1. The hemodynamics indicate cardiogenic shock . Which hemodynamic values
reflect this? What is status of preload and afterload? What medications can be given
to manage the preload and afterload?:
1. Professors Response: The hemodynamics indicate cardiogenic shock, with decreased
cardiac output increased preload and afterload. Management of all three parameters is
needed. Preload can be decreased with venous vasodilators and diuretics. Afterload can
be decreased with arterial vasodilators. Nitroprusside will vasodilate both venous and
arterial beds. Nitroglycerine may be added as a venovasodilator. Contractility can be
increased with dobutamine, dopamine or amrinone. Dopamine may increase afterload,
whereas dobutamine and amrinone will increase contractility and may also cause
vasodilation.
2. If medications are ineffective in managing preload and afterload, what
mechanical device might be used and how would it improve cardiac output?:
2. Professors Response: If these measures are not effective, an intra-aortic balloon pump
will decrease left ventricle workload by decreasing afterload and increase coronary artery
blood flow.
3. Mr.G. improves and is discharged from the hospital; however, he returns to the
hospital ED within 10 days with a diagnosis of heart failure. He states that I can t
catch my breath and my legs are as big as tree trunks and I have pain on my right
side . On assessment you find that he is strictly following the fluid and salt
restriction ordered since recent hospital admission but still reports that he has been
gaining 1 to 2 pounds every day since discharge. He states that he takes the
following medications: Enalapril (Vasotec) 5 mg bid, digoxin 0.125mg qd,
furosemide 40 mg qd; potassium chloride 20 mEq qd. The admitting physician
orders all the medications but changes the furosemide to 40 mg intravenous push
(IVP) qd and 80 mg IVP now. What error in teaching most likely occurred when
Mr.G. was discharged 10 days ago? :
3. Professors Response: He was not instructed when to call with early weight gain, thus
leading to current ER visit. Patients need to be instructed when to call their provider after
being discharged from the hospital for exacerbated heart failure. Complete selfmanagement patient education is considered a standard of care and is mandated by the
Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) when
providing care to hospitalized patients. The goal of the discharge treatment plan is to
minimize symptoms and prevent readmission.
4. Most heart failure admissions are related to fluid volume overload. Patients who
do not require intensive care monitoring can most often be treated initially with IVP
diuretics, oxygen, and angiotensin converting enzyme (ACE) inhibitors. What is the
rationale for giving the furosemide IVP? How will you evaluate its effectiveness?:
4. Professor's Response: Mr.G s is fluid overloaded and needs to decrease fluid volume
in a short period. IV administration is delivered directly into the vascular system, where it
can start to work immediately. In congestive heart failure (CHF), blood flow to the entire
gastrointestinal system is compromised; therefore the absorption of orally ingested
medications may be variable and take longer to work. You administer 80 mg furosemide
IVP; evaluate its effectiveness by: _ Daily weight _ Intake and output _ Decreased
dependent edema _ Decreased shortness of breath
5. How do ACE inhibitors help in CHF?:
5. Professor's Response: ACE inhibitors prevent the conversion of angiotensin I to
angiotensin II, a potent vasoconstrictor. This results in systemic vasodilation, thereby
reducing preload (reducing the volume of blood entering the left ventricle [LV]) and
afterload (reducing the resistance to the left ventricular contraction) in patients in CHF.
6. Why was Mr.G. receiving receiving digoxin and potassium?:
6. Professor's Response: Digoxin improves cardiac output by improving myocardial
contractility; monitor potassium levels carefully, hypokalemia can lead to digitalis
toxicity.
7. How would you classify Mr.G s heart failure? What lab studies would you expect
to be done?:
7. Professor's Response: Mr. G is evidencing symptoms of both right and left-sided
heart failure: right-sided (lower extremity edema, JVD, abdominal discomfort
(hepatomegaly); left-sided heart failure: dyspnea, tachycardia, crackles, fatigue and
probably an S3 can be heard. Chest x-ray to show heart enlargement, Echocardiogram to
show decreased ventricular function and decreased EF, elevated liver function studies,
elevated BUN and creatinine, elevated prothrombin time (liver congestion impairs livers
ability to synthesize procoagulants, BNP elevated; EKG show hypertrophy, ischemic
changes, tachycardia and arrhythmias.
8. Mr.G is ready for discharge. What key management concepts should be taught to
prevent relapse and another admission?:
8. Professor's Response: The most essential aspect of teaching hospitalized patients
without overloading them is to focus on realistic key points. Teaching should be aimed at
tips to improve symptoms and prevent readmission. The five most important concepts for
patients with heart failure are included in MAWDS instructions. _ Medications take as
directed, don t skip a dose, and do not run out of medications. _ Activity stay as active as
you can while limiting your symptoms. _ Weight weigh every morning, call if you gain
or lose 2 pounds overnight or 5 pounds from your target weight. _ Diet follow a low-salt
diet and limit fluids to less than 2 quarts/liters per day. _ Symptoms know what
symptoms to report to your provider; report early to prevent readmission.