Page 1705 - Saunders Comprehensive Review For NCLEX-RN

myocardial reserve is exhausted and clinical
manifestations of heart failure develop.
4. Compensatory mechanisms include increased heart
rate, improved stroke volume, arterial
vasoconstriction, sodium and water retention, and
myocardial hypertrophy.

E. Assessment (Table 52-1)

1. Right- and left-sided heart failure
2. Acute pulmonary edema
a. Severe dyspnea
b. Tachycardia, tachypnea
c. Nasal flaring; use of accessory breathing
muscles
d. Wheezing and crackles on auscultation;
gurgling respirations
e. Expectoration of large amounts of
blood-tinged, frothy sputum
f. Acute anxiety, apprehension,
restlessness
g. Profuse sweating
h. Cold, clammy skin
i. Cyanosis

Signs of left ventricular failure are evident

in the pulmonary system. Signs of right ventricular
failure are evident in the systemic circulation.
F. Immediate management of acute episode (see Priority Nursing
Actions)

G. Following the acute episode

1. Assist the client to identify precipitating risk factors of
heart failure and methods of eliminating these risk
factors.
2. Encourage the client to verbalize feelings about the
lifestyle changes required as a result of the heart
failure.
3. Instruct the client in the prescribed medication
regimen, which may include digoxin, a diuretic, ACE
inhibitors, low-dose beta blockers, and vasodilators.
4. Advise the client to notify the PHCP if side effects
occur from the medications.
5. Advise the client to avoid over-the-counter
medications.
6. Instruct the client to contact the PHCP if she or he is
unable to take medications because of illness.

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