Medical Surgical Heart failure #8

Question

The nurse is performing an assessment on a client with a history of cardiovascular disease, diabetes, hypertension, and hypothyroidism. The client is experiencing exhaustion with simple activities of daily living and short ambulation, and states a 5 pound weight gain over 4 days. Assessment reveals 4+ edema to lower extremities and jugular distention. The nurse will report findings to the health care provider and anticipates which medical condition?

Answers

  1. Acute pericarditis
    • Rationale:

      This answer is not correct because acute pericarditis, inflammation of the membranous sac that surrounds the heart, does not cause a 5 pound weld gain over 4 days, 4+ edema to lower extremities with jugular distention. Pericarditis has acute pain and a characteristic pleural friction rub, a scratching, grating sound similar to leather rubbing against leather. Right-sided heart failure (HF) occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, face/neck, legs, and feet.

  2. Myocardial infarction
    • Rationale:

      This answer is not correct because myocardial infarction (MI) or blockage of the cardiac vessels, has symptoms of pain (chest, arm, jaw), shortness of breath, and diaphoresis.

  3. Left-sided heart failure
    • Rationale:

      This answer is not correct because left-sided heart failure is most associated with pulmonary symptoms which include pulmonary edema, dry, hacking cough, paroxysmal nocturnal dyspnea, and exertional dyspnea, and orthopnea. Right-sided heart failure (HF) occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, face/neck, legs, and feet. Fluid backs up into the body because the right side of the heart is not pumping efficiently. Excessive fluid causes weight gain, distended neck veins or jugular vein distention (JVD), and swelling of the liver.

  4. Right-sided heart failure
    • Rationale:

      This answer is correct because right-sided heart failure (HF) occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, face/neck, legs, and feet. Fluid backs up into the body because the right side of the heart is not pumping efficiently. Excessive fluid causes weight gain, distended neck veins or jugular vein distention (JVD), and swelling of the liver.

Overview

Right-sided heart failure (HF) occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, face/neck, legs, and feet, causing weight gain, distended neck veins or jugular vein distention (JVD), and swelling of the liver.

Explanation

Learning Outcomes

Right-sided heart failure (HF) occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, face/neck, legs, and feet. Fluid backs up into the body because the right side of the heart is not pumping efficiently. Excessive fluid causes weight gain, distended neck veins or jugular vein distention (JVD), and swelling of the liver. Clients with heart failure should be taught to weigh themselves daily at the same time in similar clothing to monitor HF. Weight gain of 2-3 pounds a day or 5 pounds over the client’s baseline should be reported to the healthcare provider. Left-sided heart failure is most associated with pulmonary symptoms which include pulmonary edema, dry, hacking cough, paroxysmal nocturnal dyspnea, and exertional dyspnea, and orthopnea.

Test Taking Tip

Left heart failure produces “Lung” or pulmonary symptoms, (pulmonary edema, dry, hacking cough, paroxysmal nocturnal dyspnea, and exertional dyspnea, and orthopnea). Right heart failure produces symptoms that come from fluid going “Right back” to the body from the right side (fluid buildup in the abdomen, face/neck, legs, and feet).

Video Rationale