Article 125 Nursing Care for Obese Patients with Heart Failure and Coma

(1) Closely observe and record vital signs: ① Heart rate and rhythm: Contact the doctor immediately if any of the following occur: heart rate <40 beats/min or >130 beats/min; irregular heart rhythm; sudden doubling or halving of heart rate; sudden increase in heart rate in patients with a history of palpitations or precordial pain; blood pressure higher or lower than normal. ② Respiration: When obese patients lie flat, the diaphragm rises, the thoracic cavity volume is relatively reduced, and the respiratory movement becomes smaller, which easily leads to shallow and rapid breathing. This should be differentiated from dyspnea due to left ventricular failure. Obese patients with heart failure should be placed in a semi-recumbent position to reduce the influence of abdominal organs on thoracic cavity pressure, increase respiratory volume and respiratory movement, reduce cardiac load, and thus improve heart failure. ③ Changes in consciousness: Due to reduced cardiac output, insufficient blood supply to the brain, hypoxia, and increased carbon dioxide, symptoms such as dizziness, irritability, slow reaction, drowsiness, and syncope may occur. Timely monitoring of these conditions is beneficial for the doctor's comprehensive judgment. ④ Blood Pressure Changes: In the early stages of heart failure, blood pressure may be slightly elevated, while in hypertensive heart disease, blood pressure may be significantly elevated. A drop in blood pressure and an increased pulse rate should raise suspicion of cardiogenic shock. When measuring blood pressure in obese individuals, attention should be paid to the effect of cuff width on blood pressure to prevent severely hypotension from being overlooked or not addressed promptly due to readings from a standard cuff. When measuring blood pressure, the brachial artery, sphygmomanometer, and heart should be kept horizontal. If the brachial artery is higher than the heart, the measured blood pressure will be lower than the actual value, and vice versa. ⑤ Body Temperature: When measuring body temperature, it should be noted that obese individuals often have thick subcutaneous fat tissue, and the folds of skin are moist and sweaty, especially during heart failure, so the temperature measured under the armpit may be lower than the patient's actual temperature.

(2) Pay attention to edema symptoms: Edema is one of the main symptoms of heart failure. Mild edema caused by fat accumulation and poor venous return in obese individuals should be differentiated from edema caused by heart failure. Edema caused by heart failure is also easily overlooked due to obesity. For obese individuals with heart failure, observing fluid retention through changes in body position may be more accurate.

(3) Understanding the issues to be aware of when using digitalis preparations to treat heart failure: Digitalis is one of the most commonly used drugs for heart failure patients. It is used to treat certain types of heart failure and certain rapid arrhythmias, and can be used for short-term or long-term maintenance therapy as appropriate. Because the therapeutic dose and the toxic dose are very close, poisoning often occurs during treatment. The following points should be noted: ① Manifestations of toxic reactions: Gastrointestinal symptoms, such as nausea, vomiting, and anorexia. Digitalis poisoning can cause various arrhythmias. Neurological symptoms, such as headache, insomnia, depression, dizziness, and even confusion. Visual changes, such as yellow vision or green vision. ② Management of toxic reactions: Immediately discontinue digitalis drugs. Administer appropriate potassium supplementation according to the condition. Phenytoin sodium is the safest and most effective commonly used drug for treating various premature beats and rapid arrhythmias caused by digitalis poisoning. 50-100 mg is dissolved in 20 ml of water for injection and slowly injected intravenously. However, it has side effects such as respiratory depression and transient hypotension, which should be carefully monitored and strictly controlled. Magnesium sulfate (4g) can also be added to 250-500ml of 5% glucose solution and administered intravenously to alleviate poisoning reactions. ③ Precautions during application: Adhere to the principle of individualized medication; dosage, course of treatment, and method should be determined according to the specific patient. Dosage should not be adjusted solely based on heart rate, especially for patients with hyperthyroidism, anemia, myocarditis, or myocardial damage, as this can easily lead to digitalis overdose. Pay attention to correcting acid-base and electrolyte imbalances, especially when used in combination with potassium-depleting diuretics. Hypokalemia, hypomagnesemia, and alkalosis can easily lead to digitalis poisoning, and arrhythmias are common. Heart rate should be monitored before injecting digoxin or strophanthidin K. The injection rate should be slow, generally completed over 10-15 minutes. Heart rate should be monitored and recorded promptly 30 minutes to 1 hour after injection. Digitalis has increased volume distribution and relatively low blood concentration in obese individuals; a higher dose is needed to reach the therapeutic dose. Careful observation of efficacy, such as bradycardia, improvement of heart failure symptoms, and toxic reactions, is necessary.

(4) Points to note when using diuretics: ① Observe adverse drug reactions: If urine output >2500 ml/24 hours after administration, it indicates excessive diuresis, and patients may experience increased heart rate and decreased blood pressure. Symptoms such as general weakness, poor responsiveness, weakened tendon reflexes, abdominal distension, nausea, and vomiting may be signs of hypokalemia and hyponatremia. Obese individuals have low water content in their adipose tissue, meaning that the water content per kilogram of body weight is less than that of normal individuals. When using diuretics, hypovolemia may occur before urine output increases significantly. This is especially important to note for obese elderly patients. ② Injection techniques: When injecting into patients with edema, the injection site should be pressed first, and then a slightly longer needle should be used for deep intramuscular injection at the pressed area to avoid affecting drug absorption due to edema.

(5) Avoid factors that can trigger heart failure: Many factors in life can trigger or worsen heart failure in heart patients, such as overwork, excitement, infection, and arrhythmia. Preventive measures: ① Family members should proactively provide psychological support to obese patients, helping them relieve anxiety and avoid excessive excitement and fatigue. ② Provide good daily care; obese patients should control their diet, avoiding overeating and high-salt, high-calorie diets, and actively prevent respiratory infections. ③ When administering intravenous fluids, carefully control the infusion volume and rate, minimizing unnecessary infusions and preventing excessive or rapid infusions, especially for elderly patients. ④ Patients in the recovery period should balance work and rest, adjust their mindset, and seek medical attention promptly if any abnormal symptoms occur.

(1) Closely monitor changes in the patient's condition: ① Regularly monitor blood pressure, pulse, respiration, pupil size, and pupillary light reflex. ② Frequently call out to the patient to check their level of consciousness. If central hyperventilation occurs, cover the nasal cavity with a moist gauze to prevent excessive air intake and exhaust. Do not use respiratory stimulants. ③ If Cheyne-Stokes respiration, sighing respiration, or ataxia occurs, administer respiratory stimulants and prepare endotracheal intubation or tracheotomy equipment. ④ If signs of intracranial hypertension such as elevated blood pressure and a slow, strong pulse appear, administer mannitol rapidly for dehydration treatment. ⑤ If body temperature rises, use physical cooling methods such as ice packs or alcohol rubs. ⑥ Strengthen dynamic monitoring of the patient's condition. If there are any changes in the condition, contact the doctor and take timely measures.

(2) Prevention of accidental injury: ① For restless patients, bed rails should be added, and protective straps should be used if necessary to prevent falls from the bed. ② Maintain a clear airway. The patient should be placed in a supine position with their head turned to one side or in a lateral decubitus position to allow vomit to drain from the corner of the mouth and prevent aspiration that could cause lung infection. ③ If the tongue has fallen back, lift the mandible immediately or pull the tongue out with tongue forceps. Suction should be performed promptly if vomiting occurs. If removable dentures are present, they should be removed to prevent aspiration into the trachea. For patients with convulsions or spasms, a bite block should be placed on the biting surface of the teeth to prevent tongue biting. ④ Treat urinary and fecal incontinence promptly, and monitor pupil changes during the recovery period. If the patient is restless or abnormally excited, provide symptomatic treatment. ⑤ Hot water bottles should generally not be used on comatose patients. If they must be used, the water temperature must be below 50℃, and the patient should be wrapped in a cloth to prevent burns. ⑥ Trim nails regularly to prevent scratches.

(3) Prevention of pneumonia: Turn the patient over and pat their back every 2-3 hours, and stimulate the patient to cough or suction sputum to help drain sputum. Prevent sputum retention that can lead to infection. For patients who have undergone endotracheal intubation or tracheotomy, strict aseptic technique should be used during sputum suction. Keep the patient warm and avoid exposure to cold.

(4) Prevention of stomatitis: Perform oral care every morning and evening. If oral diseases are found, apply medication promptly.

(5) Prevention of bedsores: Keep skin dry frequently, turn the patient over and bathe frequently. Obese individuals have many folds in the neck, armpits, groin and perineum, which easily accumulate sweat and wet secretions. These areas should be cleaned frequently and the moisture absorbed with a clean, dry towel. The buttocks should not be soaked in urine, and diapers should be changed frequently.

(6) Prevention of thrombosis: Obese people are prone to thrombosis due to hypercoagulable factors, coupled with coma and less activity. It is important to turn them over regularly and perform passive limb exercises.

(7) Keep bowel movements and urination regular to prevent urinary tract infections. Regularly check the patient's stool and pay attention to any occult blood reaction.

(8) Prevention of limb deformities and contractures: Patients in a long-term coma should be given passive limb movements twice a day.

(9) Reasonable diet: Provide a low-fat, low-salt, low-sugar, high-vitamin diet, with small, frequent meals. Obese individuals should restrict their calorie intake to control their weight appropriately, but calorie intake should not be reduced too quickly to avoid acidosis caused by rapid fat metabolism.

(10) Pay attention to water and electrolyte balance: Record 24-hour fluid intake and output if necessary. The average adult fluid intake in 24 hours is 2500 ml, and the urine output is 1500 ml. Obese people are prone to shortness of breath and sweating. In dry and hot environments, the water and sweat evaporated by respiration should be estimated into the total output.

(11) Mental health care and health guidance: ① For obese patients with coma caused by systemic diseases, and patients whose symptoms have improved after hepatic coma, it is important to build confidence in treatment, keep them warm, avoid getting cold, prevent secondary infections, and avoid using barbiturates that damage the liver. ② For patients with coma caused by renal failure, during recovery, patients should maintain an optimistic spirit and build confidence in treatment. ③ Appropriate bed rest is recommended, and the dietary principle should be low in fat, low in calories, high in quality low protein, and high in vitamins. ④ Patients who need peritoneal dialysis should understand the purpose of treatment and learn how to perform home peritoneal dialysis.