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Chapter 20: Heart Failure Heart Failure New York Heart Association (NYHA) Functional Classification Measures the effect that symptoms (fatigue and dyspnea) of heart failure have on physical activities: ± Class I: No limitation of activities ± Class II: Slight limitation of activities, no symptoms at rest ± Class III: Marked limitation of activities, symptoms at rest ± Class IV: Not able to do any activities without symptoms; symptoms at rest The ACC/AHA Guidelines for Stages of Heart Failure Four stages enhance the NYHA Functional Classification system Used to outline the prevention, diagnosis, clinical management, and prognosis of patients with heart failure Only stages C and D correlate with the NYHA Functional Classification system Compensatory Mechanisms in Heart Failure See Figure 20-2. Assessment of Severity of Heart Failure Changes in neurological status Respiratory status ± Can patient speak in complete sentences?

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hepatojugular reflex. bloating Possible Cardiac Auscultation Findings in Patients With Heart Failure S3: warning of imminent or worsening heart failure Summation gallop Mitral regurgitation murmur Tricuspid regurgitation murmur Laboratory Studies Used in Evaluation of Heart Failure BNP and NT: pro-BNP test .diagnose and grade severity of heart failure . S4 Right-Sided Heart Failure Dependent edema. weight gain.2 ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ± Presence of dyspnea on exertion and at rest. crackles. JVD Hepatomegaly. Cheyne-Stokes respirations ± Orthopnea ± Paroxysmal nocturnal dyspnea Chest pain or discomfort Chronic Heart Failure Left-Sided Heart Failure Crackles Orthopnea Nocturia and coughing at nighttime S3. ascites Right upper quadrant pain Decreased appetite.

8 to 12 mm Hg. 20 mm Hg. CK-MB. decrease C. go slow . decreased. 8 to 12 mm Hg. it would result in a decreased cardiac output and an increase in renal insufficiency because the client needs a higher PAWP for ventricular filling because of the dilated cardiomyopathy. increase D. increased. A. decreased. 20 mm Hg.3 ‡ Cardiac biomarkers (CK. 8 to 12 mm Hg. decreased. decreased. a PAWP of ____ results in a(n) __ cardiac output and a(n) ___ in renal insufficiency. decrease ‡ Answer C. increase B. increase Rationale: If the client was diuresed and had a normal PAWP (8 to 12 mm Hg). Troponin) ‡ CBC ‡ Thyroid function tests ‡ Renal profile ‡ Liver function tests ‡ Lipid panel ‡ Question In the client with heart failure secondary to dilated cardiomyopathy. ‡ Medications Used in the Treatment of Chronic Heart Failure ‡ ACE inhibitors and ACE II blockers ± Main drug used in treatment ± Start low.

stop drug immediately ± Cough is annoying but harmless ‡ Medications Used in the Treatment of Chronic Heart Failure (cont.) ‡ Hydralazine and nitrates: given together when patient cannot take ACE inhibitors/blockers ± Monitor for tachycardia. hypotension ‡ Digoxin: blockade of norepinephrine ± Improves exercise tolerance and improves symptoms of heart failure ± Decreased dose in renal insufficiency or if taking amiodarone ± Keep blood level at 1. go slow .4 ± Monitor serum creatinine and potassium ± Watch for angioedema.0 ng/mL ± Medications Used in the Treatment of Chronic Heart Failure (cont.) ‡ Diuretics ± ACE inhibitors and beta-blockers provide maximum therapeutic effect when patient is euvolemic ± Educate patient on need to follow sodium restriction and weigh self daily ‡ Beta-blockers ± Use as long-term treatment with stable patients ± Improve exercise tolerance and ejection fraction ‡ Medications Used in Treatment of Acute Exacerbation of Heart Failure Inodilators: dobutamine. milrinone ‡ Monitor for ventricular dysrhythmias and tachycardia ‡ Start low. headache.

± See package insert for dosage formulas. ‡ Monitor BP continuously via arterial line.) Nesiritide ‡ If hypotension occurs. monitor BP. Hydralazine ‡ Give IVP over 3 to 5 minutes. decrease dose or discontinue and give IV fluids. BP every 15 min x4. Monitor cyanide level if used >24 hours. ‡ Wrap bottle in aluminum foil. visual blurring. mental status changes).) Nitroprusside ‡ Avoid high doses or prolonged use. ‡ Medications Used in Treatment of Acute Exacerbation of Heart Failure (cont. ‡ Question Nesiritide is a BNP approved by the FDA for its ability to do which of the following? A. urine output ‡ Give only in a central line ‡ Medications Used in Treatment of Acute Exacerbation of Heart Failure (cont. then every hour x2. ‡ Monitor for cyanide toxicity (tinnitus.5 ‡ Beta-blockers help prevent tachycardia Dopamine ‡ Higher doses increase afterload. Reduce preload . antidote is sodium thiosulfate. ‡ Monitor pulse. ‡ Bolus must be given from prepared IV bag. and place in supine position. cyanide level increases.

‡ Strategies to Manage Heart Failure to Decrease Incidence of Rehospitalization ‡ Educate client on sodium restriction and importance of label reading. Increase renal perfusion ‡ Answer B. Control blood pressure D. The medication does not increase renal perfusion. Nesiritide is very expensive and is not used to control blood pressure. improve diuresis. Act as a vasodilator Rationale: Nesiritide is a BNP approved by the FDA for its ability to vasodilate (reduce afterload). Hydralazine is used for blood pressure control and helps reduce afterload.6 B. Caution should be used if the systolic blood pressure is <90 mm Hg. ‡ Educate on a system to ensure medications are taken and recorded. Nitrates can be used to reduce preload. Act as a vasodilator C. ‡ Explain how walking 15 to 20 minutes/day will improve energy level. Dopamine is the drug that can be used to increase renal perfusion and improve diuresis. ‡ Explain why the client should avoid alcohol. ‡ Explain importance of taking daily weights and taking prompt action to resolve fluid retention. or decrease preload. ‡ Oxygenation/Ventilation Outcomes ‡ Hgb 10 g/dL or greater ‡ Pulse oximetry 90% or greater ‡ No dyspnea at rest ‡ NYHA class at baseline or better ‡ BNP within normal range .

0 Weight at baseline or better Urine output >30 mL/hr Mental status at baseline Vital signs normal Peripheral pulses intact Fluid/Electrolyte Outcomes Baseline BUN and serum creatinine and GFR Electrolytes within normal range Baseline weight or better No edema present No ascites present Mucous membranes moist and intact Teaching/Discharge Planning Outcomes Adequate verbal understanding of care and follow-up ± States ways to meet sodium restriction ± States process to weigh self daily to ensure accuracy ± States what to do if weight is 3 to 5 lb over baseline ± States will abstain from smoking and alcohol ± States realistic plan for exercise ± States plan to ensure medication compliance .7 ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Circulation/Perfusion Outcomes Cardiac index >2.

8 ‡ Home Care: Heart Failure ‡ Question The nurse is teaching a group of patients with chronic heart failure about home management. .´ D. ³I will watch food labels for hidden salt. ³I will weigh myself every day and act fast if I gain 2 pounds. ³I will walk for 25 minutes every day.´ C.´ B. ³Drinking a glass of wine every day will decrease my risk of coronary artery disease. it has deleterious effects on the heart with systolic dysfunction. Which statement during class discussion warrants further teaching? A.´ Rationale: Alcohol is a cardiac depressant. ³Drinking a glass of wine every day will decrease my risk of coronary artery disease. and although wine has been linked to a decreased risk for CAD.´ ‡ Answer A.

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