CHF: 220 test II

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mthompson17
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263377
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CHF: 220 test II
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2014-02-22 21:52:06
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CHF nursing
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CHF 220 Test II: Vickers
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  1. 7 primary risk factors for CHF?
    • 1. CAD
    • 2. advanced age
    • 3. HTN
    • 4. DM
    • 5. smoking
    • 6. obesity
    • 7. high serum cholesterol
  2. Culture/Ethnic disparities in CHF & its Tx?
    • 1. AA high incidence, mortality, & develops at earlier age than in whites
    • 2. AA have more ACE inhibitor angioedema
    • 3. Asians have extremely high risk for ACE cough
  3. Only medication approved specific for AA for CHF?
    bidil
  4. Primary causes of HF?
    • 1. CAD including MI--> kills tissue --> HF
    • 2. HTN & hypertensive crisis --> stretches heart tissue --> HF
    • 3. rhumatic heart disease
    • 4. congenital heart defects
    • 5. pulmonary hypertension
    • 6. cardiomyopathy:  potpartum, substance abuse
    • 7. hyperthyroidism
    • 8. valvular disorders
    • 9. myocarditis
  5. 3 primary precipitating causes of CHF?

    7 others?
    • 1. anemia
    • 2. infection
    • 3. dysrhythmias

    • 1. thyrotoxicosis
    • 2. hypothyroidism
    • 3. bacterial endocarditis
    • 4. pulmonary disease
    • 5. paget's disease
    • 6. nutritional deficiencies
    • 7. hypervolemia
  6. What is hemodynamic monitoring?

    What is it used for?
    shows CO, SVR (vasoconstriction/dilation)

    used to calculate CO, SVR, pulmonary art wdge pressure, SV, central venous pressure
  7. What does pulmonary artery wedge pressure show?
    function of L side of heart
  8. Swan-Ganz?

    Where is it & what does it show?
    pulmonary artery catheter 

    sits in pulmonary artery & shows R-side pressure
  9. How is central venous pressure measured?

    What does it show?
    can measure with a central line

    shows fluid status (overload or dehydration) & gives info about why BP is decreased
  10. Tx of decreased central venous pressure?
    blood & fluids or if r/t heart not pumping can Tx with HF meds
  11. Preload?
    volume coming back to heart
  12. What occurs with preload in CHF?
    it is increased
  13. What meds are given for increased preload/CHF?
    diuretics & vasodilators/BP meds
  14. Nursing intervention that can decrease preload in CHF pt?
    dangling legs
  15. What AE can occur when placing central venous lines?
    can go too far & hit ventricle --> arrhythmias
  16. How would lasix affect preload?
    decrease
  17. How would vasodilation affect the preload?
    decreases preload
  18. 3 goals of CHF Tx?
    • 1. decrease preload
    • 2. decrease afterload
    • 3. increase CO
  19. What is afterload?
    SVR
  20. What effect does lasix have on SVR?
    decreases
  21. Should CHF pt legs be elevated?
    no - will drown them
  22. What is CO?  What is normal CO?
    volume of blood pumped by heart in one minute

    normal -4-8L/min
  23. What is SVR?  What does it indicate?
    systemic vascular resistance - afterload
  24. What is central venous pressure?

    What does central venous pressure indicate?
    R atrial pressure

    indicates preload
  25. What hemodynamic devices are used to measure R atrial pressure/CVP?

    What do they also indicate?
    Schwann Ganz or pulmonary wedge

    fluid status, increased CVP, volume overload or R ventricular failure, decreased CVP, hypovolemia
  26. What is reflected by pulmonary wedge pressure?
    L ventricle preload (measures pulmonary capillary pressure & R atrial pressure)
  27. What is indicated by an elevated PAWP?
    heart failure/fluid overload
  28. Counterregulatory mechanisms that occur in HF?
    natriuretic peptides (ANP & BNP) are released by heart muscle & promote vasodilation to reduce afterload & preload
  29. What will occur with systolic failure?
    no forward BF, decreased EF & BP
  30. Causes of systolic failure?
    • 1. MI
    • 2. htn
    • 3. cardiomyopathy
    • 4. valvular heart disease
  31. Hallmark of systolic failure?
    decreased EF
  32. Diastolic failure?
    ventricles do not fill during diastole --> decreased SV & CO
  33. Swan-Ganz & pulmonary artery wedge are used to measure what?
    CVP & R atrial pressure - shows functioning of the L side of the heart
  34. Patho of diastolic failure?
    high filling pressure in ventricles r/t noncompliance/stiffness --> venous engorgement in pulmonary & systemic systems --> pulmonary congestion, pulmonary HTN, ventricular hypertrophy, and normal EF
  35. Cause of diastolic failure?
    results from LV hypertrophy r/t chronic systemic HTN, aortic stenosis, or hypertrophic cardiomyopathy
  36. How does dilation of the ventricles contribute to CHF?

    Why does this occur?
    muscles of heart stretch to increase CO & force of contractions --> enlarged heart will start to fail
  37. What test can be used to distinguish CHF from lung problem?
    elevated BNP indicates HF
  38. What will happen to BNP with Tx of CHF?
    will drop
  39. How does hypertrophy of the ventricles contribute to heart failure?
    poor contractility
  40. How does SNS contribute to HF?
    responds to decreased CO by releasing catecholemines (EPI & NE) to increase HR & contractility & vasoconstricts (increased preload) --> strains already failing heart
  41. What is affected by L sided HF?
    lungs
  42. What diuretic cannot be given to CHF pt?

    Why?
    mannitol - pulls fluid from tissue into BV --> will stress overworked heart r/t increased BF
  43. Important consideration with use of mannitol?
    need IV filter
  44. How does the neurohormonal response contribute to fluid retention during CHF?
    decreased CO --> renin/angiotensin/aldosterone release --> retention of Na/water & vasoconstriction --> increased BP --> increased stress on heart 

    decreased CO also causes release of ADH
  45. What type of CHF is usually seen first?
    L sided
  46. Patho of L-sided HF?
    LV dysfunction --> blood backs up through L atrium into pulmonary veins --> increased pulmonary pressure --> fluid from pulmonary capillary bed shifts into interstitum & alveoli --> pulmonary congestion/edema
  47. 4 causes of L sided CHF?
    CAD, HTN, cardiomyopathy, rheumatic heart disease
  48. What may occur as a result of L sided CHF?
    R-sided HF
  49. How may pulmonary congestion be monitored in L sided HF?
    CXR will show decreased fluid in the lungs
  50. R-sided failure patho?
    backflow to R atrium & venous circulation --> venous congestion --> peripheral edema, hepatomegaly, splenomegaly, vascular congestion of GI, JVD
  51. Med that may be given to increase BP & decrease peripheral edema in R sided HF?
    albumin
  52. 5 causes of R sided HF?
    • 1. L sided dysfunction
    • 2. chronic pulmonary HTN/cor pulmonale
    • 3. COPD
    • 4. pulmonary emboli
    • 5. MI
  53. What occurs in ADHF/acute decompensated HF?
    lung alveoli filled with fluid - manifests as pulmonary edema
  54. 12 S/S of acute decompensated HF? (ADHF)
    • 1. agitation
    • 2. pale
    • 3. may be cyanotic
    • 4. skin clammy & cold
    • 5. dyspnea
    • 6. RR >30
    • 7. orthopnea:  feel like drowning when lay flat
    • 8. wheezing
    • 9. frothy blood-tinged sputum
    • 10. bubbling crackles
    • 11. pulmonary edema
    • 12. enlarged heart on CXR
    • 13. paroxysmal nocturnal dyspnea
  55. What usually occurs with chronic CHF?

    10 S/S?
    • usually have biventricular failure
    • 1. tachycardia
    • 2. edema
    • 3 nocturia
    • 4. behavioral changes:  r/t hypoxia 
    • 5. skin changes
    • 6. weight changes
    • 7. chest pain
    • 8. fatigue
    • 9. dyspnea
    • 10. orthopnea:  orthopnea X5 - sleep with 5 pillows
  56. What could be 1st s/s of CHF exacerbation?
    dry hacking cough
  57. Why may anemia occur with HF?
    poor nutrition, renal disease, or durg therapy (ACE)
  58. Orthopnea?
    dyspnea when in supine position
  59. Paroxysmal nocturnal dyspnea?
    pt wakes in panic with feelings of suffocation & has strong desire to sit up for relief
  60. L or R sided HF cause skin open with seeping fluids?
    R sided
  61. Why may tachycardia not be evident in a pt with CHF?
    if taking beta blockers
  62. Where may edema occur with CHF?
    peripheral, lungs, liver(hepatomegaly), dependent areas, abd cavity (ascites)
  63. What is the cause of dyspnea with CHF?
    increased pulmonary pressures
  64. Why does pt with CHF have nocturia?
    daytime UO is decreased by decreased CO & fluid in interstitial areas

    at night fluid shifts back into BF
  65. What skin changes occur with CHF?
    • 1. dusky
    • 2. cool & damp/diaphoretic
    • 3. LE shiny & swollen with diminished or absent hair growth
    • 4. pigment changes r/t chronic selling
    • 5. brown or brawny ankles & lower legs
  66. What behavioral changes may occur with CHF?

    Cause?
    unusual behavior:  restlessness, confusion, decreased att. span or memory 

    caused by decreased CO --> decreased BF to brain & hypoxia
  67. Why may chest pain occur with CHF?
    decreased CO --> decreased coronary circulation
  68. Weight changes that occur with CHF?
    may initially gain r/t fluid retention

    eventually will lose weight b/c of anorexia & N:  loss of muscle & fat
  69. Why may pt muscle & fat loss with CHF go unnoticed?
    may be masked by fluid retention & edema
  70. 5 complications of CHF?
    • 1. pleural effusions
    • 2. arrhythmias:  high risk for fatal 
    • 3. L ventricular thrombus
    • 4. hepatomegaly
    • 5. renal failure
  71. What causes pleural effusion r/t CHF?

    Where effusion usually seen?
    increase pressure in pleural capillaries --> fluid into pleural space

    in R lower lobe
  72. What is the cause of nearly 1/2 of sudden cardiac death in CHF?
    ventricualr tachyarrhythmias
  73. What arrhythmias may occur with CHF?
    tachyarrhythmias & afib
  74. 2 causes of arrhythmias with CHF?
    low EF increases risk

    lasix & other drugs that alter K
  75. 2 risks associated with low EF?
    • 1. arrhythmias
    • 2. formation of clots in L ventricle r/t blood pooling
  76. How may clots be prevented with CHF?
    may be on heparin
  77. What may occur is thrombus forms in L ventricle r/t decreased EF & CHF?
    can further decrease CO & can cause embolism
  78. When is hepatomegaly most likely to occur with CHF?

    What can it lead to?
    more likely with R-sided failure

    can lead to liver failure & cirrhosis
  79. Why may renal failure occur with CHF?
    decreased perfusion of the kidneys
  80. Acronym to remeber s/s of CHF?
    • FACES
    • Fatigue
    • Activity limitation
    • Cough
    • Edema
    • Shortness of breath
  81. How is CHF classified?
    based on tolerance of physical activity
  82. Class I CHF?
    no limitation of activity
  83. Class II CHF?
    slight limitation of activity:  no s/s at rest

    ordinary activity causes fatigue, dyspnea, palpitations, or pain
  84. Class III CHF?
    marked limitation of activity:  usually comfortable at rest & some s/s with activity
  85. Class IV CHF?
    inability to carry on anyphysical activity without discomfort

    s/s of cardiac insufficiency or anigna may be present even at rest
  86. Dx studies for HF?
    • 1. physical exam
    • 2. CXR
    • 3. ECG
    • 4. hemodynamic assessment
    • 5. echo
    • 6. cardiac cath
    • 7. BNP
  87. What may show on ECG for CHF?
    may have BBB r/t enlarged heart
  88. 2 tests that will show EF for CHF?

    Which is more accurate?
    echo & cardiac cath

    cath more accurate
  89. Tx of acute decompensated HF?
    • 1. high folwers
    • 2. O2 by mask or BNC
    • 3. BiPaP
    • 4. ET & mechanical ventilation
    • 5. cont ECG & pulse ox monitoring
    • 6. hemodynamic monitoring
    • 7. VS, UO at least q 1h
    • 8. drug therapy
    • 9. possible cardioversion (for afib, etc)
    • 10. ultrafiltration
  90. Meds used for acute decompensated HF?
    • 1. diuretics
    • 2. ACEs, ARBs, & aldosterone inhibitors
    • 3. vasodilators:  nipride, nitrates, B-type natriuretic peptides, hydralazine, isosorbide dinitrate, & bidil
    • 4. Beta blockers
    • 5. positive inotropes:  dig, beta agonists: dopamine, dobutamine; phosphodiesterase inhibitors:  inocor, primacor
    • 6. antidysrhtyhmic drugs
    • 7. anticoagulants
  91. Tx goals for CHF?
    • increase Co without increase work of heart
    • 1. decrease intravascular volume
    • 2. decrease venous return (preload)
    • 3. decrease afterload
    • 4. improve gas exchange
    • 5. increase CO
    • 6. decrease anxiety
  92. Med that may be given for anxiety in CHF?
    morphine
  93. What finding can be used to distinguish b/t systolic and diastolic failure?
    EF
  94. BNP levels correlate with what?
    degree of L ventricular dysfunction
  95. Ultrafiltration?
    remove extracellular & intravascular fluid volume
  96. 4 core measures for heart failure?

    What will occur if these are not done?
    • 1. written discharge instructions or educational materials including:  activity, d/c meds, follow-up, weight monitoring, & what to do if s/s worsen
    • 2. L ventricular function is documented 
    • 3. pt EF<40% are prescribed ACE or ARB at discharge
    • 4. current smokers are given smoking cessation advice

    if not done:  insurance won't pay
  97. Tx of CHF?
    • 1. O2 admin
    • 2.biventricular pacing or cardiac resynchronization therapy 
    • 3. implantable cardioverter/defibrillator with CRT
    • 4. mechanical options to sustain pt:  intraaortic balloon pump, ventricualr assist devices (used as bridge to transplant)
    • 5. Drugs:  diuretics, ACE/ARB/aldosterone inhibitors, vasodilators, beta blockers, positive ionotropes, 
    • 6. nutrition:  low Na diet & weight mgmt
  98. Nursing interventions for CHF?
    • 1. admin O2 & semi-fowlers & monitor ABG's & pulse ox
    • 2. adequate rest to decrease O2 needs
    • 3. monitor fluid status:  weight, I&O
    • 4. give ice chips, gum, hard candy, or popsicles for pt on fluid restrictions to decrease thirst
    • 5. Teach:  weight gain 2lb/day or 5lb/wk - need to call MD
    • 6. Monitor electrolytes
    • 7. monitor pulses & circulation to det CO
    • 8. reduce anxiety to decrease SNS stimulation:  benzos or morphine
  99. 2 psych issues that are common with CHF?
    anxiety & depression
  100. Effects of diuretics on CHF?
    decrease venous return/preload, increase CO, & decrease pulmonary congestion --> increased gas exchange
  101. Pt teaching for CHF?
    • 1. low Na diet & lifestyle
    • 2.should get vaccinations against flu & pneumonia
    • 3.s/s of exacerbations
    • 4. s/s of drug toxicity & how to take pulse & home BP monitoring
    • 5. s/s of hypokalemia & hyperkalemia
  102. First choice diuretics for HF?
    thiazides
  103. 3 AE of loop diuretics?

    3 loop diuretic meds?
    • 1. hypokalemia
    • 2. ototoxicity
    • 3. allergy in pt allergic to sulfa drugs

    lasix, demadex, bumex
  104. Effects of ACE inhibitors?
    • 1. decrease hypertrophy
    • 2. decrease BP
    • 3. increase CO
    • 4. increase diuresis
  105. AE of ACE inhibitors/captopril?
    • 1. hypotension 
    • 2. hyperkalemia
    • 3. rebound hypertension if d/c
    • 4. angioedema - can develop suddenly & may be life-threatening
  106. Consideration with elderly & ACE?

    Who may also have this issue?
    decreased renal efficiency  could cause increased drug levels

    may also occur in renal failure
  107. Aldosterone antagonist actions?

    Drugs?
    decrease Na & fluid retention - K sparing diuretics

    spironolactone & inspra
  108. 4 AE/considerations with  aldosterone antagonists/K sparing diuretics?
    • 1. hyperkalemia
    • 2. can decrease dig effects if hyperkalemia occurs
    • 3. Teach pt to avoid high K foods:  oranges, bananas, apricots
    • 4 assess male pt for gynecomastia with long-term use
  109. 2 types of vasodilators used for CHF?
    nitrates & bidil
  110. AE of nitrates to watch for?
    decreased BP - must monitor
  111. Important consideration when giving IV nitrates?
    adheres to plastic - must waste 50-100mL before running med
  112. How may nitrates be used in pt who cannot tolerate ACE or ARBs?
    may take nitrate combined with hydralazine
  113. 2 AE of nitrates?
    • 1. tolerance
    • 2. ED - ED meds are CI
  114. Bidil?

    Use?

    Actions?
    combo of isosorbide dinitrate & hydralazine

    for AA already being Tx with standard therapy 

    isosorbide - relaxes vessels & releases nitric oxide 

    hydralazine - relaxes arteries & decreases work of heart
  115. Action of beta blockers?
    block SNS stimulation on failing heart
  116. 2 reasons a pt with HF may have cough?
    may be r/t HF or ACE inhibitor
  117. Major AE of beta blockers?
    • 1. edema
    • 2. worsening HF
    • 3. hypotension
    • 4. fatigue
    • 5. bradycardia
  118. S/S of beta blocker OD?
    extreme hypotension & bradycardia, bronchospasm, & cardiogenic shock
  119. How to assess tolerance of beta blocker?
    assess standing BP 1h after dose
  120. 3 AE that may occur with abrupt w/d of beta blockers?
    sweating, palpitations, & HA
  121. S/S of dig toxicity?
    • GI:  anorexia, NV
    • Visual:  blurred vision, yellow tinge, visual halos around dark objects
    • CNS:  fatigue, drowsiness, HA, depression
    • CV:  dysrhythmias, bradycardia, tachycardia, apical-radial pulse deficit, HF
  122. What dysrhythmias may occur with dig toxicity?
    afib, PVC, Vfib, heart block
  123. Most common cause of dig toxicity?
    K wasting diuretics & hypokalemia
  124. What pt have increased risk for dig toxicity?
    elderly, renal & liver dysfunction
  125. What is the Tx of dig toxicity?
    withhold the med and/or digibind
  126. When may fluid restrictions be implemented for CHF?
    moderate to severe HF & renal insufficiency
  127. Pt postion that can decrease venous return?

    Effects?
    high flowlers with feet dangling or horizontal  - pools blood in extremeities & improves ventilation
  128. Consideration if giving beta blocker with CHF?
    should check CO & CHF exacerbation before giving beta blocker:  any s/s of exacerbation or decreased CO --> should hold beta blocker
  129. Why is it important to monitor BP in CHF pt?
    if give too many BP meds and BP gets too low it cannot be increased with fluids
  130. Med to decrease afterload?

    Effect?

    Monitoring?
    nipride decreases afterload & preload

    potent vasodilator

    need to monitor BP
  131. Consideration when giving nipride IV?
    put in paper bag- light sensitive
  132. 2 effects of ACE inhibitors?

    What med may be given with ACE inhibitors & why?
    decrease afterload & SVR

    may be given with thiazide diuretic b/c ACE holds K & thiazides get rid of it
  133. 2 EX of ARBs?
    cozaar & diovan
  134. What meds should be held during exacerbation of CHF?
    beta blockers - will decrease CO too much
  135. Interventions to improve gas exchange?
    • 1. morphine - decreases O2 demand
    • 2. sats decreased may need mask or nonrebreather
    • 3. severe pulm edma may need vent
    • 4. monitor ABG, pulse ox, 
    • 5. rest
    • 6. may use BiPaP to deliver O2
  136. Drug of choice for pt in pulmonary edema?
    nipride
  137. Interventions to improve cardiac function?
    • 1. dig 
    • 2. dobutrex, inocor, primacor, natrecor - peripheral vasodilation
  138. AE of meds that cause vasodilation in CHF?

    dobutrex, inocor, primacor, natrecor
    can die if stop taking these meds abruptly:  when d/c must monitor for CHF exacerbation
  139. Nursing care for chronic CHF?
    • 1. ID underlying cause:  HTN, valvular defects, etc
    • 2. ventricular tachyarrhythmias - implantable cardioverter (ICD)
    • 3. Swan-Ganz 
    • 4. intra-aortic balloon pumps (IABP) - balloon inflates during diastole so heart doesn't have to pump as hard to pump blood out during systole
    • 5. ventricular assist devices (VAD) - longer-term support to wait for heart transplant
  140. Does pt with VAD have a pulse?
    may or may not have pulse
  141. Complication of IABP?
    • 1. if balloon moves can block aorta & BF to areas of body
    • 2. dislodging plaque
    • 3. aortic dissection
    • 4. thrombocytopenia
    • 5. infection
  142. Complication of VAD?
    sepsis & death
  143. Major AE of nipride?

    Therapeutic use?
    hypotension - monitor BP, cyanide poisoning after 48h

    need to keep MAP>60
  144. Monitoring of IABP?
    pulses, UO, bowel sounds (ischemia & embolism)

    CV checks, neuro, & hemodynamic assessments q15-60 minutes
  145. Nursing care after IABP?
    • 1. relatively immobile in sidelying or supine positions with HOB elevated <45 degrees
    • 2. sedation, pain relief, skin care & comfort measures
    • 3. weaning pt off of IABP
  146. IABP causes increased risk for ___ & ____ especially.
    clots & sepsis
  147. Action of VAD?
    augment or replace ventricular action when heart is failing and needs to recover or when waiting for transplant
  148. Nutritional therapy for CHF?
    • 1. low Na diet:  mild CHF <2g, severe <500-1000mg
    • 2. fluid restrictions with no more than 2L/day
    • 3. daily weight before breakfast:  gain of 3lb in 2 days or 3-5lb in a week:  need to call
    • 4. no alcohol- cardiotoxic
  149. Ejection fraction?

    normal?
    percentage of total ventricular volume ejected during each contraction

    normal is >55% & usually is 65%
  150. Aquadex?
    pulls off fluid but doesn't affect electrolytes

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