Nursing intervention for Acute Heart Failure

  1. 1 I am having a difficult time finding the answer for this question...

    1. A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification?

    a. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain
    b. 0.9% normal saline IV at 250 mL/hr continuous
    c. Laboratory testing of serum potassium upon admission
    d. Bumetanide (Bumex) 1 mg IV bolus every 12 hr

    Am I on the right track....

    In my mind and rationale... Acute heart failure means fluid overload and pain.... So, I wouldn't question the morphine, or the Bumetanide because its a loop diuretic. I wouldnt question the labs for serum potassium either because of the loop diuretic... which leaves B... 0.9% normal saline IV at 250 mL/hr continuous
  2. Visit  sander1x profile page

    About sander1x

    From 'Bonney Lake, Washignton'; Joined Sep '11; Posts: 5; Likes: 1.

    12 Comments so far...

  3. Visit  hurleygirli1 profile page
    0
    I wouldn't want to give more fluid to someone whose pump (heart) isn't working....think of patho of heart failure
  4. Visit  LadyFree28 profile page
    0
    OP, you are on the right track.
  5. Visit  Esme12 profile page
    0
    Quote from sander1x
    I am having a difficult time finding the answer for this question...

    1. A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification?

    a. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain
    b. 0.9% normal saline IV at 250 mL/hr continuous
    c. Laboratory testing of serum potassium upon admission
    d. Bumetanide (Bumex) 1 mg IV bolus every 12 hr

    Am I on the right track....

    In my mind and rationale... Acute heart failure means fluid overload and pain.... So, I wouldn't question the morphine, or the Bumetanide because its a loop diuretic. I wouldn't question the labs for serum potassium either because of the loop diuretic... which leaves B... 0.9% normal saline IV at 250 mL/hr continuous
    Again...think this through.....

    a) Morphine is not only for pain but it also has a vaso-dilatory affect on the heart therefore decreasing the hearts workload and decreases anxiety (pre-load after-load reduction)

    b) If someone is fluid overloaded would you want an IV at 250ml.hr?

    c) if you are giving large/frequent doses of a diuretic causing massive diuresis what electrolyte would you be concerned with in a patient with a failing irritated heart?

    c) What does Bumex do?

    Now....which order would you question?
  6. Visit  DidiRN profile page
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    Moved to Nursing Student Assistance
  7. Visit  KelRN215 profile page
    1
    An IV running at 250 mL/hr would give the patient over 6L of fluid in a day. Is this ok in a patient with heart failure?
    4boysmama likes this.
  8. Visit  lazz1 profile page
    0
    I would be most concerned with the NS continuous infusion order. There should also be a daily weights order too. The patient should be on strict in/outs and sodium restriction. If a patient is overloaded with fluid, you do not want to be giving more fluid IV. The patient is not dehydrated. The patient is overloaded, meaning has too much fluid volume in the blood which over stretches the heart and causes the pump failure. This extra fluid also tries to infiltrate the interstitial spaces of the lungs and other body tissues causing edema. Also, in heart failure, the kidneys are actually hypo-perfused, because of the pump failure, so the kidneys act as if the body is dehydrated and retains fluid (worsening the heart failure). Therefore, the diuretic is necessary to get the kidneys making a lot of urine to pull off that extra fluid volume.

    Now if the patient was crashing, a fluid bolus would be necessary of course, but a continuous one at 250 cc and hour would warrent some serious questioning.
  9. Visit  Esme12 profile page
    0
    Quote from lazz1
    I would be most concerned with the NS continuous infusion order. There should also be a daily weights order too. The patient should be on strict in/outs and sodium restriction. If a patient is overloaded with fluid, you do not want to be giving more fluid IV. The patient is not dehydrated. The patient is overloaded, meaning has too much fluid volume in the blood which over stretches the heart and causes the pump failure. This extra fluid also tries to infiltrate the interstitial spaces of the lungs and other body tissues causing edema. Also, in heart failure, the kidneys are actually hypo-perfused, because of the pump failure, so the kidneys act as if the body is dehydrated and retains fluid (worsening the heart failure). Therefore, the diuretic is necessary to get the kidneys making a lot of urine to pull off that extra fluid volume.

    Now if the patient was crashing, a fluid bolus would be necessary of course, but a continuous one at 250 cc and hour would warrant some serious questioning.
    Even if a patient is crashing fluids would not be an intervention....they need alpha drugs to increase cardiac outout like dopamine, and epinephrine.
  10. Visit  lazz1 profile page
    0
    Hi,

    I still think fluid boluses can be one of many interventions that are applicable in a crashing/code situation. Have you been a code? All the ones I have been in, nurses are running NS fast to at least keep the BP up while meds are being administered. When the meds are working, then the boluses slow down, but fluids can be giving in a code situation.
  11. Visit  Esme12 profile page
    2
    Quote from lazz1
    Hi,

    I still think fluid boluses can be one of many interventions that are applicable in a crashing/code situation. Have you been a code? All the ones I have been in, nurses are running NS fast to at least keep the BP up while meds are being administered. When the meds are working, then the boluses slow down, but fluids can be giving in a code situation.
    As critical care nurse for 35 years and a trauma flight nurse working exclusively in critical care emergency medicine and cath lab......for 35 years......I have been in few codes.

    I will use the fluids to flush the lines after meds and yes..... fluids run free during a code to facilitate the administration of the resuscitation meds in a pulseless patient to circulation during CPR...however it is not the fluid volume the patient necessarily needs to maintain the B/P for in a failing heart and over load of fluid will cause the heart to stop pumping and fail.
    Last edit by Esme12 on Oct 8, '13
    KelRN215 and 4boysmama like this.
  12. Visit  lazz1 profile page
    0
    I'm not disagreeing with you. Medications to improve BP and CO are much better and more effective than just NS boluses, I was only stating that boluses have their place in codes and to not be afraid to run the line open during a code until proper help has arrived. I am not a critical care nurse, I worked on a cardiac stepdown unit, so when one of our patients coded or were crashing, we immediately called the code for the code team to arrive and the second thing we did was run fluids until the doctor and ICU nurses were present to give the meds. That is the perspective I am coming from.
  13. Visit  Esme12 profile page
    0
    Absolutely...point taken. I have read your posts....you are gaining a good grasp in cardiac medicine. Keep going forward. You should consider critical care....I think you'd like it.
  14. Visit  GrnTea profile page
    1
    One thing that might help you understand this is getting the concepts summarized in the Frank Starling Law of the heart, about preload and afterload. It's really not that complicated and once you get it, you'll never get caught on this sort of question or clinical situation again.

    It's helpful if you can step back first and think of what the anatomy of the circulatory system is supposed to accomplish. It's supposed to move a fluid around in a bunch of blood vessels, pumped out at high pressure from the left side of the heart, returned to the heart by passive squeezing in the veins and kept from sloshing backwards by valves in the vessels. Then the right side of the heart is supposed to push it through the lungs (at a lower pressure, because it only has to perfuse the lungs right next door, not all the way down to the toes like the arterial system) to do the gas-exchange thing. Then the fluid goes back to the left side of the heart and out to the body again.

    Ventricular filling pressure is just the pressure that is in the ventricles at the end of diastole (LVEDP, left ventricular end-diastolic presssure). For a given volume delivered to a ventricle, pressure can be lower if the ventricle is nice and soft and flexible and empty, ready to accept a new load, than if it's hard and scarred up or has leftover blood in it from the last systole because the AV is hard to open OR because its contractility was so lousy that it didn't empty well. Another term that is used could be "preload," pre- meaning "before systole," and load, well, being the load of blood delivered to the ventricle that it is gonna have to move out in systole. You can measure load as weight or volume, but the way we look at it is by measuring the pressure that occurs there. Pressure changes tell us what's going on in there. Think about a soft balloon (low pressure) and a hard one (high pressure). Which has more air in it?

    Let's look at the blood flow in a linear fashion. I regret that I cannot give these in color so you can see the blue of venous, the red of arterial. But hey. Draw them on a piece of paper in color. The lungs are pink

    Body > Veins > Vena Cava > Right Atrium > tricuspid valve > Right Ventricle > pulmonic valve > Pulmonary Artery > LUNGS >Pulmonary Vein > Left Atrium > mitral valve > Left ventricle > aortic valve > Arteries > Body

    Think about when the valves between two chambers are OPEN. By definition, each chamber must be at the same pressure, right? So, at the end of diastole, just before systole, the pressure in the LV is the same as LA pressure is the same as the pressure in the pulmonary vein (no valve in the way there) and in the pulmonary capillary bed. And since there are no valves in the pulmonary capillary bed, tracking backwards, you can see that LV end diastolic pressure equals end-diastolic PULMONARY ARTERY PRESSURE, which is, conveniently, what we look at when we are wondering what's going on in the left heart. You can even follow it back all the way to the right atrium, and the vena cava-- central venous pressure! Wow!

    OK. Now, why do we care about LV end-diastolic (filling) pressure? It's because that's where the work of supplying the whole body goes. For that, I wish I could draw you a nice little curve here. I can't, so I will describe it and YOU will draw it on a piece of paper to look at while we chat.

    Horizontal axis: label this "preload" or any other term you like. Filling pressure, PA diastolic pressure is the same thing (see above) and you can even extrapolate all the way back to central venous pressure, for a rough trend-setting bit of data.
    The vertical axis you will call "cardiac output," or "blood pressure," because the line we are going to draw is going to explain something really cool.
    Start lowish on the left, near the vertical axis-- low filling pressure means low BP. Think: hemorrhage, hypovolemia, makes your BP low, right?
    Slant the line upwards to the right, showing that blood pressure (cardiac output) increases the more blood you put into the heart. (Tank up that hypovolemic guy, and BP improves.) But at some point, that upward-going curve peaks, flattens out...and then it DROPS as the preload keeps increasing. This is because cardiac muscle is like a rubber band-- the more you stretch it, the harder it contracts...to a point, at which point it gets too stretched out and actually contracts less well. Draw a little asterisk at the top of that curve, where it starts to fall, then let it fall a little bit. That asterisk marks the best cardiac output you can get-- preload and output are optimal for that heart. Beyond that point, where the line slopes downwards, lies congestive heart failure- the heart is too full, has more than it can handle, and it fails. (This is, BTW, called the Frank-Starling Law of the heart, and you just drew the Frank-Starling curve) Pressure backs up into the pulmonary capillary bed making the lungs get wet and heavy. This is when people get diuretics (to decrease that excessive preload) AND drugs to improve their contractility.

    Of course, if contractility is lousy because of coronary artery disease, previous MI, or whatever, this whole curvy line thing will kinda slide over to the left-- the myocardium will fail with lower pressures than it would if it had better contractility. Better contractility (a right shift) means it will handle more preload (higher filling pressures) and make better BP out of it. Draw a second curve to the right of the first one, parallel to it, to see that. With me so far?

    I think you can see how CAD will give you higher filling pressures-- when the heart is failing a bit, it goes past the top of its curve more easily because its contractility is diminished. Drop in BP might mean hypovolemia (run in that NS!) but in a primarily cardiac situation you are more likely to be dealing with too much preload so running the NS wide open is usually a bad idea, and now you know why.

    Mitral STENOSIS will, in fact, decrease your LV preload, but it will increase pressures back into the lungs and, eventually, the right heart, because of the resistance to flow from the right side to the LV. Mitral REGURGITATION, on the other hand, will result in higher filling pressures because when the ventricle contracts in systole, some of the blood goes backwards, leaving excess sloshing around between the atrium and ventricle; the ventricle will have to accept a higher reload at diastole, and it doesn't like it. Over the top of the curve again.

    Well, I hope this hasn't confused you. I used to tell my students they had to know this because we saw lots of people with all sorts of deficits, but if they didn't have hearts and lungs, they were dead and we didn't have to take care of them anymore. Works in every possible area you could work, except pathology. Please ask me if I've confused you anywhere.
    pmabraham likes this.


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