Transcript Ekaterini Lambrinou

Managing Acute Heart Failure in the Emergency Department
Patient Case Study
Click on the icons for more information
Initial Diagnosis
and Care Plan
Case Introduction
1
Revised Diagnosis
and Care Plan
3
2
Teaching Points
Discussion and Conclusions
5
4
7
6
Glossary
Case Details
and Initial Triage
Diagnostic
Results
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Disposition
Decision
Supplementary
material
?
Questions
Home
Case
Introduction
CASE INTRODUCTION
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Ekaterini Lambrinou, RN, BSc, MSc,
PhD, NFESC
Nursing Department, School of Health Sciences,
Cyprus University of Technology
(Limassol; Cyprus)
•
Assistant Professor
•
Director, MSc in advanced acute and
intensive cardiology care
More
Home
Case
Introduction
CASE INTRODUCTION
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Background
•
•
•
•
•
This is the ER of a tertiary care hospital in the
capital city of a European island
You completed training as a degree nurse
5 years ago and for the last 4 years you have
been working as an emergency nurse
You have a certified emergency physician
who is acting as Department Head, two
residents on duty, and a full complement of
nurses (one of them is an advanced nurse in
clinical practice)
You have 24-hour access to a catheterization
laboratory
Essentially, this ED handles any type of
emergency
ER=Emergency Room
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Click on the icons for more information
Past History, Allergy
History, Medications,
and Social History
Review of
Systems
Chief Complaint
and Vital Signs
Physical
Examination
CASE DETAILS
AND INITIAL TRIAGE
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Chief Complaint
•
•
A 79-year-old man, who was brought in by his
daughter, enters the ED at 7.00 am
He complains of worsening shortness of
breath. It’s worse at night, and he can no
longer lay flat. In addition, he reports waking
up from sleep suddenly short of breath.
ED=Emergency Department
More
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
CASE DETAILS
AND INITIAL TRIAGE
“My lungs and legs feel like they are filled with
water. Last night when I went to bed, I felt like I
was drowning. I couldn’t lay down flat even when
I used three or four pillows. I thought I would
drown in my sleep so I got up and sat on the sofa.
I slept there a little and waited until morning
because I didn’t want to wake up my daughter”
More
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
•
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
The daughter informs the physicians and
nurses about her father’s long history of
exertional dyspnea that has recently
worsened
“He has been having these progressive
symptoms over the last 2 weeks. Previously he
could walk 1 km but currently he develops
dyspnea on exertion in a few meters. His diet was
quite salty over the previous few days – maybe
that made him thirsty and increased his fluid
consumption”
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
During Acute Heart Failure
•
•
ED nurses have an important role in the
assessment of patients, both early and during
follow up.
Importantly, nurses help to ensure delivery of
evidence-based care for early treatment and
faster symptom improvement through:
– symptom management
– monitoring of patient’s response to
therapy and care
ED=Emergency Department
More
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
During Acute Heart Failure
(cont’d)
•
A rapid nursing assessment is necessary in
order to optimize the triage of patients to the
appropriate level of care and inform the
management therapeutic plan:
1. Follow the Airway, Breathing, Circulation,
Disability , Exposure (ABCDE) approach
2. Evaluate the severity of symptoms
3. Assess hemodynamic profile*
*Most patients with AHF are wet and warm
AHF=acute heart failure
More
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Hemodynamic/Clinical State in
Acute Heart Failure
SIGNS OF LOW
PERFUSION
Cool extremities
Low urine output
Altered mental status
Inadequate response
to IV diuretic
Prerenal azotemia
Congestion
+
+
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Perfusion
Case
Introduction
-
Home
Dry and
Warm
Wet and
Warm
Dry and
Cold
Wet and
Cold
SIGNS OF
CONGESTION
 JVD
 HJR
Peripheral edema
S3
DOE/SOA
Orthopnea/PND
Rales
Recent weight gain
Adapted from Nohria A, et al. JAMA 2002;287:628–640.
Reproduced with permission from Dr Lynne Warner Stevenson (Harvard Medical School, Boston, MA, USA)
=increased; =positive; –=negative; DOE=dyspnea on exertion; HJR=hepatojugular reflux; JVD=jugular venous
distention; PND=paroxysmal nocturnal dyspnea; S3=ventricular filling murmur; SOA=shortness of air.
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Vital Signs
•
•
•
•
•
BP: 110/70 mmHg
HR: 95 bpm
RR: 18/min
Temperature: 36.9 °C / 98.4 °F
O2 sat: 90% on room air
BP=blood pressure; bpm=beats per minute; HR=heart rate; RR=respiratory rate; O 2 sat= oxygen saturation
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Review of Systems
•
•
•
•
•
•
•
Paroxysmal nocturnal dyspnea
Four pillow orthopnea
Fatigue
Loss of appetite
Increasing lower extremity edema
5 kg weight gain
No fevers, no cough, no chest pain
Disposition
Decision
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Past History
•
Ischemic heart disease (EF 25%), CAD
(remote MI, CABG), Hypertension,
Type II diabetes mellitus
CABG=coronary artery bypass graft; CAD=coronary artery disease; EF=ejection fraction;
MI=myocardial infarction
More
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Allergy History, Medications,
and Social History
Allergies
Home Medications
•
•
•
•
•
•
•
•
NKDA
Social History
•
Patient lives near
his daughter who
takes care of him
NKDA=no known drug allergies
ASA
81 mg daily
Lisinopril
5 mg daily
Furosemide
40 mg daily
Metoprolol
25 mg
Spironolactone 25 mg
Anti-diabetic pills
Atorvastatin
10 mg
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
CASE DETAILS
AND INITIAL TRIAGE
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Physical Examination
•
•
•
•
•
•
•
General: appears uncomfortable, able to speak short
sentences, looks fatigued
Jugular venous distention at 7 cm
Chest: (+) bibasilar pulmonary rales throughout
bottom half of lung fields bilaterally
CV: regular rhythm, a prominent third heart
sound [(+) S3], (-)S4, (-) murmurs or rubs
Abdomen: distended, (+) hepatojugular reflux
Extremities: bilateral pedal edema (2+ pitting edema
up to knees), 2+ DP and PT pulses
Hemodynamic profile: wet and warm
CV=cardiovascular; DP=dorsalis pedis ; PT=posterior tibial
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Click on the icons for more information
Initial Impression
Holistic Nursing Plan
INITIAL DIAGNOSIS
AND CARE PLAN
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Home
Case
Introduction
INITIAL DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Initial Impression
•
Current presentation consistent with acute
decompensated heart failure
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
INITIAL DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Holistic Nursing Plan
•
•
•
•
•
•
•
Nursing assessment/follow up
Information from the patient’s medical history
Individual’s management needs
The results of all necessary diagnostic and
laboratory tests
The presence of comorbid diseases
Differential diagnosis
Recommendations (guidelines, protocols)
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
INITIAL DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Considerations of Potential
Triggers of AHF:
•
•
•
•
•
Acute myocardial ischemia
Uncorrected high BP
Infections
Arrhythmias (e.g. AF)
Comorbid conditions (e.g. anemia, endocrine
abnormalities, exacerbation of COPD, kidney dysfunction)
•
Non adherence to treatment
•
Additional acute cardiovascular disorders (myocarditis,
aortic dissection, endocarditis)
Use of drugs that increase salt retention (steroids,
NSAIDS), initiation of negative inotropic drugs, excessive
alcohol or illicit drugs
Pulmonary embolism
•
•
AF=atrial fibrillation; BP=blood pressure; COPD=chronic obstructive pulmonary disease;
NSAIDS=non-steroidal anti-inflammatory drugs
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Click on the icons for more information
ECG, Lab Results
and X-ray
DIAGNOSTIC RESULTS
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Home
Case
Introduction
DIAGNOSTIC
RESULTS
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
ECG, Laboratory Results and
Chest X ray
ECG demonstrates sinus tachycardia at 101 bpm, no new ischemic
changes, consistent with old ECG except for mild tachycardia
(reference range)
(135–145 mmol/L)
(3.5–5.0 mmol/L)
(17–48 mg/dL)
(0.5–1.2 mg/dL)
(13–18 g/dL)
(≤0.1 ng/mL)
(<125 pg/mL)
(60–110 mg/dL)
•
•
•
•
•
•
•
•
Na
K
Urea
Creatinine
Hb
Troponin I*
NT-proBNP#
Glucose
•
CXR: cardiomegaly, vascular engorgement, mild interstitial
edema
128 mmol/L
5.8 mmol/L
82 mg/dL
1.8 mg/dL
11.0 g/dL
0.1 ng/mL
1,300 pg/mL
140 mg/dL
*Troponin I Ultra (Siemens Healthcare Diagnostics); negative for myocardial necrosis <0.1 ng/mL. #Pro-BNP II
(Roche Diagnostics Deutschland GmbH); normal levels <100 pg/mL. bpm=beats per minutes; CXR-chest X ray;
ECG=electrocardiogram; Hb=hemoglobin; NT-proBNP=N-terminal pro-B-type natriuretic peptide.
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Click on the icons for more information
Next Actions
Clinical
Impression
H
REVISED DIAGNOSIS AND
CARE PLAN
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Disposition
and Discharge
Home
Case
Introduction
REVISED DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Clinical Impression:
Moderately breathless due to AHF
•
•
Begin i.v. furosemide 40 mg x 1
Reassess in 30 minutes for I/O’s and symptom
improvement
AHF=acute heart failure; I/O=inputs and outputs; i.v.=intravenous
Home
Case
Introduction
REVISED DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Next actions
(based on re-assessment)
•
•
If response: ward environment, optimize medication,
treat underlying cause, plan discharge
If no response: consider environment for close
monitoring whilst reducing afterload (nitrates)
?
QUESTION
Home
Case
Introduction
REVISED DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Monitoring Fluid Management
•
•
•
•
Body weight
Fluid volume status: Strict recording of input and
output
Need for an indwelling urinary catheter
Fluid restriction
Fluid Balance charts
mL
Input
Output
Per shift
REVISED
DIAGNOSIS
AND
i.v.
p.o.
Skin
PLAN –
300 CARE
300
–
–
150
Urine
–
750
More
i.v.=intravenous; p.o.=by mouth
Home
Case
Introduction
REVISED DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Monitoring Mental Status1,2
•
•
Glasgow Coma Scale: 14
AVPU/ACDU scales
A
V
The patient
is awake.
ACDU
 Alert
 Confused
The patient responds
 Drowsy
to verbal stimulation.
 Unresponsive
REVISED DIAGNOSIS
AND
P
The patient responds
CARE
to painful stimulation.
U
The patient is completely
unresponsive.
PLANQuick and simple for initial
and follow up assessment
More
1. Kelly et al. Ann Emerg Med. 2004;44:108–13; 2. Gill et al. Ann Emerg Med. 2007;49:403–7
Home
Case
Introduction
REVISED DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Activity, Comfort and Psychosocial
Support (Holistic Approach and
Patient-Centered Care)
•
•
•
Comfortable position
Inform the patient and the family about current
condition and treatment
Psychosocial support to the person and the family
through effective communication
REVISED DIAGNOSIS AND
CARE PLAN
More
Home
Case
Introduction
REVISED DIAGNOSIS
AND CARE PLAN
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Effective communication and
management of the multi-disciplinary
team is critical!
•
Fast and effective cooperation among health
professionals, technicians, labs and assistants
REVISED DIAGNOSIS AND
CARE PLAN
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
H
DISPOSITION
DECISION
Disposition
•
The patient was transferred to the cardiology
department for observation
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Click on the icons for more information
Discussion and
Conclusions
Teaching Points
Local Variation
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Ekaterini Lambrinou
RN, BSc, MSc, PhD, NFESC
Home
Case
Introduction
TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Pearls
•
Nursing Goals in AHF are to:
– determine the trigger of decompensation
– relieve symptoms of congestion
– achieve hemodynamic and rhythm stability
– minimize risk of adverse events
– achieve effective communication among the
multi-disciplinary team
– provide patients with education to encourage
self-management
– introduce patients to effective disease
management programs
More
AHF=acute heart failure
Home
Case
Introduction
TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Pearls
•
Once the condition is stabilized a structured
clinical, psychological and social assessment
should be undertaken as the basis for the
discharge plan and referral to a multidisciplinary
disease management program
Home
Case
Introduction
TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Discussion and Conclusions
•
•
Nurses are challenged to have comprehensive
knowledge related to the disease state of HF and the
factors that impact admissions for AHF
This includes:
–
–
–
–
–
–
being familiar with appropriate assessment of signs
and symptoms of congestion and hypoperfusion
using diagnostic tools (e.g. BNP) to decipher if
symptoms are related to HF or other comorbid factors
in cooperation with the physicians
using the hemodynamic profile to develop the
treatment plan (Nursing Process)
evaluating the effectiveness of the treatment plan and
assessing for possible side-effects
responsibility for effective communication and
management of the multidisciplinary team
introducing a more effective management program
AHF=acute heart failure; BNP=brain natriuretic peptide; HF=heart failure
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Local Variation
•
GPs and nurse specialists in cardiology and HF
are only available in hospital settings
GP=General Practitioner; HF=heart failure
Home
Case
Introduction
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Supplementary Material
Teaching Points
Discussion and Conclusions
Home
Case
Introduction
TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Nursing Management Algorithm
Immediate assessment (ABCDE)
Vital signs (BP, HR, RR, T, SatO2)
Triage
Initial clinical assessment and short history
(peripheral i.v. line, ECG, CXR, blood test,
non invasive monitoring)
Bedside ECHO
Determine precipitant of AHF
Determine the hemodynamic profile
Start pharmacological therapy
Follow-up assessment
Psychosocial assessment and support
Monitor the effects of pharmacological therapy
(including for side-effects)
Monitor fluid management
Monitor mental status
Monitor dyspnea symptoms
Determine the trigger of decompensation
Assess educational needs
Successful
communication
on and
management
of the
multi-disciplinary
team
Discharge
Planning
Introduction to an effective
multi-disciplinary HF management
program
AHF=acute heart failure; BP=blood pressure; CXR=chest x-ray; ECG=electrocardiogram; HR=heart rate;
i.v.=intravenous; RR=respiratory rate; O2 sat= oxygen saturation; T=temperature