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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders
z Exercise intolerance z SOB, orthopnea, bendopnea z JVD z Dependent peripheral edema z Weak peripheral pulses, cool extremities, delayed capillary refill z Cardiac cachexia or generalized body wasting Nursing Diagnoses/Problem List z Impaired oxygenation related to accumulation of fluid in the lungs secondary to HF z Decreased cardiac output related to altered preload, afterload, and contractility z Ineffective peripheral perfusion related to decreased cardiac output secondary to HF z Electrolyte imbalances z Fatigue Nursing Interventions ■ Assessments z Vital signs Hypertension is present because of the increased afterload. Hypotension may be caused by acute heart failure or be an adverse effect of medications. Tachycardia can be present as the heart attempts to compensate for decreased cardiac output. Tachypnea and decreased oxygen saturation may be present when fluid accumulates in the lungs because of left-sided HF. z Breath sounds Crackles indicate pulmonary congestion. z Monitoring for irregular heart rhythm or dysrhythmias Dysrhythmias are a common adverse effect of HF and medi- cations used to treat HF. z Skin color, temperature, peripheral pulses, and capillary refill time Pale or cyanotic color, cool extremities, weak peripheral pulses, and sluggish refill time result from inadequate cardiac output. z Dry, persistent cough Common complication of ACE inhibitors z Activity tolerance Dyspnea on exertion, weakness, and fatigue indicate decreased cardiac output and worsening heart failure. z Urine output Output may be reduced with decreased renal perfusion. It can also be used to assess the effectiveness of diuretic therapy. Less than 30 mL/hr should be reported to the provider. z Daily weight To evaluate fluid retention and effectiveness of diuresis z Laboratory data Elevated BNP and NT-proBNP indicate overstretching of heart tissue. Elevated creatinine and BUN may be indic- ative of prerenal failure due to decreased cardiac output or overdiuresis. Elevated hepatic enzymes can be indicative of hepatomegaly; hypokalemia is a common complication of diuretic administration. Anemia can be caused by reduced kidney perfusion resulting in decreased erythropoietin production and function.
Complications Pulmonary edema is an acute complication of HF charac- terized by the accumulation of fluid in the interstitial and alveolar spaces of the lung, resulting from elevated filling pressures within the heart. The symptoms of pulmonary edema include SOB, low oxygen saturation, pink and frothy sputum, orthopnea, bendopnea, tachycardia, chest pain, and anxiety/fear. Treatments include supplementary oxygen administration and initiation of higher-dose or IV diuretics. Depending on the severity of the edema, the patient may need more aggressive respiratory support with continuous positive airway pressure (CPAP), bilevel posi- tive airway pressure (BiPAP), or intubation with mechan- ical ventilation. Dysrhythmias can also occur as the heart enlarges and catecholamine levels increase. Renal failure is another common complication seen in HF patients. This is due to the decrease in blood flow to the kid- neys. Renal failure is discussed in more detail in Chapter 62. Nursing Management Assessment and Analysis The clinical manifestations of HF are due to the weak- ened myocardial contraction resulting in decreased cardiac output, a backup of blood, and poor peripheral perfusion. Common findings include the following: z Poor mentation z Anorexia Heart Failure and Older Adults Heart failure (HF) is more common with aging. Older patients are more likely to have heart failure with pre- served ejection fraction (HFpEF), for which fewer evidence-based treatment guidelines exist. They often have five or six additional comorbidities, which create complexities in care and a greater potential for medi- cation interactions. Depression, anxiety, and cognitive impairment, which often go undiagnosed, can reduce self-management abilities and medication adherence, warranting careful screening for these conditions. Few studies of HF focus exclusively on the older adult. Some studies show that HF medications are underused in older adults, whereas others show that more intensive medi- cation therapy is not associated with additional benefits. Many HF medications have hypotensive effects or cause nocturia, which may increase fall risk. A careful risk/ benefit analysis of interventions is required, particularly when medication changes occur. Due to declining renal function, potential poor nutritional status, and greater risk for dehydration, older patients need to be moni- tored more carefully for adverse effects. Telephone and telemonitoring may be useful strategies after discharge. Geriatric/Gerontological Considerations
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