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Heart Failure- Managing Systolic Dysfunction

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¡LINICAL Heart failure: Managing systolic dysfunction SHERILYN A, SERDAHL RN, MS, CNP 24 R N JUNE2C www.mweb.com
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Page 1: Heart Failure- Managing Systolic Dysfunction

¡LINICAL

Heart failure:Managing systolic

dysfunctionSHERILYN A, SERDAHL RN, MS, CNP

24 R N JUNE2C www.mweb.com

Page 2: Heart Failure- Managing Systolic Dysfunction

CLINICAL

The effective management of systolic dysfunctionincludes medication, lifestyie changes, andcomprehensive patient education.

Heart failure affects an estimated 5 millionAmericans, accounting for nearly a million hospi-talizations each year.^-^ In addition, almost500,000 new cases are diagnosed yearly.'" In theUnited States, the most common causes of heartfailure are coronary artery disease and uncon-trolled hypertension.

The diagnosis of heart failure is a clinical one,distinguished by a constellation of signs and symp-toms caused by either systolic or diastolic dysfunc-tion, or both. Here, we'll review heart failurecaused by systolic dysfunction, so that you'll beequipped to recognize its manifestations and readyto help your patients manage their disease.

What happenswhen the heart failsIn heart failure caused by systolic dysfunction, theleft ventricular myocardium is weakened, oftenenlarged, and the ventricles are unable to pumpblood efficiently enough to meet the body'sdemands. Stroke volume, the amount of bloodejected from the ventricles with each contraction,is reduced. The blood that's not expelled remainsin the ventricles during relaxation, or diastole,and this can lead to pulmonary congestion. '*

Initially, when cardiac output drops, compensa-tory neurohormonal mechanisms ensure that per-fusion to vital organs remains adequate. Heartrate rises to increase cardiac output, and ventri-cles enlarge—hypertrophy—allowing more bloodto be ejected with each contraction. With theseadaptive mechanisms in effect, the individualexperiences few or no symptoms in the short

SHERILYN SERDAHL is a nurse practitioner withUriiversiiY of Minnesota Physioians, Fairview, MN, Tineauthor has no financiai reiationships to disciose.EDiTOR: Kathieen A, Moore. RN, BS

term. However, these compensatory responsesrequire higher energy expenditure and increasethe workload of the heart. Damage may continuefor years—undetected. When adaptive mecha-nisms eventually fail, symptoms appear, indicat-ing that the disease has progressed.

The most common presenting signs of heartfailure are fatigue and shortness of breath, or dys-pnea. Fatigue in the presence of heart failure isoften a sign of low cardiac output.'-^ Dyspneais the result of pulmonary congestion and anindication of fluid overload.

Dyspnea that occurs when the person liesdown but lessens when he or she sits up orstands is called orthopnea. Lying flat increasesvenous blood return to the heart, which mayprecipitate pulmonary edema—and hence,shortness of breath. Patients with orthopneafrequently sleep with their upper bodypropped up on pillows. Shortness of breaththat occurs several hours after falling asleepand is eased by sitting upright is called parox-ysmal nocturnal dyspnea (PND), and is a signof severe heart failure.''

The fluid overload of heart failure maybecame evident as edema—usually in depen-dent areas such as ankles or feet—or as overallweight gain. Fluid may also accumulate in theliver and manifest as ascites and/or hepatomegaly,and in severe cases, cause jaundice. A patient withgastrointestinal congestion from heart failure mayreport abdominal pain, bloating, ^

Two-thirds ot pallents

with systolic dystunction

have coronary ortery

disease,

Angiütensin-converting

enzyme (ACE) inhibitors

are first-iine agents for

systolic dysfunction.

Potienfs with heoti foiiure

who participate In

supervised exercise

programs report reduced

symptoms and improved

quaiity ot lite.

The all-important patient historyA thorough history is invaluable to the diagnosisand work-up of heart failure. Ask if the patientexperiences shortness of breath or fatigue, andwhat and how much activity causes it. Document

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Page 3: Heart Failure- Managing Systolic Dysfunction

SYSTOLIC DYSFUNCTION

Classifying heart failureOnce heart failure is diagnosed, its severity is determined using the NewYork Heart Association (NYHA) Classification of Functional Capacity,summarized below:

Class I: Heart has identifiable structural changes, but individual'sphysical activity is not limited. Able to perform activities thatrequire 10 metabolic equivalents (METs)' of oxygenconsumption.

Class II: Physical activity slightly limited, but individual comfortableand asymptomatic at rest. Abie to perform 5 or 6 METs ofactivity.

Class III; Indicates increased severity of heart failure. Minimal physicalactivity causes fatigue, palpitations, shortness of breath, orangina. Able to perform 3.6 to 4.2 METs of activity.

Class IV: Debilitating symptoms. Individual unabie to cany out anyphysical activity without discomfort. Angina, shortness ofbreath, fatigue, and palpitations may occur at rest.Symptoms increase with activity. Able to perform 2 METs ofactivity.

*An MET is a measure of physical activity intensity; 1 MET equals energy (oxy-gen) used by the body as it stts quietly.

Source: Braunwald, E. (2005). Approach to the patient with cardiovascular dis-ease. In. D. L. Kasper, E. Braunwald, et al. (Eds.). Harrison's principles of inter-nal medicine 06th eó., pp. 1301-1304), New York; McGraw-Hill.

your findings using objective language. For exam-ple, write: "John Doe is able to walk two blocksbefore stopping because of shortness of breath."Note whether the patient has to sleep on multiplepillows, and whether he or she wakes up at nightwith breathing difficulty.

Also ask if the patient has gained any weightrecently, and if so, how much and over what periodof time. A gain of two pounds Ln 24 hours or fivepounds in one week can indicate increased fluidretention. Ask if he or she has experienced swellingof the ankles, feet, or legs, or if shoe size or widthhas recently increased—a clue that this conditionmay exist.

Since coronary artery disease is one of the lead-ing causes of heart failure, screen for angina.Choose your words carefully, however, becausenot all patients with angina describe it as "pain."instead, they may report a feeling of "heaviness"or "discomfort."

To evaluate angina, ask if the sensation is pres-ent at rest or only with activity, and whether itsubsides with rest. Also inquire about risk factorsfor coronary artery disease, including hyperten-sion, hyperlipidemia, smoking, obesity, diabetes,physical inactivity, and family history of heartdisease. Furthermore, diabetics do not typically

experience anginal-type pain, so they mayrequire more detailed evaluation and fre-quent monitoring.^

As part of the physical exam, assess res-piratory rate and pattern. Auscultate thelungs, noting any crackles or other adventi-tious sounds. Examine the patient's lowerextremities, checking for pitting edema,uneven hair distribution, wounds, pro-longed capillary refill time, and diminishedor absent pedal pulses. Be aware, however,that peripheral edema is a nonspecific indi-cator of systolic dysfunction. It can occurwith diastolic dysfuncHon and with a mul-titude of other conditions as well.

Also assess apical rate and heart sounds.Tachycardia may indicate that the heart iscompensating for a drop in cardiac output.An S heart sound, or ventricular gallop, is aspecific indicator of systolic dysfunction. It'slow-pitched and occurs during diastole, after

S;.' Because life-threatening arrhythmias can occurin patients with heart failure, be sure to assessheart rhythm, noting any abnormalities. Ask if thepatient has ever experienced light-headedness orsudden fainting spells.

You can also estimate the size of the heart bylocating the point of maximal impulse (PMI),which is normally palpated at the left fifth inter-costal space at the midclavicular line; the pulsationyou'll feel is the contraction of the left ventricle.As the heart enlarges and dilates, the PMIbecomes weaker and is displaced laterally, inwhich case you'll note the pulsation below thefifth intercostal space, lateral to midclavicular line.

Observe the jugular veins for distention, a signof vascular congestion. Jugular venous pressuregreater than 4 cm from the sternal notch suggestsfluid overload or right-sided heart failure.'

Confusion in an elderly patient may be a sign ofheart failure, so be sure to note it. As cardiac out-put falls, perfusion to vital organs is compro-mised. Hypoperfusion of the brain can lead tochanges in mental status.

A closer look at the failing heartHeart failure is a cliiucal diagnosis made after adetailed history and physical and confirmed with

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C L I N I C A L • CE SYSTOLIC DYSFUNCTION

Treating systolic dysfunctionThe three main classes of drugs for treating systolic dysfunction are listed below. Other drugs may be indicated for specific patientsand classes of heart failure, including, for example, digoxin (Lanoxin), the diuretic spironolactone (Aldactone), nitrates, such asnitroglycerin, plus hydralazine.

Drug group

Angiotensin-converting enzyme (ACE)inhibitors, such as enaiaprii (Vastoec),captoprii (Capoten), If ACE inhibitorscannot be used, consider angiotensinreceptor biockers (ARBs), such asirt>esartan (Avapro), candesartan (Atacand),valsarían (Diovan).

Beta adrenergtc biockers, such asmetoproloi (Lopressor, Toprol XL),carvediloi (Coreg).

Loop diuretics, such as furosemide (Lasix),torsemide (Demadex),

Action and benefits

Block vasoconstriction and promotevasodilation and sodium excretion.Reduce ieft ventricuiar dysfunction byslowing ventricuiar remodeling.Increase or preserve ejection fraction.Siow progression of heart faiiure andreduce mortality.

Reduce blood pressure and heartrate. Slow progression of heart faiiureand reduce moriality.

Enhance sodium and water excretionto reduce symptoms of fiuid overload.

Comments and considerations

First-iine agents for heart faiiure. Titratedose upward as tolerated. May increasepotassium. Check potassium level andrenal function before start of therapyand periodically. May cause dry cough.

Do not initiate if patient acutelydecompensated. May begin after Ml ifpatient hemodynamically stable. Ineideriy, begin at low dose and titrate upslowly to therapeutic dose. Avoid non-selective beta biockers for patients withCOPD. asthma; may precipitatebronchospasm.

Paramount in the treatment of systolicdysfunction. Potassium-wasting;typically given with KCI supplements.Monitor potassium levd.

Sources: 1. Hunt. S, A.. Baker, D. W., at al. (2001). ACG/AHA Guidelines for Evaluation and Management of Chronic Heart Failure in the Adult,Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation,104, 2996. 2. Hunt, S. A., Baker, D. W,. eî al. (2005). ACC/AHA Guideline Update for the Diagnosis and Management of Chronic Heart Failure inthe Adult: A report of the American College of Cardiology/American Heart Assoctaticn Task Force on Practice Guidelines. Circulation. 112. e l 54.3. Kopecky, S., Festin, R.. et a¡. "Health care guidelines: Heart failure in adults." 2007. viww.icsi.org/heart_failure_2/ heart_failurejn_adults_.htm!(1 Aug. 2007),

the appropriate testing. "' Some of these tests willalso help determine disease severity.

An echocardiogram is the most useful and sen-sitive noninvasive test for detecting heart failure. Itenables the examiner to look at heart wall motionand chamber size, to evaluate valve function, andto determine ejection fraction (EF), which is thepercentage of blood pumped out of the left ventri-cle with each heartbeat. An ejection fraction lessthan 40% indicates systolic dysfunction.''

Cardiac catheterization, or coronary angiogra-phy, is the gold standard for evaluating heart func-tion. It allows for direct visualization of blood flowthrough the coronary arteries, and for measurementof EF and heart pressures. It is, however, invasive.

Another test used in the diagnosis and manage-ment of heart failure is brain natriuretic peptide

(BNP). This blood test measures the level of aprotein that's released in response to the stretch-ing of cells in the myocardium. A level greaterthan 500 pg/ml can be an indicator of heart fail-ure in patients with other signs and symptoms.''If the BNP level is less than 100, heart failure isunlikely.'-^

Other tests that are ordered as part of thework-up for heart failure include: chest X-ray,which may reveal a hypertrophied heart andpulmonary congestion; EKG, which might showa bundle branch block, or left axis deviation, anindicator of left ventricular hypertrophy,'' andblood tests such as serum creatinine, electrolytes,and liver enzymes, which are helpful in evaluat-ing hepatic and renal function before and duringdrug treatment.

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ILINICAL CE SYSTOLIC DYSFUNCTION

ACC/AHA 2005 Guidelinesstage A: Patients at high risk for HF due to presence of HTN,

diabetes, obesity.Treatment is to control these conditions.

Stage B: Patients with left ventricular hypertrophy and/or history of M!but no symptoms.Treatment is to stop the progression.Might use pharmacological agents.

Stage C: Patients with symptoms.Treatment is more aggressive.

Diuretics. ACE inhibitors, beta blockers.Modify fluid and dietary intake.Biventricular pacing.

Stage D: Patients with advanced HF symptoms at rest requiringintervention in the acute care setting.Treatment includes aggressive therapies used in Stage C andpossibly heart transplant or left ventricular assist device.

Source: Hunt, S. A,, Baker. D. W.. et al. {2005). ACC/AHA Guideline Update for theDiagnosis and Management of Chronic Heart Failure in the Adult: A report of the Amer-ican College of Cardiofogy/American Heart Association Task Force on Practice Guide-lines Qrcu/af/on, 772,6154.

Common treatment optionsThe treatment depends on the cause; therefore,determiniag the cause is very important. If heartfailure is due to valvular heart disease, a heart valvereplacement can be done. If it's due to coronaryartery disease or hypertension, the goal is to slowthe progression of heart failure. Furthermore,because systolic and diastolic heart failure resultfrom different mechanisms, the two requiredistinctly different treatment. Tlie medications com-monly used to treat systolic dysfunction are dis-cussed in the table on page 27.

Arrhythmias and sudden cardiac death arepotential sequelae to heart failure; therefore, it'snot surprising that the use of interventionaldevices in the treatment of heart failure is rapidlyevolving. Implantable cardioverter defibrilla tors,for example, are recommended for the preventionof life-threatening ventricular arrhythmias inheart failure patients with ischémie or nonis-chemic cardiomyopathy, EF of 35% or less, andNew York Heart Association (NYHA) class II orin functional status.^ (The classes of heart failureare discussed in the box on page 26).

A complementary set of guidelines was estab-lished by the American College of Cardiology(ACC) together with the American Heart Associa-tion (AHA). These ACC/AHA Guidelines offer away to evaluate and manage chronic heart failureby classifying symptoms into Stages A through D.(The stages are described in detail in the box at theleft.) They range from Stage A for individuals atrisk for heart failure through Stage D for those withadvanced heart failure s)miptoms at rest requiringinter\'ention in the acute care setting. This classifi-cation system is intended to complement but notreplace the NYHA funchonal classification, whichprimarily gauges the severity of symptoms inpatients who are in Stage C or D.

iyianaging heart failure requireslifestyle changesIn addition to utilizing drug therapy and/or inter-ventional devices, most patients with heart failurewill need to make lifestyle changes. Since coronaryartery disease and hypertension can cause or con-tribute to heart failure, patient teaching shouldalso address these conditions and their risk factors.

Remind smokers that they face a significantlygreater risk of heart attack than individuals who'venever smoked, and encourage them to stop. If apatient is ready to quit, help implement an appro-priate plan. Success is more likely when pharma-cotherapy, such as nicotine replacement, is used.

Teach patients that even a small decrease indietary sodium—say, from 10 to 5 grams a d a y -can significantly decrease blood pressure.** Tellthem to watch their intake of sodium and torefrain from adding salt to their food. Make surethey know how to look for the sodium content offood on package labels. The ACC and AHA rec-ommend that people with heart failure limit theirdaily sodium intake to 2 to 3 grams.'" If hyper-kalemia is a concern, patients should avoid saltsubstitutes, since they're often high in potassium.

Instruct patients to weigh themselves andrecord their weight daily, and to report a weightgain that could signify fluid retention. Mostpatients with heart failure won't need to restricttheir fluid intake, but they should avoid drinkingexcessive amounts. Candidates for fluid restric-tion include patients with severe heart failure.

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C L I N I C A L • CE SYSTOLIC DYSFUNCTION

extreme edema, or hyponatremia. Sucking onhard candy or mints may help abate thirst.

Make sure patients know that nonsteroidal anti-inflammatory drugs (NSAIDs) can decrease theeffectiveness of certain antihypertensive drugsand can lead to fluid retention''" Advise them tocheck with their physician before using NSAIDs.Patients who take aspirin for coronary artery dis-ease, however, should continue to do so.'

Some research suggests a link between socialalcohol use and decreased left ventricular func-tion. Because the role of alcohol in heart failure isunclear, encourage patients who drirüc to do sosparingly, perhaps limiting themselves to onedrink per day. Patients with severe heart failureand those with alcoholic cardiomyopathy shouldnot drink alcohol at all.'"

Supervised exercise decreases symptoms andincreases function and quality of life in people withheart failure. Encourage patients with newly diag-nosed heart failure to participate in a cardiac reha-bilitation program once symptoms have stabilized.ParÜcipation in cardiac rehab decreases mortalityand hospitalization rates in heart failure patients.'

Addressing the moresensitive issuesThe need for intimacy continues throughout thelife span, and sexuality is part of intimacy. Reas-sure patients and their partners that sexual activityis safe in all but the most severely decompensatedindividuals. Those who can climb two flights ofstairs without symptoms should be able to toleratesexual intercourse,'^ but should do so at a levelthat's safe and comfortable, inform patients withcardiac defibrillators that the device may fire dur-ing intercourse, in response to an elevated heartrate or an arrhythmia; if that happens, their part-ners may feel a tingling but will not be harmed."

Dealing with a chronic, debilitating disease oftenleads to anxiety and depression. Encourage patientsand their loved ones to discuss their fears and con-cems openly. As heart failure progresses, treatmentmay become less effective and symptoms moreburdensome, at which point palliative care may benecessary. Specialists in palliative care are experts atmanaging pain, shortness of breath, and anorexia,and at helping patients and families explore the

ethical and legal implications of end-of-life care. Inthe meantime, urge families to review the patient'sadvanced directives regularly to be sure they reflecthis or her current wishes. Suggest that they keep acopy in a designated place in the home.

Heart failure is a chronic, progressive diseasewith an uncertain prognosis. Still, there's a lot wecan offer patients with respect to treatment, symp-tom management, and lifestyle modification. Inall of these areas, the nurse's role is vital. R N

REFERENCES

1. Braunwald, E. (2005). Approach to the patient with cardio-vascuiar disease, in. D. L. Kasper, E. Braunwald, et al. (Eds.),Harrison's principles of internal medicine (16th ed., pp.1301-1304). New Yori<: McGraw-Hiii.

2. Braunwaid, E. (2005). Normai and abnormai myocardial func-tion, in. D. L. Kasper, E. Braunwald, et al. (Eds.). Harrison's prin-cipies of internal medicine (16th ed., pp. 1358-1367). NewYori<: McGraw-iHill.

3. Rodgers, J. M.. & Reeder, S. R. (2001). Managing heartfaiiureiPart i.Cr/Wca/Care, 37(11), 1.

4. Rodgers, J. M., & Reeder, S. R. (2001). Managing heartfaiiure: Part 2. Critical Care, 3^^2), 1.

5. Tabibiazar. R., & Edeiman, S. V. (2003). Siient ischemia inpeopie with diabetes: A condition that must be heard. ClinDiabetes, 21, 5. http://ciinicai.diabetesjournais.org/cgi/content/fuii/21/1/5.

6. Beyerbach, D, M. "Impiantabie cardioverter-defibriiiators."(2006). www.emedicine.com/med/topic3386.htm (10 May2008).

7. Hunt, S. A.. Baiter, D. W.. et a!. (2005). ACC/AHA GuideiineUpdate for the Diagnosis and Management of Chronic iHeartFaiiure in the Aduit: A report of the American Coiiege of Car-dioiogy/American Heart Association Task Force on PracticeGuideiines, Circulation, T12. el 54.

8. Okuyemi, K. S., Noilen, N, L, and Ahiuwalia, J. S. (2006).interventions to faciiitate smoking cessation. Am Fam Physi-cian. 74(2), 262.

9. iHe, f. J., Markandu, N, D.. & MacGregor. G. A. (2005).Modest sait reduction iowers btood pressure in isoiated sys-toiic hypertension and combined hypertension. Circulation.46(1), 66.

10. Kopecky. S., Festin, R., eî al. "Health care guidelines:iHeart faiiure in adults." 2007. www.icsi.org/heart_faiiurs_2/heartJailure_in_adufîs_.html (1 Aug, 2007),

11 - iHuerta, C, Varas-Lorenzo, C, et ai. (2006). Non-steroidalanti-inflammatory drugs and risk of first hospitai admission forheart faiiure in the gênerai popuiation. Heart, 92(11), 1610.

12. Mears. S. (2006). The importance of exercise training inpatients with chronic heart faiiure. Nurs Stand, 20(31), 41.

13. Steinke, E. E. (2005). Intimacy needs and chronic illness:Strategies for sexual counseling and self-management. JGerontol Nurs, 3T(5), 40.

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Continuing Education Test #1137"Heart failure: Managing systolic dysfunction"OBJECTIVES After reading the article you should be able to:1. Identify signs and symptoms of systolic dysfunction.2. Discuss nursing and medical management for a patient with systolic dystunction,3. Develop a plan of care for o patient with systolic dysfunction,

Circle the one best answer for eoch question below, Transfer your answers to the card that follows page 24.Save this sheet to compare your answers with the explanations you'll receive. Or, take the test online at www.rnweb.com.

1. Heart failure affects an estimated how manymillion Americans?a. 2 million,b. 3 million.c. 4 million.d. 5 million.

2. Which of the following categories of drugsare first-line agents for systolic dysfunction?a. Angiotensin-converting enzyme (ACE)

inhibitors,b. Aipha adrenergic blockere.c. Beta adrenergic biockers.d. Calcium channel blockers.

3. Which of the following heart sounds is aspecific indicator of systolic dysfunction?a. S,.b.Sj,C.S3.d.s..

Of the following, which pathological changesoccur in heart failure caused by systolicdysfunction?a. The heart size remains unchanged.b. Stroke volume increases,c. Pulmonary congestion may occur.d. The ventricles are able to relax and fill property.

Which of the following actions should thenurse instruct a patient with an implantablecardioverter defibrillator (ICD) to take if theICD fires during intercourse?a. immediateiy contact the health care provider,b. Teli the partner that he or she may feel a

tingling,c. Stop intercourse.d. Take a nitroglycerin taWet.

6. Of the following, which is a symptom ofsevere heart failure?a. Blurred vision,b. Insomnia,c. Paroxysmal nocturnal dyspnea.d. Tingling.

7. Aweight gain of how many pounds mayindicate to the nurse that the patient has anincrease in fluid retention?a Two pounds in 24 hours.b. Two pounds in five days,c. One pound in 48 hours,d. TTiree pounds in one week.

8. One of the leading causes of heart failure is:a- Buerger's disease.b. Cerebral vascular accident,c. Coronary artery disease (CAD).d. Raynaud's disease.

9. Which classification of heart failuredescribes a patient with slightly limitedphysical activity who is comfortable andasymptomatic at rest?a. Class I,b. Class II,c. Class lit.d. Class IV,

10. Of the following, which group of drugsshould be avoided in patients with COPD orasthma?a. ACE inhibitors.b. Beta adrenergic blockers,c. Calcium channel blockers.d. Loop diuretics.

11. All of the following may be symptoms ofheart failure EXCEPT:a. Confusion,b. Jugular vein distention,c. Peripheral edema,d. Point of maximal impulse at the middavicular

line,

12. Which of the following tests is the mostuseful and sensitive noninvasive test fordetecting heart failure?a. Cardiac ultrasound,b. Echocardiogram,c. Electrocardiogram (EKG).d. Treadmill test.

13. The American College of Cardiology andAmerican Heart Association recommend thatpatients with heart failure limit their dailysodium intake to how many grams?a, 1 - 2 .b, 2 - 3.C, 3 - 4 .d. 4 - 5.

14. The nurse is aware that ICDs arerecommended for ejection fractionsless than what percentage?a, 35%,b. 45%,0, 55%,d.65%.

15. Of the following, which is the gold standardfor evaluating heart function?a. Cardiac catheterization,b. Cardiac MRI,c. EKG.d. Echocardiogram.

16. Of the following, which will the nurseinclude in a teaching plan for a patientwith heart failure?a. Drink alcohol at bedtime.b. Use nonsteroidal anti-inflammatoiv drugs for

CAD,0. Weigh self weekly,d, Exercise under supervison.

17. Of the following, which is the most commonpresenting sign of heart failure?a. Bradycardia.b. Fatigue.c. Urinary frequency.d. Vision ch£uiges.

18. Which of the fallowing are risk factors forCAD?a. Diabetes insidipus,b. Hyperthyroidism.c. Hypotension.d. Physical inactivity.

This continuing education offering is co-provided by AHC Media LLC and R N ,AHC Media LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.This program has been approved by the ,ûfnerican Association of Critical-Care Nurses [AACM) tor 1 Contact Hour, Category A, file number 10852,Provider approved by the Caiilomia Board ol Registered Nursing. Provider« 14749, for 1 Contact Hour, This activity is approved (or 1 nursing contact hour using a 60-minute contact hour.Credit will be granted tor this unit through Juns 2010, It was preparad by Marilyn Hertierî-Ashton, RN, BC, MS.

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