysrthymias to detect cardiac decompensation Monitor for dyspnea, fatigue, tachypnea, and orthopnea to identify involvement of respiratory system Instruct pt and caregivers on activity restriction and progression to allay fears and anxiety. b. Excessive fluid volume Administer prescribed diuretics Monitor therapeutic effect of diuretic (increase urine output, decrease CVP/ PAWP, and decreased adventitious breath sounds) to assess response to treatment

Monitor potassium levels after dieresis to detect excessive electrolytes loss Weight pt daily and monitor trends to evaluate effect of treatment Monitor intake and output to assess fluid status. Monitor respiratory pattern for symptoms of respiratory difficulty to detect pulmonary edema. Monitor hemodynamic status, including CVP, MAP, PAWP, if available to evaluate effectiveness of therapy Monitor changes in peripheral to assess response to treatment.

c. Activity intolerance: Encourage alternate rest and activity periods to reduce cardiac workload and conserve energy Provide calming diversionary activities to promote relaxation to reduce O2 consumption and to relieve dyspnea and fatigue. Monitor pts O2 response (pulse rate, cardiac rhythm, and respiratory rate) to self-care or nursing activities to determine level of activities that can be performed. Teach pt and caregiver techniques and self-care that will minimize O2 consumption (self-monitoring and pacing techniques for performance of ADLs) Collaborate with occupational, physical, and/or recreational therapists to paln and monitor activity exercise program Determine pts commitment to increase frequency and/or range of activities/exercise to provide pt with obtainable goals. d. Ineffective health maintenance Encourage alternate rest and activity periods to reduce cardiac workload and conserve energy Provide calming diversionary activities to promote relaxation to reduce O2 consumption and to relieve dyspnea and fatigue. Monitor pts O2 response (pulse rate, cardiac rhythm, and respiratory rate) to self-care or nursing activities to determine level of activities that can be performed. Teach pt and caregiver techniques and self-care that will minimize O2 consumption (self-monitoring and pacing techniques for performance of ADLs) e. Deficient community health; Appraise the pts current level of knowledge related to specific disease process to identify needed areas of teaching Describe common signs and symptoms of the disease so pt will know signs and symptoms to report to health care provider Instruct pt and caregiver on measures to prevent/ minimize SE of treatment for the disease so pt may be able to decrease number of acute episodes of HF. 10. List the signs and explain the interdisciplinary interventions for each of the following nursing diagnoses related to pulmonary edema. a. Impaired gas exchange:

Monitor rate, rhythm, depth, and effort of respiration to evaluate changes in a respiratory status Auscultate breath sound, noting areas of decreased/absent ventilation and presence of adventious sounds to detect presence of pulmonary edema. Monitor for increased restlessness, anxiety, and air hunger to detect increasing hypoxemia Administer supplemental O2 as ordered to maintain O2 levels Monitor the O2 liter flow and postion of O2 delivery device to ensure O2 is adequately delivered Change O22 delivery device from mask to nasal prongs during meals as tolerated to sustain O2 levels while eating Monitor the effectiveness of O2 therapy to identify hypoxemia and establish range of O2 saturation Position to alleviate dyspnea (semi Fowlers position) as appropriate, to improve ventilation by decreasing venous return to the heart and increasing thoracic capacity.

b. Decreased cardiac output: Perform a comprehensive appraisal of peripheral circulation (check pt pulses, edema, capillary refill, color, and temperature of extremity) to determine circulatory status Note signs and symptoms of decreased cardiac output to detect changes in status Monitor for cardiac dysrthymias to detect cardiac decompensation Monitor for dyspnea, fatigue, tachypnea, and orthopnea to identify involvement of respiratory system Instruct pt and caregivers on activity restriction and progression to allay fears and anxiety c. Anxiety: Carefully explain the situation and provide emotional support and reassurance to help relieve the pts anxiety.