Nursing intervention for Acute Heart Failure

[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 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

[hurleygirli1]

I wouldn't want to give more fluid to someone whose pump (heart) isn't working....think of patho of heart failure

[LadyFree28, BSN, LPN, RN]

OP, you are on the right track.

[Esme12, ASN, BSN, RN]

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?

[DidiRN]

Moved to Nursing Student Assistance

[KelRN215, BSN, RN]

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?

[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 warrent some serious questioning.

[Esme12, ASN, BSN, RN]

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.

[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.

[Esme12, ASN, BSN, RN]

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.

[lazz1]

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.

[Esme12, ASN, BSN, RN]

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.