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LECTURE 22.docx

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NURS 287
Rick Nilson

Lecture 22: ADHF AND PULMONARY EDEMA  The goals of therapy for both ADHF and chronic HF are to decrease patient symptoms, reverse ventricular remodeling, improve quality of life, and decrease mortality and morbidity.  Treatment strategies should include the following: o Decreasing intravascular volume with the use of diuretics to reduce venous return and preload. o Decreasing venous return (preload) to reduce the amount of volume returned to the LV during diastole. o Decreasing afterload (the resistance against which the LV must pump) improves CO and decreases pulmonary congestion. o Gas exchange is improved by the administration of IV morphine sulfate and supplemental oxygen. o Inotropic therapy and hemodynamic monitoring may be needed in patients who do not respond to conventional pharmacotherapy (e.g., diuretics, vasodilators, morphine sulfate). o Reduction of anxiety is an important nursing function, since anxiety may increase the SNS response and further increase myocardial workload. COLLABORATIVE CARE: CHRONIC HEART FAILURE  The main goal in the treatment of chronic HF is to treat the underlying cause and contributing factors, maximize CO, provide treatment to alleviate symptoms, improve ventricular function, improve quality of life, preserve target organ function, and improve mortality and morbidity.  Administration of oxygen improves saturation and assists greatly in meeting tissue oxygen needs and helps relieve dyspnea and fatigue.  Physical and emotional rest allows the patient to conserve energy and decreases the need for additional oxygen. The degree of rest recommended depends on the severity of HF.  Nonpharmacologic therapies used in the management of HF patients who are receiving maximum medical therapy, continue to have NYHA Functional Class III or IV symptoms, and have a widened QRS interval include the following: o Cardiac resynchronization therapy (CRT) or biventricular pacing. Involves pacing both the right and left ventricles to achieve coordination of right and left ventricle contractility. o Cardiac transplantation. Strict criteria are used to select the few patients with advanced HF who can even hope to receive a transplanted heart. o Intraaortic balloon pump (IABP) therapy. The IABP can be useful in the hemodynamically unstable HF patient because it decreases SVR, PAWP, and PAP as much as 25%, leading to improved CO. However, the limitations of bed rest, infection, and vascular complications preclude long-term use. o Ventricular assist devices (VADs). VADs provide highly effective long-term support for up to 2 years and have become standard care in many heart transplant centers. VADs are used as a bridge to transplantation. o Destination therapy. The use of a permanent, implantable VAD, known as destination therapy, is an option for patients with advanced NYHA Functional Class IV HF who are not candidates for heart transplantation.  General therapeutic objectives for drug management of chronic HF include: (1) identification of the type of HF and underlying causes, (2) correction of sodium and water retention and volume overload, (3) reduction of cardiac workload, (4) improvement of myocardial contractility, and (5) control of precipitating and complicating factors. o Diuretics are used in HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload.  Thiazide diuretics may be the first choice in chronic HF because of their convenience, safety, low cost, and effectiveness. They are particularly useful in treating edema secondary to HF and in controlling hypertension.  Loop diuretics are potent diuretics. These drugs act on the ascending loop of Henle to promote sodium, chloride, and water excretion. Problems in using loop diuretics include reduction in serum potassium levels, ototoxicity, and possible allergic reaction in the patient who is sensitive to sulfa-type d
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