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TL HF
Nursing of the adult with Heart Failure
| Question | Answer |
|---|---|
| Define Heart Failure. | Inability of the heart to pump sufficient blood to meet the oxygen demands of the tissues |
| What are some primary underlying conditions that lead to heart failure (5)? | Ischemic heart disease, Valvular heart disease, MI, Cardiomyopathy, Hypertension |
| Define Left sided heart failure. | pulmonary edema, left ventricular failure, pulmonary congestion due to the inability of the left ventricle to pump blood to the periphery |
| What findings would the nurse expect on the assessment of a patient with left sided heart failure (9)? | Dyspnea, Orthopnea, Wet lung sounds, Cough, Fatigue, Confusion, Anxiety, Restlessness, Tachycardia |
| Define Right Sided Heart Failure. | Peripheral edema, Right ventricular failure, Peripheral congestion due to inability of the right ventricle to pump blood to the lungs |
| Give two frequent causes of right sided heart failure. | left sided heart failure or pulmonary disease |
| What symptoms might the nurse find on assessment of the client with right sided heart failure (6)? | Peripheral edema, weight gain, distended neck veins, anorexia/nausea, nocturia, weakness |
| Why would sodium restriction be useful for right sided heart failure? | Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload. |
| Give 5 applicable nursing diagnoses for HF. | Decreased cardiac output, Impaired urinary elimination, Activity intolerance, Anxiety, Ineffective tissue perfusion |
| What should the nurse monitor and watch for when her patient has experienced HF? What assessments are required? | Monitor vital signs Q 4 hrs for changes; Apical heart rate (esp. before digitalis - <60 hold); dysrhythmias; S3 and S4 sounds; Assess for hypoxia; auscultate for wet lung sounds, observe for signs of edema |
| What symptoms would indicate hypoxia? | Restlessness, Angina, Tachycardia |
| How does the nurse assess for edema? | Weigh daily, monitor I&O, abdominal girth, check ankles and fingers |
| What prescriptions might the nurse expect for the HF patient? What are the related nursing indications? | Oxygen as needed; Diuretics – administer in the a.m.; Digoxin – apical heart rate first, hold if <60bpm |
| Discuss nursing of the HF patient in regards to rest and activity, positioning, and dietary restrictions. | provide periods of rest after periods of activity, elevate head of bed for orthopnea, elevate extremities while seated, limit sodium |
Created by:
Perseverandovercome
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