1. Ram, 50 yrs is admitted in ICU with acute left ventricular failure.
(a) Enumerate the clinical features of the above condition.
b) Using the nursing process draw out a nursing care plan for this patient
Left Ventricular Failure
Definition
is inadequate pumping of blood by the left ventricle;
left side of the heart pumps blood from the lungs to the organs, failure to do so leads to congestion of the lung veins and symptoms that reflect this, as well as reduced supply of blood to the tissues.
Clinical Featrues
Symptoms
Dyspnea on exertion or in severe cases at rest - and easy fatigueability.
Orthopnea
Paroxysmal nocturnal dyspnea
Dizziness
Confusion and
Diaphoresis and cool extremities at rest.
Peripheral edema or anasarca and
Nocturia
Signs
Laterally displaced apex beat (as the heart is enlarged)
Gallop rhythm (additional heart sounds) in case of decompensation.
Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of the heart failure.
tachypnea
dullness of the lung fields to percussion
rales or crackles, which suggests the development of pulmonary edema
cyanosis
ICU patients usually present in late stage of the disease with acute cardiogenic pulmonary oedema or cardiogenic shock
Nursing Interventions
general measures
Start an IV line
Provide a comfortable bed with back rest
Provide O2
Organ support : airway, breathing, circulation
Non invasive ventilation BiPAP/CPAP may be intubated and mechanically ventilated with high PEEP
identify and treat underlying / contribting conditions eg. : myocardial ischemia, rapid AF valvular heart disease, diastolic dysfunction concurrent sepsis eg. pneumonia
treatment of cardiogenic shock , ischaemia, hypertension, arrrhythmia
monitor input and output
monitor BP, Pulse, Oxygen saturation
administer required medications
monitor diet : salt restricted diet; monitor fluid intake
monitor weight : weight gain an indicator of fluid retention
medications that cause fluid retention (such as NSAIDs and thiazolidinediones) are stopped
Arrange for investigations
CXR
ECG
Cardiac enzymes - cTnT, CPK
Echocardiogram
septic workup if infection suspected /viral studies /atypical pneumonia serology
Treatment of symptomatic Left Ventricular Systolic Dysfunction
First line (Class I recommendation)
Diuretics and fluid restriction in patients who have evidence of fluid retention.
ACE inhibitor for all patients, unless contraindicated (eg. renal artery stenosis, unstable renal function, hypotension)
Beta-adrenergic blockade in all stable patients, unless contraindicated
Digitalis for the treatment of symptoms of HF, unless contraindicated(eg. renal insufficiency)
withdrawal of drugs known to adversely affect the clinical status of patients (eg. nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking durgs)
Second line ( Class II a recommendation)
spironolactone in patients with refractory symptoms (preserved renal function and a normal potassium c oncentration)
Angiotensin receptor blockade in patients who are being treated with digitalis, diuretics, and betablocker and who cannot be given an ACEI because of cough or angioedema
Combination of hydralazine and nitrate in patients who are being treated with digitalis, diurtics and a beta-blocker and who cannot be given an ACE inhibitor because of hypotension or renal insuficiency.
Consider
Infusions of either/both positive inotropic agents(dobutamine) and vasodilator drugs (nitroglycerin or nitroprusside) in an effort to improve cardiac performance. Noradrenaline may be necessary for severe hypotension
Decrease Left Ventricular volume overload - Diuretics
If associated with severe renal dysfunction and the oedema becomes resistant to treatment, ultrafiltration or hemofiltration may be needed to remove excess fluid
