b) Enlargement of joints
c) Potassium levels
d) Flexion contractures
A key concern associated with digoxin therapy is digitalis toxicity. Clinical manifestations of toxicity include anorexia, nausea, visual disturbances, confusion, and bradycardia. The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.
a) Complete blood count (CBC)
c) Blood urea nitrogen (BUN)
d) Brain natriuretic peptide (BNP)
The BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of HF. A BUN, creatinine, and CBC are included in the initial workup.
b) Paroxysmal nocturnal dyspnea (PND)
Orthopnea occurs when the patient is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.
a) Increased urinary output
b) Hyperactive bowel sounds
c) Restlessness and confusion
d) High blood pressure
Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).
a) Pulmonary congestion
b) Pulmonary hypertension
c) Heart palpitations
d) Mitral valve stenosis
Crackles heard in the bases of the lungs are a sign of pulmonary congestion. Heart palpitations are caused by tachydysrhythmias. Crackles heard in the bases of the lungs are not signs of pulmonary hypertension and mitral valve stenosis.
a) Assess oxygen saturation level
b) Administer angiotensin-converting enzyme inhibitors
c) Administer angiotensin II receptor blockers
d) Administer diuretics
Assessment is priority to determine severity of the exacerbation. It is important to assess the oxygen saturation level of a heart failure patient, as below normal oxygen saturation level can be life-threatening. Treatment options vary according to the severity of the patient’s condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve patient symptoms and reduce the workload on the heart by reducing afterload and preload.
a) Pulmonary embolism
b) Myocardial infarction
d) Pulmonary edema
Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction where emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.
a) Cystic fibrosis
b) Ineffective right ventricular contraction
c) Pulmonary embolus
d) Myocardial ischemia
Myocardial dysfunction and HF can be caused by a number of conditions including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of patients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, the death of myocardial cells, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.
b) Jugular vein distention (JVD)
c) Pulmonary crackles
JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.
a) Under the sacrum
b) Lips, earlobes
c) Upper arms
d) Feet, ankles
When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.
a) Acute exacerbation of chronic obstructive pulmonary disease
b) Decompensated heart failure with pulmonary edema
c) Bilateral pneumonia
Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated HF with pulmonary edema.
a) Ability to sleep through the night
b) Weight loss
c) Persistent cough
d) Increased appetite
Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite should be reported immediately. Weight gain should be reported immediately. Frequent urination, causing interruption of sleep, should be reported immediately.
Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.
a) JVD is noted 3 cm above the sternal angle.
b) JVD is noted at the level of the sternal angle.
c) No JVD is present.
d) JVD is noted 1 cm above the sternal angle.
JVD is assessed with the patient sitting at a 45° angle. Jugular vein distention greater than 3 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.
a) Bumetanide (Bumex)
b) Chlorothiazide (Diuril)
c) Ethacrynic acid (Edecrin)
d) Spironolactone (Aldactone)
Aldactone is a potassium-sparing diuretic. A thiazide diuretic is Diuril. Bumex and Edecrin are loop diuretics.
a) Accumulation of blood in the lungs
b) Reduction in cardiac output
c) Congestion in the peripheral tissues
d) Reduction in forward flow
Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues.
a) Paroxysmal nocturnal dyspnea
c) Dyspnea on exertion
Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position. Dyspnea on exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.
a) Pulmonary congestion
b) Basilar crackles
c) Low ejection fraction (EF)
d) Limitation of activities of daily living (ADLs)
A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the patient’s symptoms.
Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In Class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In Class II there is a slight limitation of ADLs. In Class III there is marked limitation on ADLs.
a) Titrate milrinone rate slowly before discontinuing
b) Teach patient about safe home use of the medication
c) Encourage patient to ambulate in room
d) Monitor blood pressure frequently
Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to patients with severe HF, including patients who are waiting for a heart transplant. Because the drug causes vasodilation, the patient’s blood pressure is monitored prior to administration since if the patient is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and following infusions of milrinone.
a) First-degree heart block
b) Sinus tachycardia
c) Atrial fibrillation
d) Supraventricular tachycardia
Cardiac dysrhythmias such as atrial fibrillation may either cause or result from HF; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.
a) Furosemide (Lasix)
b) Chlorothiazide (Diuril)
c) Chlorthalidone (Hygroton)
d) Spironolactone (Aldactone)
Lasix is commonly used in the treatment of cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide is categorized as a thiazide diuretic. Chlorthalidone is categorized as a thiazide diuretic. Spironolactone is categorized as a potassium-sparing diuretic.
b) Electrocardiogram (ECG)
c) Serum electrolytes
d) Blood urea nitrogen (BUN)
An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed in the initial workup.
a) Observe for symptoms of pulmonary edema.
b) Continue the drug and document in the patient’s chart.
c) Check for signs of toxicity.
d) Withhold the drug and inform the primary health care provider.
Before administering beta blockers, the nurse should monitor the patient’s apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.
a) Head of the bed elevated at 30 degrees and legs elevated on pillows
b) Supine with arms elevated on pillows above the level of the heart
c) Prone with legs elevated on pillows
d) Head of the bed elevated at 45 degrees and lower arms supported by pillows
Preload is the amount of blood presented to the ventricle just before systole. The patient is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the patient may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the patient’s weight on the shoulder muscles.