Chapter 34: Heart Failure
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2.
Complete the following chart with the clinical manifestations of each. Highlight
KEY differences that distinguish each type.
Right-sided heart failure (HF)
Left-sided heart failure (HF)
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Dependent edema
Jugular venous distension
Abdominal distension
Splenomegaly
Anorexia
Nocturnal diuresis
Hypertension/hypotension
SOB
Severe fatigue
Pulmonary problems:
Dyspnea
Tachypnea
Crackles
Dry cough
Paroxysmal nocturnal dyspnea
Pulmonary edema
Mark the area where the nurse would monitor for edema that occurs from rightsided heart failure & congestion occurs from left-sided heart failure.
CRITICAL THINKING
Read the following case study and answer the questions.
Mr. Stephan, age 70, is 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
• Increasing fatigue during the last 2
weeks
• Sleeps at 60-degree angle in reclining
chair
• Blood pressure 140/78 mm Hg,
pulse 108 beats per minute,
respirations 24 breaths per minute,
temperature 98.8°F (37.1°C)
• Chest x-ray examination: left and
right ventricular hypertrophy,
bilateral fluid in lower lung lobes
• Jugular vein distention at 45
degrees
• Bilateral crackles in lung bases
• Has frequent dry cough
• Nonpitting edema
1. Explain the cause of Mr. Stephan’s fatigue, cough, and shortness of breath.
 Impaired gas exchange r/t fluid in lungs
 Fluid imbalance
2. Which of Mr. Stephan’s signs and symptoms are from left-sided HF and which are
from right-sided HF?
Left: left ventricular hypertrophy, bilateral fluid in lower lung lobes, bilateral
crackles in lung bases, dry cough, activity intolerance
Right: right ventricular hypertrophy, jugular vein distention, nonpitting edema
3. Explain the purpose of each of the following therapies. How would they be
beneficial in treating Mr. Stephan’s heart failure?
• Furosemide (Lasix) 40 mg by mouth twice daily:
▪ Diuretic that would remove excess fluid buildup
• Lisinopril (Zestril) 5 mg by mouth daily:
▪ Antihypertensive (ACE inhibitor) that would lower risk of fatal
cardiovascular event, reduces afterload and SVR, dilates venule and
arterioles, improves renal blood flow, and inhibits ventricular
hypertrophy
• 2g sodium diet:
▪ Excess sodium may worsen HF symptoms and facilitate an
exacerbation
• Oxygen 4 L/min:
▪ Brings O2 saturation back up while patient’s heart recovers
• High Fowler position:
▪ Reduces chances of aspiration due to fluid in the lungs, and provides
comfort while breathing for the patient
4. Mr. Stephan suddenly becomes dyspneic and anxious. He has moist crackles
throughout his lungs and pink frothy sputum. Explain what is happening.
• His condition is worsening because excess fluid and blood is collecting in the
lungs, which is a sign that both sides of the heart are failing
6. List two priority nursing diagnoses and goals for Mr. Stephan’s chronic HF.
 Impaired gas exchange
o No crackles in lungs within next 24 hours
 Fluid Imbalance
o Input matches output by day of discharge
7. What are Mr. Stephan’s health learning needs to manage his chronic condition?
 Restrict sodium and fluid intake
 Learn signs and symptoms of worsening condition (i.e. pink, frothy sputum or
weight gain >3lbs in a day)
 What medications to take and indications for them
Lecture Notes
 Systolic dysfunction
o Inadequate contractility
 Diastolic dysfunction
o Heart is unable to relax & fill with blood
 HF usually starts on left side the progresses to right side
 Look at BNP, edema in hands/feet or lungs, urine output
 Order of systolic HF to diastolic HF
o Heart damage or dysfunction occurs
 Other form of cardiac issue precedes it
o Neurohormonal compensatory mechanisms are involved
 Responsible for signs and symptoms of HF
o Less blood is ejected from the ventricle
o Sympathetic stimulation occurs to increase cardiac output
 Release of epinephrine and norepinephrine increases HR,
decreases renal perfusion, and increase cardiac output
o Heart muscle thickens
 Aka “hypertrophy”
o Cardiac muscle becomes fibrotic
 Cardiac cells become dysfunctional and diastolic HF develops
 LEFT SIDED = LUNG
o Symptoms
 Dyspnea
 S3, s4 (murmur)
 RIGHT SIDED
o Symptoms
 JVD
 Weight gain
 Peripheral edema
 Diagnosing it
o Measure EF
 Compensatory mechanisms
o RAAS system to alleviate fluid
o Hypertrophy
 Acute HF
o Geriatric: confusion, loss of LOC
o Anxious pale, cyanotic
o Diaphragmatic breathing, nasal flaring
o Left sided
 Cough
 Hemoptysis
 Orthopnea
 Pulmonary congestion
o Right sided
 Hepatomegaly
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 Edema (bipedal)
 Ascites
 Distended neck vein
BNP levels (400 is normal)
EF < 40
Drug therapy
o Diuretics
o Vasodilators
 Nitro IV
o Morphine for dyspnea and anxiety (and resp depression)
o Positive inotropes
o Anticoagulants
 Avoid clot formation
Monitor hemodynamic status
Chap 37 notes
 Indicative of PAD
o Lower peripheral pulse
o Shiny leathery skin of legs with eczema
o Compression stockings are recommended
 S&S of DVT
o Pain on dorsiflexion
 DVT
o Elevate extremities (prevents edema)
o Rest
o Anticoagulants
o Compression stockings
o Lovanox (subq) to help with the reduced ambulation
 Look up Virchow’s triad
 PAD venous disorders
o Symptoms occur when arteries are 60-70% blocked
o Clots will be from chest down in the arteries
o S&S
 Intermittent claudication
 Paresthesia (pressure, sensation loss in lower extremities)
 Pain at rest
 Venous: spider veins
 Arterial: pale feet??
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Hemoglobin levels
Cholesterol level
BMI level
NSAIDs can cause bleeding in GI so educate not to take while on
anticoagulants
Atherectomy can be an intervention
Ineffective tissue perfusion
Acute care
 Monitor skin and temperature
 Capillary refill
 Presence of peripheral pulses distal to the operative site
 Sensation and movement of extremity
At risk
 Immobility
 Chronic HF or atrial fibrillation
 Obese
 Pregnant
Superficial vein thrombosis
Vitamin K antagonists
 Warfarin (antidote protamin sulfate)
 Vitamin K levels
Avoid foods with vitamin K while on warfarin
 Green leafy vegetables
 Don’t increase amount in diet
Thrombin inhibitors
 Heparin
 Or lovanox
Tutorial Notes
 Usually never do nothing, call doctor, or continue to monitor
 Continue to monitor = focused assessment
 S3 gallop = worsening HF
Anime recs
1. Dorohedoro
2. Samurai champloo
3. Michiko to hatchin
4. Mob psycho 100
5. Space dandy
6. Cowboy bebop
7. Aggretsuko
8. Pop team epic
9. Super crooks
10. Demon slayer
11. Ajin demi human
12. Ghost in the shell