What happened to the
plumbing?
NUR 1006
Nichole Moore, MSN, RN
Compensatory Measures - Starling’s Law
The more the myocardium is stretched, the greater
the force of contraction and the greater the cardiac
output
The greater the preload (amount of blood returning to
the heart), the farther the myocardial muscle
stretches, the more forceful the cardiac contraction
After time or with too much resistance the heart has
to pump against, the compensation methods fail to
work
1. SNS Activation
2. RAAS
3. Ventricular Dilation &
Hypertrophy
4. Counter-regulatory Mechanisms
Mr. Donner is a 72-year-old male admitted to the
cardiac unit for increasing dyspnea on exertion
and fatigue
Subjective Data
Objective Data
• History of HF for 2 years
• Unable to walk one block
without increasing dyspnea
• Sleeps at a 60-degree angle in
the reclining chair
• Increasing fatigue during the
last 2 weeks
• BP 140/78, P = 108, R= 24,
t= 98.8 (37.1)
• JVD at 45 degrees
• Frequent dry cough
• Bilateral crackles in lung
bases
• Nonpitting edema
• CXR – left and right
ventricular hypertrophy,
bilateral fluid in lower lungs
1. Explain the cause of Mr. Donner’s fatigue, cough &
dyspnea.
2. Which of Mr. Donner’s signs and symptoms are from
a. Left sided HF
b. Right sided HF
3. Explain the purpose of each of the following
therapies
a. Furosemide 40 mg PO BID
b. Benazepril 10 mg PO daily
c. 2 g sodium diet
d. 4L oxygen
4. Mr. Donner suddenly becomes dyspneic and
anxious, has moist crackles throughout his lungs,
and pink frothy sputum. Explain what is happening.
HF - Priority Assessments or
Cues
HF - Priority Laboratory Tests/
Diagnostics
HF - Priority Interventions or
Actions
HF - Priority Potential & Actual
Complications
Anxiety
Frustration
Grieving
Psychosocial
aspects
Depression
Lifestyle changes
Quality of life
Coping mechanisms
Hope
• An 89-year-old female client is admitted to the telemetry unit with a diagnosis
of heart failure exacerbation. She reports a medical history of osteoarthritis
and coronary artery disease including a myocardial infarction and coronary
artery bypass surgery 22 years ago. She is alert and her daughter is at her
bedside. The nurse’s initial client assessment findings include
• Oriented to person only
• Clear speech
• Follows simple commands
• Has sinus tachycardia
• Respirations = 26 breaths per min
• Oxygen saturation = 90% (room air)
• Breathing labored with use of accessory muscles
• Has productive cough with pink frothy sputum
• Crepitus in bilateral knee joints
• Enlarged bony nodes on hands
• Hemoglobin = 12.4 g/dL
• Hematocrit = 39%
Indicate which nursing action listed in the far-left column is appropriate for
each potential heart failure complication. Note that not all actions will be
used.
Nursing Action
Potential Heart Failure
Complication
1. Reduce sodium intake to 1
g daily
Acute pulmonary edema
2. Administer oxygen therapy
Hypokalemia
3. Weight the client each
morning on the same scale
Hypoxemia
4. Administer furosemide 20
mg intravenous push
5. Teach the client pursed-lip
breathing techniques
6. Administer potassium
supplements
7. Reposition every 2 hours
while in bed
Appropriate Nursing
Action for Each Potential
Heart Failure
Complication
For each assessment finding, use an X to indicated
whether the interventions were Effective (helped
to meet expected outcomes), Ineffective (did not
help to meet expected outcomes), or Unrelated
(not related to expected outcomes).
Assessment Finding
States she has no shortness of breath
since hospital discharge
Has 2+ pitting edema in both ankles
and feet
Blood pressure = 128/76 mm Hg
Has had no chest pain since hospital
discharge
Reports feeling like she has more
energy now when compared with
before her hospital stay
Has new-onset fungal skin infection
Effective
Ineffective
Unrelated