Patient scenarios (HF) Heart Failure CHD HTN Patient scenarios (HTN)
100
Full set vital signs
Heart sounds
Lung Sounds
Pulses
Edema
Skin condition (color, temperature, etc.)
Mr. Jones, a 69-year old male, presents to the Emergency Department (ED) after visiting his primary physician complaining of general fatigue for 4 days, shortness of breath, and abdominal discomfort. Mr. Jones’s medical history includes hypertension and coronary artery disease. He had a previous 90% LAD blockage and 50% RCA blockage with stent placements in both. What initial nursing assessments need to be performed for Mr. Jones?

100
Left: decreased cardiac output, and inability to
pump blood into the systemic circulation causing a “back-up” into the pulmonary circulation.
EF below 40%
Acute or chronic (mild to severe)
1st sign- s3 gallop (early filling of the atrium)
later sign: Hypertrophy or ischemia and pulmonary congestion/edema
Risk factors: Lt: CAD, MI, HTN, HLD, DM, obesity, diet and exercise, cardiomyopathy, valve disorders, arrhythmias, ect

Describe left side heart failure including the pathophysiology and risk factors
200
Patho: structural defect in the heart
Causes: unknown, environment, hereditary
1. Congenital heart defects are abnormalities in the structure of the heart a. Caused by improper development during gestation 2. Associated with:
a. Chromosomal abnormalities b. Syndromes c. Congenital defects. 3. Risk factors: a. Parent or sibling has heart defect b. Maternal diabetes c. Maternal use of alcohol and illicit drugs d. Exposures to infections in utero (rubella) i. Increased pulmonary blood flow 1. Atrial Septal Defect 2. Ventricular Septal Defect 3. Patent ductus arteriosus 4. Atrioventricular canal ii. Decreased pulmonary blood flow 1. Tetralogy of Fallot
2. Tricuspid atresia iii. Obstruction to blood ow 1. Coarctation of the aorta 2. Aortic stenosis 3. Pulmonic stenosis iv. Mixed blood ow 1. Transposition of great arteries 2. Truncus arteriosus
3. Hypoplastic Left Heart
What is the patho and causes of CHD? Name an example of a type of CHD and what type of defect it is
100
smoking, diet/fatty foods (hyperlipidemia, atherosclerosis, lifestyle, obesity/stress, age, race (AA), family hx, ETOH, salt intake/caffeine
What are the risk factors for developing hypertension. Name 6
100
essential HTN has no known cause, but several associated risk factors. He has several factors for HTN, including family history, excessive calorie consumption, physical inactivity, smoking, and being African-American. Secondary HTN is caused by another disease process. At this point, it is unclear what the cause of his HTN could be. Further testing is needed.
The patient is a 64-year-old African-American man who is diagnosed with hypertension. He is 6
feet tall and weighs 300 lbs. He smokes two packs of cigarettes per day. He works as a salesman
and has two to three alcoholic drinks a week. He admits that he does not get as much exercise as
he used to when he was 40 years old. His mother and brother have high blood pressure, and his
father died of a heart attack at age 68. Does he have essential or secondary hypertension? What are the differences. Can this be determined at this point? Give a rationale for the answer.
200
Chest X-ray
12-lead EKG
Echocardiogram
BNP
Cardiac Enzymes
Mr. Jones, a 69-year old male, presents to the Emergency Department (ED) after visiting his primary physician complaining of general fatigue for 4 days, shortness of breath, and abdominal discomfort. Mr. Jones’s medical history includes hypertension and coronary artery disease. He had a previous 90% LAD blockage and 50% RCA blockage with stent placements in both. What diagnostic tests do you anticipate being ordered by the provider?
100
Rt: distended Rt atrium and ventricle and inability to
pump blood into the pulmonary circulation causing a “back-up” into venous circulation.
Rt: caused by Lt sided HF, COPD (conditions that restrict blood flow to the lungs; acute or chronic pulmonary diseases)
Describe right side heart failure including the pathophysiology and risk factors
100
Cyanotic heart defects are those that result in low blood oxygen level and create a bluish color of the skin. Some cyanotic heart defects include heart valve defects, Tetralogy of Fallot, and defects of the pulmonary vein. Skips the lungs and perfuses deoxygenated blood through a right to left shunt
Acyanotic heart defects are characterized by defects of the atrial septum or ventricular septum that may change the flow of blood, but does not affect the oxygen level in the blood. Left to right shunts cause oxygenated blood to be re-oxygenated instead of going out to the tissues.
Describe the difference between cyanotic and acyanotic heart defects.
200
Cause for primary is unknown (idiopathic). Cause for secondary is an underlying condition (CKD, narrowing of arteries, endocrine disorders, excess aldosterone, cortisol, or catecholamines)
Describe the difference in Primary HTN and Secondary HTN. What are the causes of both?
200
36-1 in 9th edition text
Essential: • Family history of hypertension
• African-American ethnicity
• Hyperlipidemia
• Smoking
• Older than 60 years or postmenopausal
• Excessive sodium and caffeine intake
• Overweight/obesity
• Physical inactivity
• Excessive alcohol intake
• Low potassium, calcium, or magnesium intake
• Excessive and continuous stress
Secondary:
• Kidney disease
• Primary aldosteronism
• Pheochromocytoma
• Cushing's disease
• Coarctation of the aorta
• Brain tumors
• Encephalitis
• Pregnancy
• Drugs:
• Estrogen (e.g., oral contraceptives)
• Glucocorticoids
• Mineralocorticoids
• Sympathomimetics
The patient is a 64-year-old African-American man who is diagnosed with hypertension. He is 6
feet tall and weighs 300 lbs. He smokes two packs of cigarettes per day. He works as a salesman
and has two to three alcoholic drinks a week. He admits that he does not get as much exercise as
he used to when he was 40 years old. His mother and brother have high blood pressure, and his
father died of a heart attack at age 68. What diseases would have made this patient at risk for developing secondary hypertension?
300
Because his heart cannot pump blood efficiently to the body, the blood is backing up into the lungs. This causes pulmonary edema and right sided heart failure with fluid backing up to the rest of his body. His pulmonary edema is so severe that he is struggling to breathe and struggling to oxygenate appropriately.
His heart is trying to work extra hard to compensate for the low cardiac output, that’s why his blood pressure and heart rate are so elevated. This is perpetuated by the RAAS.
We also see that his kidneys are not being perfused as his urine output has decreased.
Mr. Jones’s is being transferred to the telemetry unit from the ER after complaints of chest pain, coughing with pink-frothy sputum and SOA. After arriving to the unit his skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze. His SpO2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm. Describe what is happening to Mr. Jones physiologically.
400
LT: (LUNG) fatigue, activity intolerance, cyanosis, weak peripheral pulses, tachycardia, SOB/SOA, Dizziness
Late: pulmonary edema: pink frothy sputum

RT: (rest of the body): JVD
RUQ pain (liver enlargement)
Peripheral edema, distended abd, weight gain, nocturnal polyuria, anorexia/nausea, ascites, dependent edema, venous stasis
Describe the early and late signs of left sided heart failure and the signs and symptoms of right sided heart failure
200
Poor suckling reflex/ Poor feeding (only for 15 min if in distress or 30 min without distress- then switch to tube feeding), Tachycardia a. Murmurs b. Additional heart sounds c. Irregular rhythms, Clubbing fingers
Delayed growth= longer NICU stays, Cyanosis (lips),
Fatigue, Activity intolerance, Pale gray or blue skin color, Tachypnea, Swelling of the hands or feet, Hypotension or signs of heart failure
What are the S&S in an infant with CHD (name 6)
300
Silent killer, Headache, Later stages: , Blurry vision, Confusion, Worsening of HA, Dizziness, Nausea,
Chest pain/Angina, Anxiety, Ventricular hypertrophy
Name the S&S of HTN including a HTN emergency and distinguish the two (4)
300
To check renal disease; urinalysis, serum BUN and creatinine. To rule out Cushing's syndrome check serum corticoids. To check for cardiomegaly (heart enlargement) get a chest X-Ray. Liver enzymes: ALT and AST. HTN can cause hepatic portal vein hypertension by obstructing blood flow to the liver.
The patient is a 64-year-old African-American man who is diagnosed with hypertension. He is 6
feet tall and weighs 300 lbs. He smokes two packs of cigarettes per day. He works as a salesman
and has two to three alcoholic drinks a week. He admits that he does not get as much exercise as
he used to when he was 40 years old. His mother and brother have high blood pressure, and his
father died of a heart attack at age 68. During the initial workup for hypertension, what laboratory testing would be ordered? Explain.
400
Place into High Fowler’s position
Apply oxygen
Administer any PRN medications available for blood pressure (like hydralazine or metoprolol) if criteria are met
Notify the provider/ call rapid response
Mr. Jones’s is being transferred to the telemetry unit from the ER after complaints of chest pain and SOA. After arriving to the unit his skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze. His SpO2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm. What nursing interventions should you perform right away for Mr. Jones?
500
Low Na diet, compression stockings (Rt), daily wts, elevate legs (Rt), deep breathing and cough (Lt), avoid NSAIDS (renal damage, fluid and Na retention), Monitor lytes, Tx underline cause of HF,
Telemetry, Meds: ACE inhibitors, Diuretics, BB, ARBS, Calcium channel blockers (AA population), Vasodilators, DX: ECHO- valves, enlargement, EF <40%, BNP, Troponin, CRP, Chest x-ray: cardiomegaly, pulmonary edema, Right sided in particular: liver enzyme labs (ALT and AST)
What are the diagnostic tools (3), treatments (including medications) (3), and interventions (3) for heart failure (CHF; Lt and Rt)
500
Supplemental tube feeding, Delay sx until 2-4, Daily wts, Cluster care , Heart and lung auscultation , Sucking exercises, Rinse mouth after feeding due to residue milk not being sucked down from fatigue- could cause bacteria growth, offer High dense nutrient Based formulas, Labs: BNP, K levels, Dig levels,
What are some interventions and educational topics to discuss for patients with CHD. Include feeding information, nursing care, home care, assessments, labs and ect.
400
Low sodium (no canned food, cheese, red meat, prepackaged meals, deli meats, snack nuts, chips)
DO: take garlic (except for liver failure and increased bleeding). DASH Mrs. Dash; herbs,
Antihypertensives:
Diuretics:
Check BP before and after
Tx: stent placement
Exercise
Fluid restriction/Stick I&O
What are the interventions and treatment for a client with HTN. Include specifics about diet, medications, and home care. Consider possible surgical treatment.
400
Weight loss, smoking cessation, BP WNL depending whether or not he has renal disease or diabetes. Lab tests such as BUN, Creatinine and AST and ALT
The patient is a 64-year-old African-American man who is diagnosed with hypertension. He is 6
feet tall and weighs 300 lbs. He smokes two packs of cigarettes per day. He works as a salesman
and has two to three alcoholic drinks a week. He admits that he does not get as much exercise as
he used to when he was 40 years old. His mother and brother have high blood pressure, and his
father died of a heart attack at age 68.An interdisciplinary team consult was completed. What assessment findings would indicate
that successful outcomes have been met?
dietary and lifestyle changes, Diet - restrict sodium and fluids, avoid processed foods & lunch meats
Caution - salt substitutes are made with potassium,
Exercise, Stop smoking and avoid caffeine and alcohol, Monitoring Weight, Check blood pressure daily, Monitor signs of edema
Medication Instructions - Furosemide, Lisinopril, aspirin, Digoxin, Carvedilol, orthostatic hypotension, Signs of toxicity, Bleeding precautions, When to call the provider
Mr. Jones is being discharged from the hospital after being diagnosed with CHF. His prescriptions are to take furosemide 160 mg PO twice daily, Lisinopril (ACE inhibitor) 20 mg PO every 6 hours, 81mg Aspirin daily, and digoxin 0.125 mg PO daily. His ECG shows normal sinus rhythm and an echocardiogram showed an ejection fraction (EF) of 30%. He will be started on a low dose of carvedilol and should follow up with the cardiologist in 1 week. What patient education topics would need to be covered with Mr. Jones?
400
Daily wts
Elevation/compression
MAWDS (medications, activity, weight, diet symptoms)
Sodium restricted diet
Fluid restrictions
K levels
Dig levels
What are five educational topics for patients with heart failure? Include electrolyte information, things to avoid, care at home, comfort measures and ect.
500
Medications may be given depending on the particular defect, such as prostaglandins to keep the PDA open. Prostaglandins are used to keep a PDA patent/open until surgery occurs to close the PDA. Prostaglandin inhibitors (such as NSAIDS) can also be used to close the PDA if surgery is not needed. ACE inhibitors and beta blockers may be given to help lower blood pressure to decrease preload and afterload. Common medications; Digoxin, Ace Inhibitors, Beta-blockers, Diuretics
Dig toxicity signs; K issues (hypokalemia)
Many conditions can now be repaired with catheterization while others require open surgery or transplant. Patient will need to be NPO prior to surgery or procedure
Describe the medications and treatments commonly used for patients with CHD. Include education on these medications and treatment.
500
Diet, Document home BP, Smoking cessation, Stress management, Report s/s with meds , Withdraw syndrome, Dr. visits, Retina exam
Avoid vasodilation (hot tubes, strenuous activity)
s/e meds: orthostatic Hypotension
Name 6 education topics to discuss with your client in regards to controlling their Blood pressure. Include things to avoid, side effects, exams, diet, and ect.
500
chart 36-2 in edition 9:
Assess:
• Severe headache
• Extremely high blood pressure (BP)
• Dizziness
• Blurred vision
• Shortness of breath
• Epistaxis (nosebleed)
• Severe anxiety
Intervene:
• Place patient in a semi-Fowler's position.
• Administer oxygen.
• Start IV of 0.9% normal saline (NS) solution slowly to prevent fluid overload (which would increase BP).
• Administer IV beta blocker or nicardipine (Cardene IV) or other infusion drug as prescribed; when stable, switch to oral antihypertensive drug.
• Monitor BP every 5 to 15 minutes until the diastolic pressure is below 90 and not less than 75; then monitor BP every 30 minutes to ensure that BP is not lowered too quickly.
• Observe for neurologic or cardiovascular complications, such as seizures; numbness, weakness, or tingling of extremities; dysrhythmias; or chest pain (possible indicators of target organ damage).
The patient is a 64-year-old African-American man who is diagnosed with hypertension. He is 6
feet tall and weighs 300 lbs. He smokes two packs of cigarettes per day. He works as a salesman
and has two to three alcoholic drinks a week. He admits that he does not get as much exercise as
he used to when he was 40 years old. His mother and brother have high blood pressure, and his
father died of a heart attack at age 68. This patient was later seen in the ED with severe headache, extremely high blood pressure,
dizziness, blurred vision, and shortness of breath. He appears very frightened and anxious. His
diagnosis is hypertensive crisis. Describe other S&S of hypertensive crisis and the appropriate interventions for this problem.






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