A nurse is caring for a client who is experiencing an exacerbation of heart failure.

Findings upon admission:

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings related to the diagnosis of heart failure?

Condition:

• Left-sided heart failure

Actions to Take:

• Administer a loop diuretic.
• Assess for jugular vein distention.

Parameters to Monitor:

• Lung sounds.
• Pulse strength.

Rationale:

Condition Choices

• Right-sided heart failure: Right-sided heart failure primarily leads to systemic congestion, including peripheral edema, jugular vein distension, and hepatomegaly. The client’s symptoms—dyspnea, crackles in the lungs, and activity intolerance—are more indicative of left-sided heart failure, which results in pulmonary congestion.
• Mitral valve prolapse: Mitral valve prolapse can cause palpitations and fatigue but does not typically present with pulmonary congestion, crackles, and significant hypertension. The client’s symptoms suggest a broader issue of ventricular dysfunction rather than isolated valvular pathology.
• Infective endocarditis: Infective endocarditis often presents with fever, systemic embolic events, and new heart murmurs. The client does not have a fever or any indications of embolic complications, making this diagnosis unlikely.
• Left-sided heart failure: Dyspnea, pulmonary crackles, activity intolerance, nocturnal coughing, and hypertension are classic findings of left-sided heart failure. The irregular tachycardia may indicate atrial fibrillation secondary to heart failure. The client’s history of hypertension and coronary artery disease increases the risk of ventricular dysfunction, further supporting this diagnosis.

Actions to Take

• Administer a loop diuretic: Loop diuretics such as furosemide help reduce pulmonary congestion by promoting diuresis and decreasing fluid overload, which is essential for managing left-sided heart failure.
• Assess for jugular vein distention: Although jugular vein distention is more commonly associated with right-sided heart failure, evaluating it can provide insight into overall cardiac function and volume status, especially if biventricular failure is present.
• Obtain the client’s temperature: While temperature monitoring is standard in patient care, fever is not a primary concern in left-sided heart failure. Fever assessment would be more relevant if infection, such as infective endocarditis, was suspected.

Parameters to Monitor

• Lung sounds: Pulmonary congestion from left-sided heart failure causes crackles and respiratory distress. Monitoring lung sounds helps assess the effectiveness of diuretics and other treatments aimed at reducing fluid overload.
• Pulse strength: The client has diminished peripheral pulses, which may indicate poor cardiac output and worsening perfusion. Monitoring pulse strength can help evaluate circulatory status and response to treatment.
• Liver function tests: Liver function tests are more relevant in right-sided heart failure due to hepatic congestion. Since the primary concern here is pulmonary congestion, liver function is not a key monitoring parameter.
• Heart sounds for systolic murmur: While mitral regurgitation can accompany left-sided heart failure, a new murmur is not the primary concern in this client. The focus should be on managing fluid overload and pulmonary symptoms.
• Blood culture: Blood cultures are useful for detecting infections like infective endocarditis, which is not suspected in this client due to the absence of fever and embolic manifestations.

A. Obtain bottles of warm, sterile 0.9% sodium chloride solution: Evisceration requires immediate coverage of the exposed organs with sterile, saline-moistened dressings to prevent drying and infection. Using warm saline helps maintain tissue viability and minimizes damage.

B. Apply a firm pressure dressing across the client's abdomen: A firm pressure dressing is inappropriate, as it could cause further damage to the eviscerated organs and increase intra-abdominal pressure, leading to ischemia or perforation.

C. Attempt to reinsert the protruding viscera: Reinserting the eviscerated organs is contraindicated due to the high risk of contamination, trauma, and further complications. The nurse should instead protect the organs with moist dressings and prepare the client for emergency surgery.

D. Place the client in left lateral recumbent position: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce tension on the abdominal wound and prevent further protrusion of organs. A left lateral recumbent position does not provide the same benefit.