Primary Nursing Diagnosis

Decreased CO related to an ineffective ventricular pump

OUTCOMES. Cardiac pump: Effectiveness; Circulation status; Tissue perfusion: Abdominal organs and peripheral; Vital sign status; Electrolyte and acid-base balance; Endurance; Energy conservation; Fluid balance

INTERVENTIONS. Cardiac care; Circulatory care: Mechanical assist device; Fluid/electrolyte management; Medication administration; Medication management; oxygen therapy; Vital signs monitoring

U PLANNING AND IMPLEMENTATION Collaborative

MEDICAL. Initial management of the patient with HF depends on severity of HF, seriousness of symptoms, etiology, presence of other illnesses, and precipitating factors. Medication management is paramount in patients with HF. The general principles for management are treatment of any precipitating causes, control of fluid and sodium retention, increasing myocardial contractility, decreasing cardiac workload, and reducing pulmonary and systemic venous congestion. The physician may also prescribe fluid and sodium restriction in an attempt to reduce volume and thereby reduce preload.

398 Heart Failure

SURGICAL. If the elevated preload is caused by valvular regurgitation, the patient may require corrective surgery. Corrective surgery may also be warranted if the elevated afterload is caused by a stenotic valve. Another measure that may be taken to reduce afterload is an intra-aortic balloon pump (IABP). This is generally used as a bridge to surgery or in cardiogenic shock after acute myocardial infarction. It involves a balloon catheter placed in the descending aorta that inflates during diastole and deflates during systole. The balloon augments filling of the coronary arteries during diastole and decreases afterload during systole. IABP is used with caution because there are several possible complications, including dissection of the aortoiliac arteries, ischemic changes in the legs, and migration of the balloon up or down the aorta.

OTHER MEASURES. Other measures the physician may use include supplemental oxygen, thrombolytic therapy, percutaneous transluminal coronary angioplasty, directional coronary atherectomy, placement of a coronary stent, or coronary artery bypass surgery to improve oxygen flow to the myocardium. Finally, a cardiac transplant may be considered if other measures fail, if all other organ systems are viable, if there is no history of other pulmonary diseases, and

Pharmacologic Highlights

Medication or

Drug Class Dosage Description

Rationale

Vasodilators

Varies by drug

Diuretics

Digoxin

Varies by drug

0.125-0.375 mg PO qd

To decrease arterial and venous vasoconstriction due to activation of adrenergic and renin-angiotensin systems; increases venous capacitance; drugs such as nitroglycerin and angiotensin-converting enzyme (ACE) inhibitors such as capto-pril, enalapril, and lisinopril

Increases excretion of sodium and water with drugs such as furosemide (Lasix) and metolazone (Zaroxalyn) Cardiotonic

Reduce vasoconstriction, thereby reducing afterload and enhancing myocardial performance and decreasing preload and ventricular filling pressures

Used for patients with volume overload

Increases cardiac contractility and helps manage some atrial dysrhythmias; may increase myocardial oxygen demand

Dobutamine: Sympathomimetic, selective beta-1 stimulator that increases contractility, improves CO, decreases pulmonary capillary wedge pressure (PCWP), and increases renal blood flow (as a result of improved CO).

Dopamine: Low doses to stimulate dopaminergic receptors, causing renal vasodilation and improved renal function.

Beta-adrenergic blocking agents (metoprolol, carvedilol): Agents improve symptoms, exercise tolerance, cardiac hemodynamics, and left ventricular performance; decrease mortality in HF patients especially those with ischemic and idiopathic cardiomyopathy.

Other Drugs: Antihypertensive agents (hydralazine, minoxidil) and, in severe cases of HF, nitroprusside may be used in an attempt to reduce afterload and improve CO. Norepinephrine is used for profound hypotension; phosphodiesterase inhibitors (milrinone, amrinone) cause increased contractility, decreased pulmonary vascular resistance, decreased afterload.

if the patient does not smoke or use alcohol, is generally under 60 years of age, and is psychologically stable.

Independent

To conserve her or his energy and to maximize the oxygen that is available for body processes, encourage the patient to rest. Elevation of the head of the bed to 30 to 45 degrees may alleviate some of the dyspnea by lowering the pressure on the diaphragm that is caused by the contents of the abdomen and by decreasing venous return, thereby decreasing preload. The patient may need assistance with activities of daily living, even eating, if the HF is at end stage and the least bit of activity causes fatigue and shortness of breath. To assess the patient's response to activity, check the blood pressure and heart rate, as well as the patient's subjective response both before and after any increase in activity level. Prolonged periods of little or no activity can be very difficult to reverse; therefore, maintaining some level of activity is highly encouraged.

To control symptoms, provide ongoing monitoring throughout the acute phases of the patient's disease. Monitor the patient for signs and symptoms of fluid overload, impaired gas exchange, and activity intolerance. Routine assessment of the cardiovascular and pulmonary systems is imperative in the early detection of exacerbation. Monitor daily intake and output, as well as daily weight, and conduct cardiopulmonary assessment.

Education of the patient and family is important for preventing exacerbations and frequent hospital visits. HF is clearly a condition that can be managed on an outpatient basis. A clear explanation of the disease process helps the patient understand the need for the prescribed medications, activity restrictions, diet, fluid restrictions, and lifestyle changes. Written material should be provided for the patient to take home and use as a reference.

The patient may no longer be able to live alone or support himself or herself. Fear, anxiety, and grief can all stimulate the sympathetic nervous system, leading to catecholamine release and additional stress on an already compromised heart. Helping the patient work through and verbalize these feelings may improve psychological well-being and CO.

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