Which symptom would the nurse immediately report to the health care provider when caring for a client with heart failure?

Calcium Channel Blockers:

Calcium channel blockers (CCBs) are a common class of medication that may be used in HF clients. Overall, they work by blocking the influx of calcium into the smooth muscle surrounding blood vessels – ultimately causing dilation of blood vessels leading to lower blood pressure.

Most CCBs act only on the blood vessels utilizing this mechanism. Examples of these include nifedipine, nicardipine, and amlodipine. These protect the heart and other organs in a similar manner to ACE inhibitors or ARBs.

However, some CCBs can act on the heart, reducing heart rate and force of contraction. This helps reduce myocardial oxygen demand, and therefore protects the heart with an additional mechanism. Examples of these CCBs are verapamil and diltiazem which can be used in clients who are not already on a beta blocker.

Common side effects for CCBs include headaches, peripheral edema, and facial flushing. Clients on diltiazem or verapamil should routinely have their heart rate monitored. Lastly, all clients on CCBs are at an increased risk of orthostatic hypotension and falling.

Digoxin:

Digoxin is an older medication that used to be prescribed more commonly in clients with heart failure. It is a cardiac glycoside which can be toxic in lower doses – known as a narrow therapeutic index. Therefore, its use has been reduced as alternative agents have been released on the market with a safer side effect profile.

Specific client populations may benefit from digoxin therapy as an adjunct to other treatment modalities. Digoxin is sometimes used in clients with blood flow issues leading to excessive weakness, orthostasis, and falling. Unlike beta blockers digoxin can increase the force of the contraction, therefore increasing blood flow to the brain and muscles offsetting the symptoms of weakness.

Due to the narrow therapeutic index of digoxin serum levels should be monitored closely – especially within the first couple of weeks of initiation. Digoxin levels > 2 can yield side effects including vision changes, nausea, and dizziness.

A very serious adverse effect to monitor is severe bradycardia (low heart rate). The risk of digoxin toxicity increases in clients with hypokalemia (< 3.5) therefore serum potassium is important to monitor. These clients should also have their serum creatinine levels measured at baseline and after starting therapy to assess kidney function. A serum creatine > 1.3 serves as a contraindication for digoxin therapy.

Nitroglycerin:

Nitroglycerin is a staple treatment used in clients who have experienced an MI to reverse the symptoms of angina (chest pain) and reduce the risk of having a serious cardiac event. It works by causing dilation of the blood vessels, particularly around the heart including the coronary arteries – thereby improving blood flow to the heart. It therefore decreases vascular resistance, increases preload, and increases afterload.

There are several different formulations of nitroglycerin – the ones used in post-MI clients are the sublingual tablets used for heart attacks. Other formulations include nitroprusside, isosorbide, hydralazine, and minoxidil. Isosorbide and hydralazine may be used daily as maintenance therapy for clients experiencing frequent/chronic chest pain. Minoxidil can sometimes be used in clients with severe heart failure.

A key serious side effect of these medications is severe hypotension which can be life-threatening. If the systolic blood pressure falls below 90 mmHg or if it decreases by 30 mmHg the medication should be halted. Signs and symptoms of severe hypotension include lack of coordination or dizziness.

Less serious side effects include headaches and facial redness or flushing. Orthostatic hypotension and falling is also a problem with nitroglycerin use so clients should be counseled on not changing position too quickly.

Clients who are prescribed nitroglycerin should never be on Viagra (sildenafil) or Cialis (tadalafil) or “afil” drugs that are used for erectile dysfunction. When these medications are used with nitrates it can lead to severe hypotension and become life-threatening. Alternative treatments for erectile dysfunction should be pursued in these clients.

Milrinone:

Milrinone is a positive inotropic medication (increase contractile force) which is generally reserved as a last-line therapy for HF clients. Usually, this is used in palliative care to improve their quality of life due to poor blood flow issues.

The main side effects of this medication are headaches, tachycardia, and arrhythmia. Close heart rate monitoring should be a key monitoring parameter for these clients.

Congestive Heart Failure Nursing Interventions

Clients with heart failure should be closely monitored for side effects and therapy efficacy. Therapeutic interventions for HF should result in reduced HR and resolution of edema symptoms. Clients should be weighed daily to assess for fluid retention.

When transferring clients to other units or floors they should be evaluated for worsening conditions. Periodically checking lung sounds for worsening crackles is also imperative to assess for pulmonary edema.

Heart failure clients should be counseled on a variety of essential lifestyle interventions to reduce their risk of morbidity and mortality.

Sodium restriction is a key intervention for these clients as sodium draws water into the body and leads to swelling and edema. Specifically, they should strive to consume < 2 grams of sodium daily. They should be instructed to avoid fried foods, canned foods, and packaged foods. They should also be advised to be careful before taking over-the-counter medications as they can contain sodium.

Examples of medications that may include sodium are acetaminophen, antacids, cold or flu medications, and NSAIDs including aspirin. Careful consultations should be made with the HCP “health care provider” or pharmacists before starting new OTC medications.

Fluid restriction is another key consultation to conduct in HF clients. They should be advised to reduce fluid intake by < 2 liters of fluid every day. Excess fluid can increase blood pressure, as well as exacerbate HF symptoms such as edema.

Daily weighing of HF clients is critical to assess for fluid overload symptoms. If they gain 2-3 lbs in 1 day or 5 lbs in 7 days, they may develop severe edema and should be treated appropriately.

When edema symptoms are present these clients should be administered intravenous furosemide as well as morphine to reduce fluid retention and decrease myocardial oxygen demand. They should have their head raised in bed by a 45-degree angle to reduce lung swelling. These clients may also benefit from oxygen administration especially if they have trouble breathing.

Clients with HF should be advised not to have sex until cleared by a physician. They should be able to climb two flights of stairs without experiencing shortness of breath. This is important to counsel on as sex can cause a lot of stress on the heart and potentially trigger a heart attack.

Lastly, clients who are not mobile should be provided ted hose which are elastic stockings used to reduce blood pooling. These should be removed daily to allow for cleaning and assess edema. TED hose are critical to use in clients who are not ambulating as they can reduce the risk of a clot forming leading to other serious embolic events.

Conclusion of Congestive Heart Failure for the NCLEX

Heart failure is a life-threatening and life-changing disease that affects millions of Americans every year. It can be challenging for these clients to deal with the consequences of their condition as well as side effects from the medications they are getting put on. These clients will often require a lot of care and monitoring to treat their condition and improve their quality of life. This is why having a strong understanding of HF is crucial when preparing for the NCLEX® exam.