Nursing management of patient with hypertension and congestive cardiac failure

Hypertension- definition

Hypertension is defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg based on the average of two or more accurate blood pressure measurements taken during two or more contacts w i t h a health care provider.

Classification

  Blood pressure(mmhg)

Classsification Systolic Diastolic

Normal 119 or lower 79 or lower

Prehypertension

120-139 80-89

Stage1 hypertenson

140-159 90-99

Stage2 hypertension

160 0r higher 100 or higher

Causes

In general the major causes of hypertension are the following:

Hectic and stress filled life style Unhealthy food habits Obesity Excessive consumption of liquors Smoking Over consumption of tea/coffee Insufficient rest and sleep Metabolic disorders

Contd……

Hardening of the arteries Excessive use of pain killers and

other strong medicines Genetic disorders Over consumption of oily food and

fast food High salt intake Emotional and Physical stress Family history of hypertension

Secondary causes

Sleep apnoea Drug-induced or drug-related Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing syndrome Phaeochromocytoma Acromegaly Thyroid or parathyroid disease Coarctation of the aorta Takayasu Arteritis  

Primary hypertension

Primary (essential) hypertension is the most common form of hypertension, accounting for 90–95% of all cases of hypertension. Numerous common genetic variants with small effects on blood pressure have been identified as well as several environmental factors influence blood pressure. Insulin resistance, which is common in obesity and is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension

Secondary hypertension

Secondary hypertension results from an identifiable cause. Renal disease is the most common secondary cause of hypertension. Hypertension can also be caused by endocrine conditions, such as Cushing's syndrome, hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or hyperaldosteronism, hyperparathyroidism and pheochromocytoma.

Resistant hypertension

Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of concurrent use of three antihypertensive agents belonging to different antihypertensive drug classes

Hypertensive crisis

Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic of 110 — sometime termed malignant or accelerated hypertension) is referred to as a "hypertensive crisis.People with blood pressures in this range may have no symptoms, but are more likely to report headaches (22% of cases) and dizziness than the general population.Other symptoms accompanying a hypertensive crisis may include visual deterioration or breathlessness due to heart failure or a general feeling of malaise due to renal failure.

Malignant hypertension

A "hypertensive emergency", previously "malignant hypertension", is diagnosed when there is evidence of direct damage to one or more organs as a result of the severely elevated blood pressure. This may include hypertensive encephalopathy, caused by brain swelling and dysfunction, and characterized by headaches and an altered level of consciousness (confusion or drowsiness). Retinal papilloedema and/or fundal hemorrhages and exudates are another sign of target organ damage. Chest pain may indicate heart muscle damage

Pathophysiology Etiological factors

sed periphral resistance

¯ sed venous compliance

sed venous return

cardiac preload

Diastolic dysfunction

Signs and symptoms.

Headaches - Headaches may be experienced due to elevation in blood pressure. Sometimes morning headaches can also be due to hypertension.

Dizziness - Dizziness is often experience by people with high blood pressure. However dizziness cannot always be treated as a symptom of hypertension. If dizziness is experienced it is always wise to consult a medical practitioner.

Heart pain Palpitations Nosebleeds - Nosebleeds without particular reason might be a

symptom of high blood pressure. It is better to check the blood pressure in such cases.

Difficulty in breathing Tinnitus (ringing or buzzing in the ears) Blurred Vision Frequent urination

  On physical examination, hypertension may

be suspected on the basis of the presence of hypertensive retinopathy detected by examination of the optic fundus found in the back of the eye using ophthalmoscopy

Diagnosis

History and physical examination   laboratoryTests 

Renal Microscopic urinalysis , proteinuria, BUN and/or creatinine   Endocrine Serum sodium, potassium, calcium, TSH   Metabolic Fasting blood glucose, HDL, LDL, and total cholesterol,

triglycerides Hematocrit

  

Others

Electrocardiogram

Echo cardiography

Prevention maintain normal body weight for adults (e.g. body mass

index 20–25 kg/m2) reduce dietary sodium intake to <100 mmol/ day (<6 g

of sodium chloride or <2.4 g of sodium per day) engage in regular aerobic physical activity such as brisk

walking (≥30 min per day, most days of the week) limit alcohol consumption to no more than 3 units/day

in men and no more than 2 units/day in women consume a diet rich in fruit and vegetables (e.g. at least

five portions per day); Effective lifestyle modification may lower blood

pressure

Management

Me d i c a l M a n a g e m e n t

Lifestyle modifications

Medications

Adopt DASH (Dietary Approaches to Stop Hypertension

Eating more fruits, vegetables, and low-fat dairy foods

Cutting back on foods that are high in saturated fat, cholesterol, and trans fats

Eating more whole grain products, fish, poultry, and nuts

Eating less red meat (especially processed meats) and sweets

Eating foods that are rich in magnesium, potassium, and calcium

Other modifications

Maintain normal body weight (body mass index 18.5-24.9 kg/nF).

  Physical activity Reduce dietary sodium intake to no more

2,4 g sodium or 6 g sodium chloride. Engage in regular aerobic physical

activity such 4-9 mm Hg as brisk walking (at least 30 minutes per day, most days of the week

Different programs aimed to reduce psychological stress such a biofeedback, relaxation or meditation are advertised to reduce hypertension

Medications

Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating hypertension.. .One or more of these blood pressure medicines are often used to treat high blood pressure:

Diuretics are also called water pills. They help your kidneys remove some salt (sodium) from your body. As a result, your blood vessels don't have to hold as much fluid and your blood pressure goes down.

Beta-blockers make the heart beat at a slower rate and with less force.

Angiotensin-converting enzyme inhibitors (also called ACE inhibitors) relax your blood vessels, which lowers your blood pressure.

. Angiotensin II receptor blockers (also called ARBs) work in about the same way as angiotensin-converting enzyme inhibitors

. Calcium channel blockers relax blood vessels

by stopping calcium from entering cells.Blood pressure medicines that are not used as

often include: Alpha-blockers help relax your blood vessels,

which lowers your blood pressure. Centrally acting drugs signal your brain and

nervous system to relax your blood vessels. Vasodilators signal the muscles in the walls of

blood vessels to relax.

Renin inhibitors, a newer type of medicine for treating high blood pressure, act by relaxing your blood vessels

Renin inhibitors work, as the name would suggest, by inhibiting the activity of renin, the enzyme largely responsible for angiotensin II levels. In clinical trials, renin inhibitors have proven effective in not only lowering blood pressure, but also keeping blood pressure levels steadier throughout the day.One renin inhibitor, aliskiren (Tekturna), was approved by the FDA in 2007. Other drugs in this class are in development

Complications of hypertension

Hypertension is the most important preventable risk factor for premature death.

Ischemic heart disease

Strokes Peripheral vascular disease, Other cardiovascular diseases , Including heart failure,

aortic aneurysms, diffuse atherosclerosis, and pulmonaryembolism

Hypertension is also a risk factor for cognitive impairment and dementia, and chronic kidney disease. Other complications include hypertensive retinopathy and hypertensive nephropathy.

Bleeding from the aorta

Researches

Sesame and rice bran oil can treat high blood pressure and cholesterol, study showSignificant blood pressure, cholesterol level reductions

Yoga benefits high blood pressure through promoting relaxation of the mind and body. Practicing yoga helps decrease the negative impacts of stress, including tension, shallow breathing and elevated heart rate. It also improves physical strength and flexibility, plus may assist with weight loss

Heart failure

Heart failure is an illness in which the pumping action of the heart becomes less and less powerful. When this happens, blood does not move efficiently through the circulatory system and starts to back up, increasing the pressure in the blood vessels and forcing fluid from the blood vessels into body tissues

Incidence

Heart failure affects 2% of the adult population. In the United States, nearly four million people have heart failure. Each year about 550,000 new cases are diagnosed. The condition is more common among African Americans than Caucasians.

Heart failure affects 1% of people age 50 years or older, about 5% of those age 75 years or older, and 25% of those age 85 years or older.

Left-sided failure

When the left side of the heart (left ventricle) starts to fail, fluid collects in the lungs (pulmonary edema). This extra fluid in the lungs (pulmonary congestion) makes it more difficult for the airways to expand as a person inhales. Breathing becomes more difficult and the person may feel short of breath, particularly with activity or when lying down

Right-sided failure

When the right side of the heart

(right ventricle) starts to fail, fluid

begins to collect in the feet and

lower legs. Puffy leg swelling (edema

) is a sign of right heart failure,

especially if the edema is pitting

edema.

Biventricular failure

Dullness of the lung fields to finger percussion and reduced breath sounds at the bases of the lung may suggest the development of a pleural effusion .Though it can occur in isolated left- or right-sided heart failure, it is more common in biventricular failure because pleural veins drain both into the systemic and pulmonary venous system. When unilateral, effusions are often right sided.

Systolic heart failure

This condition occurs when the

pumping action of the heart is reduced

or weakened. A common clinical

measurement is ejection fraction (EF)..

Systolic heart failure is diagnosed when

the ejection fraction has significantly

decreased below the threshold of 55%.

Diastolic heart failure

This condition occurs when the heart can contract normally but is stiff, or less compliant, when it is relaxing and filling with blood. The heart is unable to fill with blood properly, which produces backup into the lungs and heart failure symptoms. Diastolic heart failure is more common in patients older than 75 years of age, especially in patients with high blood pressure, and it is also more common in women. In diastolic heart failure, the ejection fraction is normal or increased.

Causes Congestive heart failure (CHF) is a

syndrome that can be brought about by several causes,or a combination of several problems, including the following:

Weakened heart muscle (cardiomyopathy) Damaged heart valves Blocked blood vessels supplying the heart

muscle which may lead to a heart attack (This is known as ischemic cardiomyopathy.

Contd……….. Toxic exposures, such as alcohol or cocaine Infections, commonly viruses, which for

unknown reasons affect the heart in only certain individuals

High blood pressure that results in thickening of the heart muscle (left ventricular hypertrophy)

Congenital heart diseases Certain genetic diseases involving the

heart

Risk Factors Some of the most common risk factors for

heart failure include: Age Hypertension Physical inactivity Diabetes Obesity Smoking Metabolic syndrome Family history of heart failure

Contd………….

Enlargement of the left ventricle Some types of valvular heart disease,

including infection Coronary artery disease High cholesterol and triglycerides Excessive alcohol consumption Prior heart attack Certain exposures, such as to radiation and

some types of chemotherapy Infection of the heart muscle (usually viral)

. Cardiac compensatory mechanisms

1.tachycardia 2.ventricular dilation-Starling’s law 3.myocardial hypertrophy

Hypoxia leads to dec. contractility

B. Homeostatic Compensatory mechanisms Sympathetic Nervous System

1. Vascular system- norepinephrine- vasoconstriction 2. Kidneys

A. Dec. CO and B/P B. Aldosterone release > Na and H2O retention

3. Liver- stores venous volume (ascites, Hepatomegaly-Counter-regulatory-

Inc. Na > release of ADH (diuretics) *Release of atrial natriuretic factor > Na and H20

excretion, prevents severe cardiac decompensation

Compensatory mechanisms- activated to maintain adequate CO Neurohormonal responses: Endothelin -

stimulated by ADH, catecholamines, and angiotensin II > Arterial vasoconstriction Inc. in cardiac contractility Hypertrophy

Cntd……………..

**Counter regulatory processes Natriuretic peptides: atrial

natriuretic peptide (ANP) and b-type natriuretic peptide Released in response to inc. in atrial volume and ventricular pressure

Promote venous and arterial vasodilation, reduce preload and afterload

Prolonged HF > depletion of these factors

Counter regulatory processes Natriuretic peptides- endothelin and

aldosterone antagonists Enhance diuresis Block effects of the RAAS

Natriuretic peptides- inhibit development of cardiac hypertrophy; may have antiinflammatory effects

Pathophysiology-Structural Changes with HF Dec. contractility Inc. preload (volume) Inc. afterload (resistance) **Ventricular remodeling Ventricular hypertrophy

Ventricular dilation

Ventricular remodeling

Symptoms and Signs

Left sided heart failure Common respiratory signs are tachypnea and increased work of breathing (non-specific

signs of respiratory distress).  Backward failure of the left ventricle

causes congestion of the pulmonary vasculature,

 dyspnea (shortness of breath) on exertion and in severe cases, dyspnea at rest.  orthopnea, occurs. It is often measured in the number of pillows required to lie comfortably.

"Cardiac asthma" or wheezing 

 paroxysmal nocturnal dyspnea 

Rales or crackles suggestive of pulmonary

edema

Cyanosis which suggests severe hypoxemia,

is a late sign of extremely severe pulmonary

edema

gallop rhythm may be heard as a marker of increased blood flow, or increased intra-cardiac pressure

Heart murmurs

Due to reduced systemic circulation, dizziness, confusion and cool extremities at rest can occur.

Right heart failure

Physical examination may reveal pitting peripheral edema, ascites, and hepatomegaly

Increased jugular venous pressure

If the right ventricular pressure is increased, aparasternal heave may be present, signifying the compensatory increase in contraction strength.

Backward failure of the right ventricle leads to congestion of systemic capillaries peripheral edema or anasarca Sacral edema in lying patients Nocturia  Hepatomegaly Significant liver congestion may

result in impaired liver function, and jaundice and even coagulopathy

What is present in this extremity, common to right sided HF?

What does this show?

Symptoms

Diagnostic measures

Imaging Echocardiography is commonly used to

support a clinical diagnosis of heart failure. This modality uses ultrasound to determine the stroke volume , the end-diastolic volume , and the SV in proportion to the EDV, a value known as the ejection fraction (EF Normally, the EF should be between 50% and 70%; in systolic heart failure, it drops below 40%. Echocardiography can also identify valvular heart disease and assess the state of the pericardium .

Transesophageal echocardiogram

TEE

But

Chest X-rays are frequently used to aid in the diagnosis of CHF. In the compensated patient, this may show cardiomegaly ), quantified as the cardiothoracic ratio (proportion of the heart size to the chest). In left ventricular failure, there may be evidence of vascular redistribution ("upper lobe blood diversion" or "cephalization"), Kerley lines, cuffing of the areas around thebronchi, and interstitial edema.

X ray finding

Electrophysiology An electrocardiogram (ECG/EKG) may

be used to identify arrhythmias, ischemic heart disease, right and left ventricular hypertrophy, and presence of conduction delay or abnormalities (e.g. left bundle branch block). Although these findings are not specific to the diagnosis of heart failure a normal ECG virtually excludes left ventricular systolic dysfunction

Left bundle branch block

Others comparing BNP and N-terminal pro-BNP (NTproBNP) in

the diagnosis of heart failure, BNP is a better indicator for heart failure and left ventricular systolic dysfunction.

Angiography Heart failure may be the result of coronary artery

disease, and its prognosis depends in part on the ability of the coronary arteries to supply blood to the myocardium.As a result, coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or bypass surgery

 Classification

There are many different ways to categorize heart failure, including the side of the heart involved (left heart failure versus right heart failure).

whether the abnormality is due to insufficient contraction (systolic dysfunction), or due to insufficient relaxation of the heart (diastolic dysfunction), or to both.

NYHA –functional classification

Functional classification generally relies on the New York Heart Association functional classification. The classes (I-IV) are:

Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.

Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.

Class III: marked limitation of any activity; the patient is comfortable only at rest.

Class IV: any physical activity brings on discomfort and symptoms occur at rest.

This score documents severity of symptoms, and can be used to assess response to treatmen

ACC- stages of heart faiure American College of Cardiology/

American Heart Association working group introduced four stages of heart failure:

Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder.

Stage B: a structural heart disorder but no symptoms at any stage.

Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment.

Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

The ACC staging system is useful in that Stage A encompasses "pre-heart failure" — a stage where intervention with treatment can presumably prevent progression to overt symptoms.

Algorithm

There are various algorithms for the diagnosis of heart failure. For example, the algorithm used by the Framingham Heart Study adds together criteria mainly from physical examination.

Framingham criteria By the Framingham criteria, diagnosis of

congestive heart failure requires the simultaneous presence of at least 2 of the following major criteria or 1 major criterion in conjunction with 2 of the following minor criteria

Framingham criteria

Major criteria: Cardiomegaly on chest radiography S3 gallop (a third heart sound) Acute pulmonary edema Paroxysmal nocturnal dyspnea Crackles on lung auscultation Central venous pressure of more than 16 cm H2O at

the right atrium Jugular vein distension Positive abdominojugular test Weight loss of more than 4.5 kg in 5 days in

response to treatment

Minorcriteria Tachycardia of more than 120 beats per minute Nocturnal cough Dyspnea on ordinary exertion Pleural effusion Decrease in vital capacity by one third from maximum recorded Hepatomegaly Bilateral ankle edema Minor criteria are acceptable only if they can not be attributed

to another medical condition such as pulmonary hypertension, chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome. The Framingham Heart Study criteria are 100% sensitive and 78% specific for identifying persons with definite congestive heart failure.

Congestive Heart Failure Treatment

Lifestyle modifications Elevate the feet and legs if they are swollen. Eat a reduced-salt diet. Weigh in every morning before breakfast and

record it in a diary that can be shown to a health care provider.

Avoid the following: Not taking prescribed medications Smoking Alcohol (up to one drink per day is usually

fine)

Excessive emotional stress and/or depression (seek professional help)

avoid high altitude :breathing is more difficult because of the lower level of oxygen in the atmosphere; pressurized cabin air travel is usually fine

Stay active Exercise; consult your doctor to determine a safe

workout routine. If you are overweight, lose weight. Reduce cholesterol Get enough sleep

Supplemental oxygen Oxygen therapy may become

necessary as heart failure progresses. The need is based on the degree of pulmonary congestion and resulting hypoxia. Some patients require supplemental oxygen only during activity

Medications Diuretics (water pills):Diuretics cause the kidneys to remove

excess salt and accompanying water from the bloodstream, thereby reducing the amount of blood volume in circulation.

Diuretics commonly used in heart failure include furosemide (Lasix), bumetanide (Bumex), hydrochlorothiazide ( spironolactone (Aldactone), eplerenone , triamterene, torsemide, or metolazone

Digoxin (Lanoxin): Digoxin is a mild inotrope and, in some cases, is beneficial as an add-on therapy to ACE inhibitors and beta-blockers. It is the most common form of digitalis. Digoxin can reduce heart failure symptoms and hospitalizations, but it does not prolong life.

Digoxin is mainly used as an antiarrhythmic to control the rate of the heart in atrial fibrillation and flutter

Vasodilators: These medications enlarge the small arteries or arterioles, which relieve the systolic workload of the left ventricle. ACE inhibitors are the most widely

used vasodilators for congestive heart failure. They block the production of angiotensin II, which is abnormally high in congestive heart failure. Some common examples of ACE inhibitors are captopril, enalapril. Lisino pril

Angiotensin II receptor blockers (ARBs) work by preventing the effect of angiotensin II at the tissue level. Examples of ARB medications include olmesartan , losartan (Cozaar),

Nitrates are venous vasodilators that include isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil). They are commonly used in combination with an arterial vasodilator, such as hydralazine

Nitroglycerin is a nitrate preparation that is administered to treat acute chest pain, or angina.

Hydralazine (Apresoline) is a smooth muscle arterial vasodilator that may be used for congestive heart failure.

Beta-blockers: These drugs slow down the heart rate, lower blood pressure, and have a direct effect on the heart muscle to lessen the workload of the heart. Specific beta-blockers, such as carvedilol and long-acting metoprolol , have been shown to decrease symptoms, hospitalization due to congestive heart failure, and deaths.

Inotropes: IV inotropes are stimulants, such as dobutamine and milrinone which increase the pumping ability of the heart. These are used as a temporary support of a very weak left ventricle that is not responding to standard congestive heart failure therapy. Commonly used inotropes are dobutamine (Dobutex) and milrinone (Primacor). Phenylephrine may be used when a patient is suffering with severe low blood pressure.

Congestive Heart Failure Interventions

Angioplasty: This is an alternative to coronary bypass surgery for some people whose heart failure is caused by coronary artery disease and may be compounded by heart damage or a previous heart attack

Pacemaker: This device controls the rate of the heartbeat. A pacemaker may keep the heart from going too slow, increasing heart rate when the heart is not increasing enough with activity. It also helps sustain regular rates when the heart is not beating in a coordinated way

Implantable Cardioverter Defibrillator (ICD): This device returns the heart to a normal rhythm by pacing or delivering an electrical shock, with a life-threatening arrhythmia.

ICDs are indicated for ischemic or nonischemic cardiomyopathy patients with slight or marked physical limitations and low left ventricular ejection fractions (<30% to 35%),

CRT-Cardiac Resynchronization Therapy

HOW IT WORKS:

Standard implanted pacemakers - equipped with two wires (or "leads") conduct pacing signals to specific regions of heart (usually at positions A and C). Biventricular pacing devices have added a third lead (to position B) that is designed to conduct signals directly into the left ventricle. Combination of all three lead > synchronized pumping of ventricles, inc. efficiency of each beat and pumping more blood on the whole.

 

 

Temporary Cardiac Support: An

intra-aortic balloon pump is used

as a temporary support of left

ventricle function, such as in a

large heart attack, waiting for the

heart to recover

Surgical management Left ventricle assist device (LVAD):

This device is surgically implanted to mechanically bypass the left ventricle. It can be used as a “bridge to transplant” until a heart transplant is available.

Alternatively, LVADs are also being used as “destination therapy” in patients who are not eligible for a transplant, but only at approved specialized medical centers.

LVAD

Total artificial heart (TAH): For patients with severe, end-stage heart failure.

These devices are most commonly used as a temporary bridge to heart transplantation, but can be used as destination therapy in patients who are not eligible for a transplant and have a high chance of mortality within 30 days.

This technique is constantly improving, but is still limited to specialized centers and is considered experimental at this time.

complications Pleural effusion Atrial fibrillation (most common

dysrhythmia) Loss of atrial contraction (kick) -reduce

CO by 10% to 20% Promotes thrombus/embolus formation

inc. risk for stroke Treatment may include cardioversion,

antidysrhythmics, and/or anticoagulants

Complications High risk of fatal dysrhythmias (e.g.,

sudden cardiac death, ventricular tachycardia) with HF and an EF <35%

HF lead to severe hepatomegaly, especially with RV failure

Fibrosis and cirrhosis - develop over time

Renal insufficiency or failure

Prognosis

Prognosis in heart failure can be assessed in multiple ways including clinical prediction rules and cardiopulmonary exercise testing. Clinical prediction rules use a composite of clinical factors such as lab tests and blood pressure to estimate prognosis

ADHERE Tree rule indicates that patients with blood urea nitrogen < 43 mg/dl and systolic blood pressure at least 115 mm Hg have less than 10% chance of inpatient death or complications

Contd……….. cardiopulmonary exercise testing (CPX

testing). CPX testing is usually required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary exercise testing involves measurement of exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 12–14 cc/kg/min indicates a poor survival and suggests that the patient may be a candidate for a heart transplant. Patients with a VO2 max<10 cc/kg/min have clearly poorer prognosis

Nursing Assessment

History

Physical examination

Vital signs

PA readings

Urine output

Nursing diagnoses

Decreased cardiac output

Activity intolerance Fluid volume excess Impaired gas exchange Anxiety Deficient knowledge

Decreased cardiac output

Plan frequent rest periods Monitor VS and O2 sat at rest and

during activity Take apical pulse Review lab results and hemodynamic

monitoring results Fluid restriction- keep accurate I and O Elevate legs when sitting Teach relaxation and ROM exercises

Activity Intolerance Provide O2 as

needed practice deep

breathing exercises teach energy saving

techniques prevent interruptions

at night monitor progression

of activity offer 4-6 meals a day

Fluid Volume Excess Give diuretics and

provide BSC Teach side effects of

meds Teach fluid restriction Teach low sodium diet Monitor I and O and

daily weights Position in semi or

high fowlers Listen to BS

frequently

Knowledge deficit

Low Na diet Fluid restriction Daily weight When to call Dr. Medications

Nursing Management Health Promotion

Treatment or control of underlying heart disease key to preventing HF and episodes of ADHF (e.g., valve replacement, control of hypertension)

Antidysrhythmic agents or pacemakers for patients with serious dysrhythmias or conduction disturbances

Flu and pneumonia vaccinations