Lewis: Medical-Surgical Nursing, 7th Edition
Critical Thinking questions- Guidelines for Case Studies
Chapter 35: Nursing Management: Heart Failure p. 840
Heart Failure
1.
Mrs. E. has acute decompensated heart failure (ADHF) of systolic origin that has resulted in
impaired ventricular emptying, most likely caused by myocardial damage from her MI. The
damaged area of the myocardium is replaced by scar tissue, increasing the workload on the
remaining functional tissue. If the functioning myocardium cannot compensate for this loss,
the ventricle is unable to generate enough pressure to eject blood forward through the highpressure aorta. Inability to move blood forward through the aorta results in (1) a decreased
left ventricular ejection fraction (EF), (2) an acute increase in left ventricular end-diastolic
pressure (LVEDP), (3) an increase in pulmonary artery wedge pressure (PAWP), and (4) an
increase in fluid accumulation in the pulmonary vascular bed (pulmonary edema). The
pulmonary edema results in dyspnea and may even result in the development of pink, frothy
sputum. The left-sided failure will eventually result in right-sided failure when the pulmonary
congestion and increased pulmonary hypertension result in right-sided hypertrophy and
failure.
2.
Clinical manifestations of left-sided heart failure that Mrs. E. exhibits are shortness of breath,
dyspnea on exertion, frequent cough, 3-pillow orthopnea, heart murmur, moist crackles in
both lungs, and cyanosis of her lips and extremities. Right-sided heart failure is manifested by
the edema in her legs.
3.
Cardiomegaly with both right and left ventricular hypertrophy indicates that both the right and
left sides of the heart have increased in size as a result of overwork and strain. Hypertrophy
occurs in chronic heart failure as a compensatory mechanism, but the hypertrophic heart
muscle has poor contractility. This is further evidenced by the severe reduction of the ejection
fraction (EF) (20%; normal >55%). The fluid in the lower lobes of the lungs indicates
pulmonary edema as a result of backward pressure into the pulmonary vasculature.
4.
Measurement of the BNP level is used to assist in the diagnosis of HF. In general, the level
correlates positively with the degree of LV dysfunction and can help to differentiate dyspnea
caused by ADHF from other causes dyspnea (e.g., exacerbation of chronic obstructive
pulmonary disease).
5.
Rationale for orders:
• Digoxin is a positive inotropic agent that increases the strength of cardiac contraction,
decreases the conduction speed within the myocardium, and slows the heart rate,
allowing for more complete emptying of the ventricles and increased cardiac output.
• Furosemide is a loop diuretic used to mobilize edematous fluid, reduce pulmonary venous
pressure, and reduce preload. By decreasing venous return to the left ventricle, the
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Answer Guidelines for Case Studies in Textbook
35-2
overfilled left ventricle contracts more efficiently and cardiac output improves.
• A 2-g sodium diet is used to treat the edema of congestive heart failure by decreasing body
sodium and fluid retention.
• Potassium supplements are prescribed for Mrs. E. to replace potassium lost through the use
of furosemide and to prevent hypokalemia, which may lead to digitalis toxicity.
• Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor that reduces the
levels of angiotensin II and aldosterone, resulting in decreased systemic vascular
resistance; maintenance of tissue perfusion; and reduction of pulmonary artery pressure,
right arterial pressure, and left ventricular filling pressure. It also reduces norepinephrine
levels, resulting in a reduction of ventricular wall stress, a decrease in ventricular
dysrhythmias, and increased vagal tone.
• Oxygen therapy is prescribed because the oxygen saturation of the blood is reduced in a
person with CHF because the blood is not adequately oxygenated in the lungs.
Administration of oxygen improves saturation, assists in meeting tissue oxygen needs,
and helps relieve dyspnea and fatigue
.• Daily weights are taken to monitor the effectiveness of therapy, as well as to identify early
signs of fluid retention.
• Daily 12-lead ECG is ordered to monitor Mrs. E.’s cardiac status. She has already
experienced a heart attack and is at risk for coronary ischemia because of the decreased
CO (and perfusion to the coronary arteries). Serum electrolytes will be monitored to
assess for electrolyte imbalance (especially potassium, sodium, magnesium, calcium).
Serial cardiac enzymes are ordered to rule out the possibility that Mrs. E. may have also
have suffered an acute myocardial infarction with this episode of ADHF.
6. Priority nursing interventions include:
• For her impaired gas exchange, the nurse should provide the following care:
- Elevate the head of the bed to Fowler’s position, with her arms supported on pillows
away from her chest
- Administer oxygen as prescribed
- Use pulse oximetry to monitor oxygenation status
- Provide emotional and physical rest to decrease oxygen consumption
- Provide small, frequent meals to decrease oxygen needed for digestion
- Monitor her lung and heart sounds and vital signs frequently to evaluate her response to
treatment, including medications
• For her fluid volume excess, the nurse should provide the following care:
- Evaluate her peripheral edema and measure abdominal girth daily
- Weigh patient daily and assess intake and output every shift
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Answer Guidelines for Case Studies in Textbook
35-3
- Provide sodium-restricted diet as ordered
• For her activity intolerance, the nurse should provide the following care:
- Assess her dyspnea, fatigue, and pulse rate to determine appropriate activity
- Provide emotional and physical rest to relieve dyspnea and fatigue
• For her risk for impaired skin integrity, the nurse should provide the following care:
- Assess edematous areas for skin breakdown
- Turn and reposition q2hr and perform passive range of motion to extremities q4hr
- Pad bony prominences to reduce pressure
7. Nursing diagnoses: impaired gas exchange, excess fluid volume, activity intolerance, anxiety,
ineffective therapeutic regimen management, risk for impaired skin integrity
Collaborative problems: pulmonary edema, pleural effusion, dysrhythmias, electrolyte imbalance,
left ventricular thrombus
8. Mrs. E. should be taught that it is critical that she take her medications as prescribed and that if
she has difficulty remembering to take them, she should develop a specific routine or association
with an activity to help her remember. She should be taught to weigh herself daily and to report a
weight gain of 3 or more pounds in a 2-day period. Other manifestations of worsening HF that she
should be taught to report include shortness of breath at rest, swelling of her ankles or feet, loss
of appetite, nausea or vomiting, persistent cough, and any visual changes. Teaching or review
regarding her low-sodium diet must also be implemented.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.