NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Valvular Disease (Murmurs)

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Mitral Stenosis

Focus topic: Medical–Surgical Nursing

Definition: A progressive fibrous thickening and calcification of the valve cusps that results in the leaflets fusing and becoming stiff, causing narrowing of lumen of mitral valve.

Assessment
A. Evaluate history for congenital heart disease or rheumatic heart disease.
B. Assess for signs of decreased cardiac output. Asymptomatic until valve area is less than 1.5 cm2 and tachycardia or atrial fibrillation occurs.
C. Assess for symptoms and signs of left, and then right, ventricular failure.
D. Auscultate heart sounds for diastolic murmur and opening snap crescendo and loud S1 at apex.
E. Assess for complications.

  • Atrial fibrillation.
  • Subacute infective (bacterial) endocarditis.
  • Thrombi formation.

Implementation
A. Treat heart failure and arrhythmias.
B. Decrease cardiac workload.
C. Prevent and/or treat infections—prophylactic antibiotic therapy used to prevent recurrence of infection.
D. Monitor administration of anticoagulants for treatment and/or prevention of thrombi/emboli in clients with atrial fibrillation.
E. Provide emotional support to client.
F. Prepare client for plan if there is no calcification of valve or for surgical replacement of the mitral valve.

Medical–Surgical Nursing

Medical–Surgical Nursing: Mitral Insufficiency

Focus topic: Medical–Surgical Nursing

Definition: Congenital or acquired abnormality of the valve that prevents the mitral valve from closing completely during systole, allowing regurgitation (backflow) of blood from left ventricle to atrium.

Assessment
A. Assess for presence of cardiac disease associated with mitral insufficiency.

  • Rheumatic heart disease.
  • Congenital disease.
  • Infective (bacterial) endocarditis.
  • Rupture of chordae tendineae supporting structures.
  • Rupture or dysfunction of papillary muscle.
  • Dilatation of left ventricle.
  • Decreased cardiac output (fatigue, weakness).
  • Dyspnea on exertion.
  • Orthopnea.
  • Atrial fibrillation.

B. Observe for evidence of heart failure.
C. Auscultate at apex for decreased intensity of S1; pansystolic murmur; S3.
D. Assess for palpable thrill.
E. Evaluate for systemic emboli. Implementation Same as for mitral stenosis.

Medical–Surgical Nursing: Mitral Valve Prolapse

Focus topic: Medical–Surgical Nursing

Definition: Leaflets of the mitral valve enlarge and prolapse into left atrium during systole.

Assessment
A. Asymptomatic.
B. May experience chest pain, palpations, exercise intolerance.

Implementation
A. Benign abnormality.
B. Can progress to mitral regurgitation.

Medical–Surgical Nursing: Aortic Valve Stenosis

Focus topic: Medical–Surgical Nursing

Definition: The narrowing of the aortic valve opening due to fibrosis and calcification. This results in increased after load to the left ventricle.

Assessment
A. Assess history for predisposing conditions.

  • Rheumatic heart disease. (Mitral valve commonly affected as well.)
  • Arteriosclerosis.
  • Congenital defect.

B. Observe for dizziness and syncope with exertion.
C. Observe for symptoms of heart failure.
D. Auscultate for systolic murmur; faint S2 at aortic area.
E. Assess for dyspnea, angina.
F. If client to receive Tridil (nitroglycerin), monitor client frequently as significant drop in BP may occur and can worsen chest pain.

Implementation
A. Follow nursing care protocols for clients with heart failure.
B. Prepare client psychologically and physiologically for prosthetic valve replacement.
C. Aortic valve replacement may be done with traditional open heart surgery or transcatheter aortic valve replacement (TAVR), also called transcatheter aortic valve implantation (TAVI).

  • TAVR is a procedure for select clients with severe symptomatic aortic stenosis who are not candidates for traditional open chest surgery or are high-risk operable candidates.
  • TAVR is performed on a beating heart and does not require cardiopulmonary bypass. The TAVR valve is made of bovine (cow) pericardium and is supported with a metal stent.
  • The most common approaches are transfemoral and transapical.

Aortic Insufficiency
Definition: Allows blood to regurgitate (backflow) into left ventricle from the aorta. The left ventricle compensates and dilates to accommodate increased blood volume; leads to left ventricular hypertrophy.

Assessment
A. Assess for presence of the following conditions:

  • Rheumatic heart disease.
  • Marfan syndrome.
  • Arteriosclerotic and hypertensive dilatation of aortic root.
  • Dissecting aortic aneurysm.
  • Prosthetic valve leakage.

B. Observe for signs of heart failure.
C. Assess for pounding arterial pulse (Corrigan-type arterial pulse) in the neck.
D. Observe if widened pulse pressure present (difference between systolic and diastolic pressure).
E. Auscultate for early diastolic murmur.
F. Assess for weakness, severe dyspnea, hypotension.

Implementation
Same as for aortic valve stenosis.

Medical–Surgical Nursing: Tricuspid Stenosis

Focus topic: Medical–Surgical Nursing

Definition: Narrowing of the valve lumen, usually
associated
with mitral valve defect (extremely uncommon).

Assessment
A. Assess for presence of the following conditions:

  • Rheumatic heart disease with mitral valve involvement.
  • Congenital disease.
  • Infective (bacterial) endocarditis.

B. Observe for evidence of heart failure.
C. Auscultate for late diastolic murmur—use bell over tricuspid area.

Implementation
A. Follow nursing protocols for clients with heart failure.
B. Prepare client psychologically and physiologically for valvotomy or tricuspid valve replacement.

Medical–Surgical Nursing: Tricuspid Insufficiency

Focus topic: Medical–Surgical Nursing

Definition: Allows regurgitant blood flow back into the right atrium from the ventricle—usually due to right ventricular dilation (extremely uncommon).

Assessment
A. Note chest x-ray for heart dilatation and failure.
B. Auscultate for holosystolic murmur over tricuspid area.
C. Observe for symptoms of heart failure.

Implementation
Same as for tricuspid stenosis.

Medical–Surgical Nursing: Heart Failure

Focus topic: Medical–Surgical Nursing

Definition: Insufficient cardiac output to meet metabolic needs of the body. Regardless of type, it results in decreased cardiac output (forward failure) and venous congestion (backward failure) secondary to pump failure.

Characteristics
A. Differentiate heart failure types: left-sided or right-sided, systolic or diastolic, high output failure, and acute or chronic.
B. Heart failure may be due to left-sided cardiac failure or right-sided failure.

  • One side of the heart may fail separately from the other side because the heart is two separate pumping systems.
  • Impaired pumping ability results in the heart’s inability to maintain adequate circulation.

C. Either the left or right ventricle may be affected; while most heart failure begins on the left side when the left ventricle cannot pump blood out of the chamber, failure usually then progresses to both ventricles.

  • Coronary artery disease and hypertension are the usual causes of left-sided failure.
  • Pulmonary congestion occurs and pressure is increased in the left ventricle, causing dyspnea and shortness of breath.
  • Pressure in the left atrium increases, which increases pressure in the pulmonary circulation.
  • Venous congestion occurs due to decreased compliance (decreased relaxation) of the left ventricle (decreased preload).
  • Acute pulmonary edema may result from left ventricular failure.

D. Right ventricular failure—congestion occurs when blood is not pumped adequately from the systemic circulation into the lungs, resulting in systemic congestion.

  • The right side of the heart cannot eject blood and, therefore, cannot handle all of the blood that flows into it from venous circulation.
  • Congestion of the viscera (liver congestion) and peripheral tissues occurs.
  • Signs of right-sided failure will be edema of the extremities; congestion of gastrointestinal (GI) tract causes nausea and vomiting.

E. Differentiating systolic from diastolic dysfunction—heart failure is manifested as systolic and diastolic dysfunction, or both.

  • Systolic dysfunction.
  • a. Inadequate ventricular emptying leads to increased preload, diastolic volume and pressure (the tissues do not receive adequate circulatory output).
    b. Most common causes are coronary artery disease, hypertension, and cardiomyopathy, with viruses and toxic substances such as alcohol and medications being a possible cause.
    c. Conventional therapy includes diuretics (loop diuretics preferred), Lanoxin (digoxin), ACE inhibitors, and beta blockers to improve performance of left ventricle.
    d. The above regimens may be inappropriate for diastolic dysfunction; avoid Lanoxin and vasodilators.
  • Diastolic dysfunction.
    a. Resistance to ventricular filling as a consequence of reduced ventricular compliance—results in prolonged ventricular relaxation time.
    b. Ejection fraction may be normal or increased.
    c. Clients cannot tolerate reduced blood pressure or plasma volume so diuretics, ACE inhibitors and vasodilators are usually contraindicated. Lanoxin is also contraindicated.
    d. May respond to calcium-channel blockers and beta blockers (to slow the heart rate).
    e. Nitrates may be used to decrease preload.
    f. High output failure occurs with hypermetabolic states (infection, hyperthyroidism) and requires increased blood flow to meet oxygen demands.
    g. Acute vs. chronic: acute is abrupt onset (MI); chronic is progressive deterioration.

Assessment: Left-Sided Failure
A. Evaluate for presence of pulmonary symptoms.

  • Dyspnea, labored breathing (early symptoms).
  • Orthopnea (difficulty breathing when lying flat).
  • Moist, hacking cough.
  • Bibasilar crackles.
  • Cyanosis or pallor; cool extremities.
  • Increased pulmonary artery and/or pulmonary wedge pressure.

B. Assess for anxiety, weakness, and fatigue (after activities that usually are not tiring).
C. Identify behavior changes.
D. Check for palpitations and diaphoresis.
E. Assess for gallop rhythm—presence of S3.
F. Evaluate for tachycardia, arrhythmias, and cardiomegaly.
G. Assess for reduced pulse pressure.

Assessment: Right-Sided Failure
A. Assess client for presence of conditions that could lead to right ventricular failure.

  • Any disease resulting in left ventricular failure.
  • Pulmonary embolism.
  • Fluid overload.
  • Chronic obstructive pulmonary disease (COPD).
    a. Pulmonary hypertension.
    b. Cor pulmonale.
  • Cirrhosis, portal hypertension.

B. Evaluate symptoms primarily related to systemic congestion.

  • Peripheral edema (pitting type) in dependent parts: feet, legs, sacrum, back, buttocks.
    a. Results from elevation in venous pressure.
    b. Necessitates good skin care and positioning.
  • Ascites, which can result in pulmonary distress.
  • Anorexia and nausea due to congestion in liver and gut.
  • Weight gain.
  • Oliguria during day and polyuria at night.
  • Hepatomegaly and tenderness in right upper quadrant of abdomen.
  • Fatigue from poor tissue perfusion.
  • Difficulty concentrating.

Implementation
A. Goal is to reduce workload on the heart, increase efficiency of contractions, and reduce fluid.
B. Provide physical rest and emotional support.
C. Optimize oxygenation—bed rest with Fowler’s position.

  • Oxygen therapy based on degree of pulmonary congestion.
  •  May require oxygen (cannula better than mask) or intubation.

D. Reduce preload (volume of blood heart receives) and afterload (resistance to pump).
E. Monitor medications.

  • ACE inhibitors (decrease renin angiotensin– aldosterone response).
    a. Monitor for hypotension, hypovolemia, and hyponatremia (if receiving diuretics).
    b. Dosage according to BP, fluid and renal status, and degree of cardiac failure.
    c. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs): Counteract action of ACE inhibitors, diuretics.
  • Diuretics to improve urine output to reduce preload: Lasix (furosemide), Aldactone (spironolactone).
  • Beta blockers to decrease effects of catecholamines.
  • Lanoxin if ejection fraction is < 40% (for systolic dysfunction).
    a. Increases contractility and improves cardiac output.
    b. Not used in diastolic failure.
  • Administer nitrates (ischemia) for vasodilation.
  • Administer beta blocker.
  • Administer potassium chloride for electrolyte replacement.

F. Monitor diet—sodium restriction, as ordered to reduce fluid retention; and monitor and maintain fluid restriction as ordered.
G. Monitor brain natriuretic peptide (BNP) assay to detect abnormal hormone levels produced by failing ventricles.
H. Monitor daily weights.
I. Monitor for complications of treatment.

  • Lanoxin toxicity.
    a. Most common predisposing factor for toxicity is hypokalemia, which potentiates the effect of Lanoxin.
    b. Low potassium levels (from diuretics) lead to excitable heart and dysrhythmias.
  • Electrolyte imbalance from diuretics, especially decreased potassium.
  • Oxygen toxicity, especially with COPD clients.
  • Myocardial failure.
  • Cardiac dysrhythmia.
  • Pulmonary infarction; emboli, pneumonia from bed rest—circulatory stasis.

J. Prepare clients psychologically and physiologically for ventricular assist devices (VADs) or paracorporeal pumps if indicated. They may need either of these devices if:

  • Their heart has been weakened after recent heart surgery (called cardiogenic shock).
  • They cannot be weaned from the heart-lung machine after heart surgery.
  • They are waiting to get a long-term, implantable VAD.

K. VADs assist the heart by helping the ventricles pump blood, easing the workload of the heart in clients with heart failure.

  • If the device is used to help (or “unload”) the left ventricle, it is called a left ventricular assist device (LVAD).
  • If it is used to “unload” the right ventricle, it is called a right ventricular assist device (RVAD).

L. Paracorporeal VADs are inserted through a long, thin tube (called a catheter) placed in the femoral vein or femoral artery.

  • One type of paracorporeal VAD, called the TandemHeart System, has an external pump that takes blood from a catheter placed in the client’s left atrium and sends it to the femoral artery.
  • Another type of paracorporeal VAD, called the Impella, has a very small pump located on the tip of a catheter.
    a. The Impella catheter is inserted into the client’s femoral artery. A camera is then cardiac output (forward failure) and venous congestion (backward failure) secondary to pump failure.

Characteristics
A. Differentiate heart failure types: left-sided or right-sided, systolic or diastolic, high output failure, and acute or chronic.
B. Heart failure may be due to left-sided cardiac failure or right-sided failure.

  • One side of the heart may fail separately from the other side because the heart is two separate pumping systems.
  • Impaired pumping ability results in the heart’s inability to maintain adequate circulation.

C. Either the left or right ventricle may be affected; while most heart failure begins on the left side when the left ventricle cannot pump blood out of the chamber, failure usually then progresses to both ventricles.

  • Coronary artery disease and hypertension are the usual causes of left-sided failure.
  • Pulmonary congestion occurs and pressure is increased in the left ventricle, causing dyspnea and shortness of breath.
  • Pressure in the left atrium increases, which increases pressure in the pulmonary circulation.
  • Venous congestion occurs due to decreased compliance (decreased relaxation) of the left ventricle (decreased preload).
  • Acute pulmonary edema may result from left ventricular failure.

D. Right ventricular failure—congestion occurs when blood is not pumped adequately from the systemic circulation into the lungs, resulting in systemic congestion.

  • The right side of the heart cannot eject blood and, therefore, cannot handle all of the blood that flows into it from venous circulation.
  • Congestion of the viscera (liver congestion) and peripheral tissues occurs.
  • Signs of right-sided failure will be edema of the extremities; congestion of gastrointestinal (GI) tract causes nausea and vomiting.

E. Differentiating systolic from diastolic dysfunction—heart failure is manifested as systolic and diastolic dysfunction, or both.

  • Systolic dysfunction.
    a. Inadequate ventricular emptying leads to increased preload, diastolic volume and pressure (the tissues do not receive adequate circulatory output).
    b. Most common causes are coronary artery disease, hypertension, and cardiomyopathy, with viruses and toxic substances such as alcohol and medications being a possible cause.
    c. Conventional therapy includes diuretics (loop diuretics preferred), Lanoxin (digoxin), ACE inhibitors, and beta blockers to improve performance of left ventricle.
    d. The above regimens may be inappropriate for diastolic dysfunction; avoid Lanoxin and vasodilators.
  • Diastolic dysfunction.
    a. Resistance to ventricular filling as a consequence of reduced ventricular compliance—results in prolonged ventricular relaxation time.
    b. Ejection fraction may be normal or increased.
    c. Clients cannot tolerate reduced blood pressure or plasma volume so diuretics, ACE inhibitors and vasodilators are usually contraindicated. Lanoxin is also contraindicated.
    d. May respond to calcium-channel blockers and beta blockers (to slow the heart rate).
    e. Nitrates may be used to decrease preload.
    f. High output failure occurs with hypermetabolic states (infection, hyperthyroidism) and requires increased blood flow to meet oxygen demands.
    g. Acute vs. chronic: acute is abrupt onset (MI); chronic is progressive deterioration.

Assessment: Left-Sided Failure
A. Evaluate for presence of pulmonary symptoms.

  • Dyspnea, labored breathing (early symptoms).
  • Orthopnea (difficulty breathing when lying flat).
  • Moist, hacking cough.
  • Bibasilar crackles.
  • Cyanosis or pallor; cool extremities.
  • Increased pulmonary artery and/or pulmonary wedge pressure.

B. Assess for anxiety, weakness, and fatigue (after activities that usually are not tiring).
C. Identify behavior changes.
D. Check for palpitations and diaphoresis.
E. Assess for gallop rhythm—presence of S3.
F. Evaluate for tachycardia, arrhythmias, and cardiomegaly.
G. Assess for reduced pulse pressure.

Assessment: Right-Sided Failure
A. Assess client for presence of conditions that could lead to right ventricular failure.

  • Any disease resulting in left ventricular failure.
  • Pulmonary embolism.
  • Fluid overload.
  • Chronic obstructive pulmonary disease (COPD).
    a. Pulmonary hypertension.
    b. Cor pulmonale.
  • Cirrhosis, portal hypertension.

B. Evaluate symptoms primarily related to systemic congestion.

  • Peripheral edema (pitting type) in dependent parts: feet, legs, sacrum, back, buttocks.
    a. Results from elevation in venous pressure.
    b. Necessitates good skin care and positioning.
  • Ascites, which can result in pulmonary distress.
  • Anorexia and nausea due to congestion in liver and gut.
  •  Weight gain.
  • Oliguria during day and polyuria at night.
  • Hepatomegaly and tenderness in right upper quadrant of abdomen.
  • Fatigue from poor tissue perfusion.
  • Difficulty concentrating.

Implementation
A. Goal is to reduce workload on the heart, increase efficiency of contractions, and reduce fluid.
B. Provide physical rest and emotional support.
C. Optimize oxygenation—bed rest with Fowler’s position.

  • Oxygen therapy based on degree of pulmonary congestion.
  • May require oxygen (cannula better than mask) or intubation.

D. Reduce preload (volume of blood heart receives) and afterload (resistance to pump).
E. Monitor medications.

  • ACE inhibitors (decrease renin angiotensin–aldosterone response).
    a. Monitor for hypotension, hypovolemia, and hyponatremia (if receiving diuretics).
    b. Dosage according to BP, fluid and renal status, and degree of cardiac failure.
    c. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs): Counteract action of ACE inhibitors, diuretics.
  • Diuretics to improve urine output to reduce preload: Lasix (furosemide), Aldactone (spironolactone).
  • Beta blockers to decrease effects of catecholamines.
  • Lanoxin if ejection fraction is < 40% (for systolic dysfunction).
    a. Increases contractility and improves cardiac output.
    b. Not used in diastolic failure.
  • Administer nitrates (ischemia) for vasodilation.
  • Administer beta blocker.
  • Administer potassium chloride for electrolyte replacement.

F. Monitor diet—sodium restriction, as ordered to reduce fluid retention; and monitor and maintain fluid restriction as ordered.
G. Monitor brain natriuretic peptide (BNP) assay to detect abnormal hormone levels produced by failing ventricles.
H. Monitor daily weights.
I. Monitor for complications of treatment.

  • Lanoxin toxicity.
    a. Most common predisposing factor for toxicity is hypokalemia, which potentiates the effect of Lanoxin.
    b. Low potassium levels (from diuretics) lead to excitable heart and dysrhythmias.
  • Electrolyte imbalance from diuretics, especially decreased potassium.
  • Oxygen toxicity, especially with COPD clients.
  • Myocardial failure.
  • Cardiac dysrhythmia.
  • Pulmonary infarction; emboli, pneumonia from bed rest—circulatory stasis.

J. Prepare clients psychologically and physiologically for ventricular assist devices (VADs) or paracorporeal pumps if indicated. They may need either of these devices if:

  • Their heart has been weakened after recent heart surgery (called cardiogenic shock).
  • They cannot be weaned from the heart-lung machine after heart surgery.
  • They are waiting to get a long-term, implantable VAD.

K. VADs assist the heart by helping the ventricles pump blood, easing the workload of the heart in clients with heart failure.

  • If the device is used to help (or “unload”) the left ventricle, it is called a left ventricular assist device (LVAD).
  • If it is used to “unload” the right ventricle, it is called a right ventricular assist device (RVAD).

L. Paracorporeal VADs are inserted through a long, thin tube (called a catheter) placed in the femoral vein or femoral artery.

  • One type of paracorporeal VAD, called the TandemHeart System, has an external pump that takes blood from a catheter placed in the client’s left atrium and sends it to the femoral artery.
  • Another type of paracorporeal VAD, called the Impella, has a very small pump located on the tip of a catheter.
    a. The Impella catheter is inserted into the client’s femoral artery. A camera is then used to guide the Impella catheter into the left ventricle.
    b. The Impella works by sending blood from the left ventricle to the ascending aorta, which is the main blood vessel leaving the left ventricle.
  • In some clients, paracorporeal VADS can be used for longer periods, such as while they are waiting for a heart transplant.
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Medical–Surgical Nursing: Cardiomyopathy

Focus topic: Medical–Surgical Nursing

Definition: Heart muscle disease that primarily affects structural or functional ability of myocardium. It is classified as primary or secondary and manifests as three types: dilated, hypertrophic, and restrictive cardiomyopathy.

Characteristics
A. Types.

  • Dilated: most common type. Diffuse inflammation and rapid degeneration of myocardial fibers, leading to decreased contractile function and dilation of both ventricles. This results in impaired systolic function and decreased cardiac output.
  • Hypertrophic: asymmetrical ventricular hypertrophy, leading to hypercontractility of the left ventricle, obstruction of the left ventricle outflow, and stiffness of the ventricular walls. This results in impaired ventricular filling and decreased cardiac output.
  • Restrictive: least common; impairs diastolic volume and stretch, resulting in decreased cardiac output.

B. Regardless of the type manifested or cause, result is impaired pumping of the heart and decreased cardiac output.
C. Decreased stroke volume stimulates sympathetic nervous system resulting in increased vascular resistance with eventual left ventricular failure.

Assessment
A. Effort dyspnea and fatigue due to elevated left ventricular diastolic pressure and low cardiac output.
B. Physical signs include pitting edema, sinus tachycardia, basal rales, low blood pressure, and possible enlarged liver.
C. Chest x-ray reveals cardiomegaly.

Implementation
A. Treatment begins with finding any specific cause (most often there is none) and treating it.

  • Therapy for heart failure and low cardiac output is implemented.
  • Combined afterload and preload reduction with ACE inhibitors, hydralazine plus nitrate, is the mainstay of treatment.
  • Lanoxin, diuretics are also used in the treatment protocol.

B. Nursing focus is aimed at improving cardiac output.

  • Bed rest and increased oxygenation.
    a. Gradually increase activity alternating with rest.
    b. Identify activities that cause shortness of breath and teach client how to plan.
  • Monitor medications—compliance is vital.
  • Plan with client how to reduce anxiety—stress exacerbates condition.

Medical–Surgical Nursing: Acute Pulmonary Edema

Focus topic: Medical–Surgical Nursing

Definition: A medical emergency characterized by excessive fluid in the pulmonary interstitial spaces or alveoli, usually due to severe, acute left ventricular decompensation.

Characteristics
A. Most common cause is greatly elevated capillary pressure resulting from acute failure of left heart pump and pooling of blood in lungs.
B. Fluid fills alveoli and causes bronchospasm.
C. May also be associated with barbiturate/opiate poisoning or other noncardiac condition.

Assessment
A. Observe initially for anxiety, feelings of impending doom, and restlessness.
B. Observe for marked dyspnea.
C. Assess for pink, frothy sputum.
D. Evaluate for marked cyanosis.
E. Observe for profuse diaphoresis—cold and clammy.
F. Evaluate for tachyarrhythmias.
G. Evaluate for (S3) diastolic sound.
H. Evaluate for marked increase in pulmonary artery and/or pulmonary capillary wedge pressure.
I. Evaluate for hypoxemia and low PCO2 (hyperventilation).

Implementation
A. Place in high-sitting position—feet over side of bed.
B. Administer oxygen at 6 L/min.
C. Administer drugs: diuretics, Lanoxin (digoxin), morphine, Tridil (nitroglycerin) to improve myocardial contractility and reduce preload (volume of blood in ventricle after diastole).

D. Instruct client in deep breathing.
E. Monitor fluid intake and output; weigh daily.
F. Monitor vital signs and hemodynamic parameters (PCWP).
G. Provide sedation with ordered medication. Observe respiratory rate and depth.
H. Monitor drug therapy used for preload or after load: Tridil (nitroglycerin), Nipride (nitroprusside), Apresoline (hydralazine).
I. Rotating tourniquets on client’s extremities used in emergency situation to reduce venous return to heart and pool blood temporarily in extremities, thus reducing preload. Not commonly used—may be used in emergencies.

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