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Managing Acute Heart Failure in the Emergency Department PowerPoint Presentation

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Description : Check out this medical presentation on Congestive Heart Failure, which is titled "Managing Acute Heart Failure in the Emergency Department", to know how to manage acute heart failure in the emergency department with the help of a patient case study.

Tags : Congestive Heart Failure, Acute Heart Failure, Emergency Department, manage, patient case study

Published on : Jul 01, 2021 | Views : 2148 | Downloads : 5

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Slide 1-

Managing Acute Heart Failure in the Emergency Department Patient Case Study 5 Revised Diagnosis and Care Plan 6 Disposition Decision Supplementary material Ekaterini Lambrinou RN, BSc, MSc, PhD, NFESC Author: Click on the icons for more information ? Questions
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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 CASE INTRODUCTION More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 CASE INTRODUCTION ER=Emergency Room Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Chief Complaint and Vital Signs Review of Systems Past History, Allergy History, Medications, and Social History Physical Examination CASE DETAILS AND INITIAL TRIAGE Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home Ekaterini Lambrinou RN, BSc, MSc, PhD, NFESC Author: Click on the icons for more information
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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 CASE DETAILS AND INITIAL TRIAGE More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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“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” CASE DETAILS AND INITIAL TRIAGE More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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” CASE DETAILS AND INITIAL TRIAGE Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 CASE DETAILS AND INITIAL TRIAGE ED=Emergency Department More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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: Follow the Airway, Breathing, Circulation, Disability , Exposure (ABCDE) approach Evaluate the severity of symptoms Assess hemodynamic profile* *Most patients with AHF are wet and warm AHF=acute heart failure More CASE DETAILS AND INITIAL TRIAGE Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Hemodynamic/Clinical State in Acute Heart Failure CASE DETAILS AND INITIAL TRIAGE Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home 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.
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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 CASE DETAILS AND INITIAL TRIAGE BP=blood pressure; bpm=beats per minute; HR=heart rate; RR=respiratory rate; O2 sat= oxygen saturation Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 CASE DETAILS AND INITIAL TRIAGE Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 CASE DETAILS AND INITIAL TRIAGE More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Allergy History, Medications, and Social History Allergies NKDA Social History Patient lives near his daughter who takes care of him Home Medications ASA 81 mg daily Lisinopril 5 mg daily Furosemide 40 mg daily Metoprolol 25 mg Spironolactone 25 mg Anti-diabetic pills Atorvastatin 10 mg CASE DETAILS AND INITIAL TRIAGE NKDA=no known drug allergies Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 CASE DETAILS AND INITIAL TRIAGE CV=cardiovascular; DP=dorsalis pedis ; PT=posterior tibial Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Holistic Nursing Plan INITIAL DIAGNOSIS AND CARE PLAN Initial Impression Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home Ekaterini Lambrinou RN, BSc, MSc, PhD, NFESC Author: Click on the icons for more information
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Initial Impression Current presentation consistent with acute decompensated heart failure INITIAL DIAGNOSIS AND CARE PLAN Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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) INITIAL DIAGNOSIS AND CARE PLAN Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 INITIAL DIAGNOSIS AND CARE PLAN AF=atrial fibrillation; BP=blood pressure; COPD=chronic obstructive pulmonary disease; NSAIDS=non-steroidal anti-inflammatory drugs Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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DIAGNOSTIC RESULTS ECG, Lab Results and X-ray Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home Ekaterini Lambrinou RN, BSc, MSc, PhD, NFESC Author: Click on the icons for more information
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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) Na 128 mmol/L (135–145 mmol/L) K 5.8 mmol/L (3.5–5.0 mmol/L) Urea 82 mg/dL (17–48 mg/dL) Creatinine 1.8 mg/dL (0.5–1.2 mg/dL) Hb 11.0 g/dL (13–18 g/dL) Troponin I* 0.1 ng/mL (≤0.1 ng/mL) NT-proBNP# 1,300 pg/mL (<125 pg/mL) Glucose 140 mg/dL (60–110 mg/dL) CXR: cardiomegaly, vascular engorgement, mild interstitial edema *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. DIAGNOSTIC RESULTS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Next Actions REVISED DIAGNOSIS AND CARE PLAN Clinical Impression Disposition and Discharge H Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home Ekaterini Lambrinou RN, BSc, MSc, PhD, NFESC Author: Click on the icons for more information
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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 REVISED DIAGNOSIS AND CARE PLAN AHF=acute heart failure; I/O=inputs and outputs; i.v.=intravenous Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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) REVISED DIAGNOSIS AND CARE PLAN Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home ? QUESTION
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REVISED DIAGNOSIS AND CARE PLAN Monitoring Fluid Management Body weight Fluid volume status: Strict recording of input and output Need for an indwelling urinary catheter Fluid restriction REVISED DIAGNOSIS AND CARE PLAN More i.v.=intravenous; p.o.=by mouth Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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REVISED DIAGNOSIS AND CARE PLAN Monitoring Mental Status1,2 Glasgow Coma Scale: 14 AVPU/ACDU scales REVISED DIAGNOSIS AND CARE PLAN More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home The patient is awake. The patient responds to verbal stimulation. The patient responds to painful stimulation. The patient is completely unresponsive. A V P U ACDU  Alert  Confused  Drowsy Unresponsive Quick and simple for initial and follow up assessment 1. Kelly et al. Ann Emerg Med. 2004;44:108–13; 2. Gill et al. Ann Emerg Med. 2007;49:403–7
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REVISED DIAGNOSIS AND CARE PLAN 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 Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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REVISED DIAGNOSIS AND CARE PLAN 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 Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Disposition The patient was transferred to the cardiology department for observation Disposition Decision H Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Local Variation TEACHING POINTS, DISCUSSION AND CONCLUSIONS Discussion and Conclusions Teaching Points Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home Ekaterini Lambrinou RN, BSc, MSc, PhD, NFESC Author: Click on the icons for more information
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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 TEACHING POINTS, DISCUSSION AND CONCLUSIONS AHF=acute heart failure More Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 TEACHING POINTS, DISCUSSION AND CONCLUSIONS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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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 TEACHING POINTS, DISCUSSION AND CONCLUSIONS AHF=acute heart failure; BNP=brain natriuretic peptide; HF=heart failure Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Local Variation GPs and nurse specialists in cardiology and HF are only available in hospital settings TEACHING POINTS, DISCUSSION AND CONCLUSIONS GP=General Practitioner; HF=heart failure Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home QUESTION 1 With regards to the potential trigger of decompensation, what would be the most important component of discharge planning for this particular person? Provide patients with education to encourage self-management Introduce patients to effective disease management programs Schedule follow up visits Relieve symptoms of congestion REVISED DIAGNOSIS AND CARE PLAN Disposition Decision
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Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home QUESTION 1 With regards to the potential trigger of decompensation, what would be the most important component of discharge planning for this particular person? Provide patients with education to encourage self-management Introduce patients to effective disease management programs Schedule follow up visits Relieve symptoms of congestion REVISED DIAGNOSIS AND CARE PLAN Incorrect answer While A is a good answer, B is the BEST answer. Self-care is critical to a patients health, however, by itself may be insufficient. Effective disease management programs include self-care and education as part of their overall program. Disposition Decision
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Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home QUESTION 1 With regards to the potential trigger of decompensation, what would be the most important component of discharge planning for this particular person? Provide patients with education to encourage self-management Introduce patients to effective disease management programs Schedule follow up visits Relieve symptoms of congestion REVISED DIAGNOSIS AND CARE PLAN Correct answer The supportive disease program must be based on the patient’s needs and background. A disease management program should include all healthcare professionals required for the patient’s care. Follow-up visits, patient and family education should also be included in the program. A patient undergoing an acute event due to therapy non-adherence needs an effective and supportive management program which is expected to minimize acute events. Disposition Decision
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Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home QUESTION 1 With regards to the potential trigger of decompensation, what would be the most important component of discharge planning for this particular person? Provide patients with education to encourage self-management Introduce patients to effective disease management programs Schedule follow up visits Relieve symptoms of congestion REVISED DIAGNOSIS AND CARE PLAN Incorrect answer While C is a good answer, B is the BEST answer. Scheduling follow up visits alone will not adequately minimize acute events in patients Disposition Decision
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Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Home QUESTION 1 With regards to the potential trigger of decompensation, what would be the most important component of discharge planning for this particular person? Provide patients with education to encourage self-management Introduce patients to effective disease management programs Schedule follow up visits Relieve symptoms of congestion REVISED DIAGNOSIS AND CARE PLAN Incorrect answer The correct answer is B. This was one of the initial goals in this case, so it is expected that this person is not experiencing symptoms of congestion in the discharge phase Disposition Decision
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Supplementary Material Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home
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Nursing Management Algorithm TEACHING POINTS, DISCUSSION AND CONCLUSIONS Case Introduction Initial Diagnosis and Care Plan Case Details and Initial Triage Revised Diagnosis and Care Plan Teaching Points Discussion and Conclusions Diagnostic Results Disposition Decision Home 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 Successful communication on and management of the multi-disciplinary team Determine precipitant of AHF Determine the hemodynamic profile Initial clinical assessment and short history (peripheral i.v. line, ECG, CXR, blood test, non invasive monitoring) Immediate assessment (ABCDE) Vital signs (BP, HR, RR, T, SatO2) Bedside ECHO 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 Discharge Planning Introduction to an effective multi-disciplinary HF management program Triage
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Acute Medicine Also known as emergency medicine ward CHA2DS2-VASC A clinical prediction rule for estimation of stroke risk in patients with atrial fibrillation CHEM7 US terminology. A basic metabolic panel including Na, K, Cl−, HCO3− or CO2, blood urea nitrogen, creatinine and glucose Community heart failure team UK terminology. A specialist community heart failure nursing service working in partnership with Hospital Trusts Consultant UK terminology. The equivalent role in the US would be an attending/staff physician C/O Complaining of EHMRG Emergency Heart Failure Mortality Risk Grade. A tool that could be used to assess mortality risk at discharge. Note, this tool has not been prospectively validated. Clinical judgement is important GP General practitioner. UK terminology. The equivalent role in the US would be family physician R/O Ruled out Stat statim (Latin) referring to speed Specialist UK terminology. See consultant