Page 148 - Critical Care Nursing Demystified

Chapter 3 CARE OF THE PATIENT WITH CRITICAL CARDIAC AND VASCULAR NEEDS 133

including atrial fibrillation or flutter, paraxoysmal atrial tachycardia, premature
ventricular contractions (PVCs), ventricular tachycardia, and ventricular
fibrillation.
Chest x-rays are done serially to determine if pulmonary edema has resulted
or resolved.
BNP (B-type natriuretic peptide) is monitored frequently to diagnose and
determine if treatment is effective. A BNP of greater than 400 pg/mL usually
indicates significant HF. The higher this value is, the poorer the prognosis for
the patient.
Serum electrolytes (K , Ca , Mg ) are monitored to serve as a baseline for
++
+
+
replacement therapy as these electrolytes need normalizing for effective
ejection fraction.
Nursing Diagnoses for HF Expected Outcomes
Ineffective tissue perfusion, Clear lung sounds
peripheral and pulmonary VS stable

HR with normal sinus rhythm or baseline
Pulmonary artery pressures stabilize Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
Urinary output >30 cc/hr
Resolution of peripheral edema
Positive peripheral pulses

Interventions
Assess daily weight—the number one accurate indicator of fluid gain or loss.
A weight gain of 1 kilogram = 1,000 cc of fluid retention.
Assess lung sounds. Lungs will start with bibasilar crackles that ascend if HF
worsens.
Assess the results of ejection fractions and echocardiograms to help deter-
mine which therapies are most effective.
Monitor BNP levels. BNP is a significant diagnostic indicator and therapeutic
tool to determine if therapy is effective.
Monitor for cardiogenic shock as indicated by a cardiac index of less than
2.0 L/min, systolic BP less than 90 mm Hg, and PAWP of above 18 mm Hg.
Administer morphine sulfate to decrease pulmonary edema and improve
oxygenation.
Administer and monitor nitroglycerin to decrease preload and PAWP.