Managing acute heart failure in the Emergency Department

Managing acute heart failure in the Emergency Department

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 Nursing Department, Department, School School of of Health Health Sciences, Sciences, Cyprus University of Technology Cyprus University of Technology (Limassol; (Limassol; Cyprus) 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 This is is the the ED ED of of a a tertiary tertiary care care hospital hospital in in an an urban urban center,

center, in in Cyprus, Cyprus, which which handles handles any any type type of emergency of emergency During During the the morning morning shift shift there there are are four four certified certified GPs on duty working as emergency physicians GPs on duty working as emergency physicians and and a a full full complement complement of of eight eight registered registered nurses nurses All the staff, doctors and nurses, are All the staff, doctors and nurses, are knowledgeable knowledgeable in in Advanced Advanced Life Life Support Support and and Pre-Hospital Trauma Life Support Pre-Hospital Trauma Life Support The The nurse nurse in in charge charge of of the the specific specific shift shift has has completed training as a board-certified Acute completed training as a board-certified Acute Care Care Nurse

Nurse Practitioner Practitioner Cardiologists Cardiologists are are requested requested as as needed needed by by emergency physicians emergency physicians Echo Echo capabilities capabilities are are used used at at the the judgment judgment of of specialists specialists A A catheterization catheterization laboratory laboratory (24-hour (24-hour access) access) is is available in this hospital available in this hospital ED=emergency department; GP=general practitioner 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 History of Present Illness and Review of systems Past History, Allergy History, Medications, and Social History I HP

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 Initial Diagnosis and Care Plan Diagnostic Results Revised Diagnosis and Care Plan Disposition Decision Teaching Points Discussion and Conclusions CASE DETAILS AND INITIAL TRIAGE Chief Complaint A A 56-year-old 56-year-old male male was was transferred transferred from from his his home to the ED at 7.30 am due to sudden home to the ED at 7.30 am due to sudden onset onset SOB SOB and and chest chest tightness tightness The The onset onset occurred occurred during during his

his daily daily morning morning swimming swimming activity activity at at 7.05 7.05 am am The The ambulance ambulance staff staff were were immediately immediately alerted alerted and and responded responded at at 7.20 7.20 am am ED=Emergency department; SOB=shortness of breath 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 A rapid nursing assessment is necessary in order to optimize the triage of patients to the appropriate level of care and contribute to the management therapeutic plan 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 Vital Signs (on arrival) BP: BP: 180/100 180/100 mmHg mmHg HR: HR: 120/min 120/min RR: RR: 40/min 40/min Temperature: Temperature: 36.0 36.0 C C // 96.8 96.8 F F O O22 sat: sat: 88% 88% on on 15 15 L LO O22/min /min supplied supplied by by a a non non rebreathing mask mask rebreathing BP=blood pressure; HR=heart rate; RR= respiratory rate; O2 sat= oxygen saturation 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 I HP CASE DETAILS

AND INITIAL TRIAGE History of Present Illness/ Review of Systems The The onset onset was was sudden. sudden. Patient Patient was was in in his his usual state of health, doing his usual usual state of health, doing his usual swimming swimming exercise. exercise. He He suddenly suddenly developed developed chest chest pain pain and and shortness shortness of of breath breath and and ambulance ambulance was was called called Other Other history history of of present present illness illness and and review review of of systems limited by acute condition systems limited by acute condition 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 Hypertension Hypertension diagnosed diagnosed 5 5 years years ago ago 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 Allergy History, Medications, and Social History Allergies Allergies NKDA NKDA Social Social History History Married Married and and lives lives with wife with wife Current Medications Enalapril 10 mg o.d. HCTZ 12.5 mg

o.d. HCTZ=hydrochlorothiazide; NKDA=no known drug allergies; o.d.=once daily 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: General: the the patient patient is is having having difficulty difficulty breathing, breathing, is is unable unable to to speak in full sentences, and appears fatigued speak in full sentences, and appears fatigued Chest: Chest: The The patient patient is is suffering suffering from from extreme extreme breathlessness, breathlessness, increased respiratory effort with the use

of accessory increased respiratory effort with the use of accessory respiratory respiratory muscles, muscles, diaphoresis, diaphoresis, agitation agitation and and confusion confusion Auscultation of of the the lungs lungs reveals reveals generalized generalized crackles crackles in in all all Auscultation the lung fields, along with the presence of rhonchi and the lung fields, along with the presence of rhonchi and wheezing wheezing CV: CV: regular regular rhythm, rhythm, a a prominent prominent third third heart heart sound sound [(+) [(+) S3], S3], (-) S4, (-) murmurs or rubs (-) S4, (-) murmurs or rubs Abdomen: distended, distended, (+) (+) hepatojugular hepatojugular reflux reflux Abdomen: Extremities: Extremities: 1+ 1+ pitting pitting edema edema to to knees, knees, 2+ 2+ DP DP and and PT PT pulses pulses Capillary Refill Refill Time Time of of 2 2 sec sec

Capillary CV=cardiovascular; DP=dorsalis pedis , PT=posterior tibial Initial Diagnosis and Care Plan Diagnostic Results Revised Diagnosis and Care Plan Disposition Decision Teaching Points Discussion and Conclusions Determine the hemodynamic profile The The Forrester Forrester Classification Classification describes describes four four groups groups according according clinical clinical and and haemodynamic haemodynamic status. status. Clinically, Clinically, the the patients patients are are classified classified upon upon peripheral hypoperfusion and pulmonary congestion and peripheral hypoperfusion and pulmonary congestion and hemodynamically hemodynamically upon upon a a reduced reduced cardiac cardiac index. index. As As a a general general rule, rule, most most ED ED patients patients are are wet wet and and warm. warm. 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;287:628640. Reproduced with permission from Dr Lynne Warner Stevenson (Harvard Medical School, Boston, MA, USA) =increased; =positive; =negative; ED=emergency department; 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 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 Clinical Impression

(Initial Diagnosis) and Differential Diagnosis INITIAL DIAGNOSIS 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 Teaching Points Discussion and Conclusions Clinical Impression (Initial Diagnosis) and Differential Diagnosis The The diagnosis diagnosis of of pulmonary pulmonary edema edema (ACPE) (ACPE) was strongly suspected, based both was strongly suspected, based both on on 1 1 history history and and the the clinical clinical examination examination Given Given the the rapid rapid onset onset of of symptoms symptoms during during exercise, exercise, ACS ACS as

as a a cause cause of of AHF AHF is is of of concern concern 1. Nieminen MS et al. Eur Heart J 2005;26:384416) ACPE=acute cardiogenic pulmonary edema; ACS=acute coronary syndrome; AHF=acute heart failure ? QUESTION 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 What are some specific nursing concerns in a patient with ACPE? Impaired Impaired gas gas exchange exchange related related to to ventilation/perfusion mismatching ventilation/perfusion mismatching or or intrapulmonary intrapulmonary shunting shunting Decreased Decreased cardiac cardiac output output related related to to alterations alterations in in preload, preload, contractility, contractility, heart heart rate rate and and rhythm rhythm

Minimal Minimal activity activity tolerance tolerance related related to to cardiopulmonary dysfunction cardiopulmonary dysfunction ACPE=acute cardiogenic pulmonary edema 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 Lab Results Click on the icons for more information Initial Plan of Care Chest X ray Ancillary Imaging ECG 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 Diagnostic testing Non Non invasive invasive monitoring monitoring ECG ECG Blood Blood pressure pressure Respiratory Respiratory rate rate Heart rate Heart rate Pulse Pulse oximetry oximetry for for continuous continuous monitoring monitoring of of oxygen saturation oxygen saturation A A 12-lead 12-lead ECG. ECG. It It may may identify identify a a potential potential cause cause such such as as arrhythmia arrhythmia or or MI MI Continuous Continuous ECG ECG monitoring monitoring Blood Blood tests tests

Urea, Urea, electrolytes electrolytes and and full full blood blood count: count: To To Identify Identify potential potential contributing contributing factor, factor, such such as as renal failure, Troponin: Identify MI as potential renal failure, Troponin: Identify MI as potential cause cause of of AHF AHF Plasma BNP/NT-Pro Plasma BNP/NT-Pro BNP: BNP: high high concentrations concentrations in heart failure in heart failure AHF=acute heart failure; BNP=B-type natriuretic peptide; ECG=electrocardiogram; MI=myocardial infarction; NT-proBNP=N-terminal pro-B-type natriuretic peptide Home Case Introduction DIAGNOSTIC RESULTS Case Details and Initial Triage Initial Diagnosis and Care Plan Diagnostic Results Revised Diagnosis and Care Plan Disposition Decision Diagnostic testing (contd) Chest Chest X X ray ray

Assess Assess pulmonary pulmonary congestion congestion Heart size Heart size Exclude Exclude other other pulmonary pulmonary cause cause of of symptoms symptoms Cardiac Cardiac ultrasound ultrasound Assess Assess heart heart function: function: overall overall ventricular ventricular function and regional myocardial function and regional myocardial dysfunction, dysfunction, valve function etc valve function etc Teaching Points Discussion and Conclusions Home Case Introduction DIAGNOSTIC RESULTS Case Details and Initial Triage Initial Diagnosis and Care Plan ECG ECG=electrocardiogram Diagnostic Results Revised Diagnosis and Care Plan Disposition Decision Teaching Points Discussion and Conclusions Click here for ECG: Interpretation

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: Interpretation The The 12 12 lead lead ECG ECG was was performed performed within within 10 10 minutes minutes upon the patients arrival in the ED and revealed upon the patients arrival in the ED and revealed Sinus Sinus Tachycardia Tachycardia with with a a pre-existing pre-existing Left Left Bundle Bundle Branch Branch Block, Block, according according to to a a previous previous ECG ECG ECG=electrocardiogram; ER=Emergency department 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 Initial Plan of Care i.v.=intravenous Relieve Relieve symptoms symptoms of of congestion congestion Ensure Ensure hemodynamic hemodynamic stability stability Minimize Minimize risk risk for for adverse adverse events events Relieve Relieve feelings feelings of of discomfort, discomfort, fear fear and and anxiety anxiety Ensuring Ensuring adequate adequate oxygenation, oxygenation, improve improve signs signs and and symptoms, improve hemodynamics symptoms, improve hemodynamics Non-Invasive Non-Invasive Positive Positive Pressure Pressure Ventilation Ventilation (NIPPV), (NIPPV), in the absence

of any contra-indications in the absence of any contra-indications Nitrates, Nitrates, diuretics diuretics as as well well as as morphine morphine to to reduce reduce the the preload and the afterload of the ventricles preload and the afterload of the ventricles In In this this patient patient 4 4 mg/h mg/h isosorbide isosorbide dinitrate dinitrate was was commenced. commenced. In In addition, addition, 40 40 mg mg furosemide furosemide i.v. i.v. and and 3 3 mg mg morphine morphine were were given given as as start start doses doses 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 ! DIAGNOSTIC

RESULTS Key Point Reassess frequently! At minimum, at least every 30 minutes 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 Lab Results Venous blood sample was extracted 5 minutes after the patients arrival to the ED for: CBC Serum electrolyte measurements Blood urea and creatinine determinations CK-MB levels TnT quantitation The following abnormal findings were identified: TnT 0.3 ng/mL CKMB 27 U/L K+ 3.3 mmol/L Creatinine 1.28 mg/dL Reference range (<0.12 ng/mL) (025 U/L) (3.55.00 mmol/L) (0.671.17 mg/dL) More CBC=complete blood count; CKMB= serum creatine kinase MB; ED=emergency department; TnT=troponin T 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 Lab Results (Contd) The arterial blood gas analysis revealed the following parameters: Reference range pH 7.16 (7.357.45) (3545 mmHg) PCO2 59 mmHg PaO2 71 mmHg (80100 mmHg) HCO3- 16.7 mmol/L (2328 mmol/L) Respiratory and metabolic acidosis: Mixed acidosis/respiratory fatigue and then metabolic acidosis 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 Need for potassium (K++) Correction and Renal Evaluation + K K+ was was replaced

replaced in in the the form form of of 20 20 mL mL of of KCl KCl 10% 10% diluted in 250 mL of D/W 5%, at an infusion rate diluted in 250 mL of D/W 5%, at an infusion rate of of 125 125 mL/h mL/h Close Close monitoring monitoring of of the the effects effects of of pharmacologic pharmacologic therapy therapy Fluid Fluid and and electrolyte electrolyte monitoring: monitoring: fluid fluid intake intake and and output output balance balance body body weight weight + + K K+ and and sodium sodium (Na (Na+)) Levels Levels D/W=dextrose/water 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 Chest X ray Click here for Chest X ray: Interpretation (30 min after presentation in ED) ? ER=emergency department QUESTION 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 Chest X ray: Radiology Interpretation Chest Chest X X ray ray showed showed pulmonary pulmonary edema edema 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 Ancillary Imaging An An echocardiogram echocardiogram was was performed performed by by the the ononcall cardiologist, within 30 minutes after call cardiologist, within 30 minutes after request request Click here for Ancillary imaging: Interpretation 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 Ancillary Imaging: Interpretation The The main main findings findings consisted consisted of: of:

diffused diffused LV LV hypokinesia, hypokinesia, less less at at the the posterior posterior wall wall LVEF LVEF 40% 40% dilated dilated LV LV ascending ascending aorta aorta dilatation dilatation no no specific specific wall wall motion motion abnormalities abnormalities were were noted noted beyond diffuse hypokinesia beyond diffuse hypokinesia LV=left ventricle; LVEF=left ventricle ejection fraction 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 Revised Clinical Impression and Differential Diagnoses H REVISED DIAGNOSIS AND CARE PLAN Author:

Ekaterini Lambrinou RN, BSc, MSc, PhD, NFESC Disposition Decision 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 Revised Clinical Impression and Differential Diagnoses The The initial initial diagnosis diagnosis remained remained ACPE ACPE as as a a clinical clinical entity characterizing AHF, which may be: entity characterizing AHF, which may be: the the first first presentation presentation of of HF HF (de (de novo novo AHF) AHF) caused by caused by an an abnormality abnormality of of cardiac cardiac function function such

such as Acute Coronary Syndrome (ACS) or Hypertensive as Acute Coronary Syndrome (ACS) or Hypertensive Crisis Crisis or or an an acute acute valve valve problem problem mildly elevated troponin mildly elevated troponin concerning. concerning. Needs Needs to to be be 1 1 repeated along with repeat ECG repeated along with repeat ECG 1. McMurray et al. European Heart Journal 2012;33: 178747 ACPE=acute cardiogenic pulmonary edema; ACS=acute coronary syndrome; AHF=acute heart failure; ECG=electrocardiogram; HF=heart failure 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 Revised Plan of Care Decision for NIPPV In In the the absence absence of of any any contra-indications, contra-indications, NIPPV NIPPV was

was prescribed for this patient, according to the criteria prescribed for this patient, according to the criteria of of the the Local Local Evidence Evidence Based Based Nurse-led Nurse-led Protocol Protocol for for NIPPV NIPPV Implication Implication for for patients patients with with ACPE ACPE patients patients these these criteria criteria include include age age 18 18 years, years, symptom symptom of of dyspnea dyspnea of of sudden sudden onset, onset, tachypnea tachypnea 20/min, 20/min, hypoxemia manifesting with a ventilation hypoxemia manifesting with a ventilation ratio* ratio* <300 mmHg, and radiological findings compatible <300 mmHg, and radiological findings compatible with with ACPE ACPE More *The ventilation ratio is the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PO 2/FiO2) ACPE=acute cardiogenic pulmonary edema; NIPPV=non-invasive positive pressure ventilation 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 Decision for NIPPV (Contd) In In the the presence presence of of the the intensivist intensivist on on call, call, an an interdisciplinary management plan was determined interdisciplinary management plan was determined in in case case of of NIPPV NIPPV therapy therapy failure, failure, according according to to the the predefined predefined protocols protocols criteria criteria for for the the need need of of ETI ETI The The IBW IBW of of the the patient patient was was estimated estimated on on 80 80 kg kg More ETI=endotracheal intubation; IBW=ideal body weight; NIPPV=non-invasive positive pressure ventilation 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 NIPPV initiation The The BiPAP BiPAP device device was was initially initially adjusted adjusted on on IPAP 15 cmH O, EPAP: 7 cmH O, and FiO IPAP 15 cmH22O, EPAP: 7 cmH22O, and FiO22 1.0 1.0 Respectively, Respectively, while while initiating initiating NIPPV, NIPPV, an an administration of an additional intravenous administration of an additional intravenous dose dose of of 2 2 mg of morphine sulphate and a reduction in mg of morphine sulphate and a reduction in isosorbide

isosorbide dinitrate dinitrate in in 2 2 mg/hour mg/hour (started (started with with 4 4 mg/hour) mg/hour) was was performed performed According to goals According to the the predefined predefined goals the initial initial REVISED DIAGNOSIS ANDthe IPAP/EPAP 18/7 IPAP/EPAP adjusted adjusted to 18/7 cmH cmH22O O CARE to PLAN Patient Patient ventilator ventilator synchrony synchrony and and patients patients comfort: comfort: excellent excellent More ETI=endotracheal intubation; EPAP= expiratory positive airway pressure; IBW=ideal body weight; IPAP=inspiratory positive airway pressure; NIPPV=non-invasive positive pressure ventilation 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

NIPPV initiation (contd) The The patient patient should should be be continuously continuously assessed! assessed! Careful attention to clinical signs and Careful attention to clinical signs and symptoms, symptoms, continuous continuous telemetry telemetry monitoring monitoring including including oxygen oxygen saturation saturation should should be be closely closely monitored. monitored. Comfort Comfort and and continued improvement with NIPPV is important to continued improvement with NIPPV is important to monitor monitor More NIPPV=non-invasive positive pressure ventilation 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 Response to NIPPV

Since Since the the patient patient featured featured optimal optimal response response to to the the targeted therapy, one hour after the NIPPV targeted therapy, one hour after the NIPPV implementation implementation and and along along with with the the absence absence of of admission admission symptoms symptoms and and the the regained regained normal normal vital vital signs, respectively, efforts of titration for weaning signs, respectively, efforts of titration for weaning from from the the ventilator ventilator were were commenced commenced NIPPV=non-invasive positive pressure ventilation 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 H

DISPOSITION DECISION NIPPV weaning and removal Two Two hours hours post post initial initial implementation: implementation: Improvement Improvement in in ABGs ABGs (pH (pH 7.36, 7.36, PCO PCO22 40 40 mmHg, mmHg, PaO PaO22 28 mmol/L) and RR 205 mmHg, HCO 205 mmHg, HCO33 28 mmol/L) and RR Urinary Urinary output output 600 600 mL mL in in 2 2 hours, hours, along along with with the the absence absence of of increased increased cardiorespiratory cardiorespiratory workload workload Patient Patient weaned weaned from from BiPAP BiPAP Admitted to CCU Admitted to CCU Repeat Repeat TnT, TnT, elevated elevated at at 1 1 ng/mL ng/mL further further ACS ACS management was continued with a loading management was continued with a loading dose dose of of ASA 300 mg p.o.,

Clopidogrel 300 mg p.o., enoxaparin ASA 300 mg p.o., Clopidogrel 300 mg p.o., enoxaparin sodium sodium 80 80 mg mg s.c. s.c. and and lovastatin lovastatin 20 20 mg mg p.o. p.o. More More comprehensive comprehensive nursing nursing history history revealed revealed important new insights. The patient complained important new insights. The patient complained of of mild mild shortness of breath and slight limitation of his ordinary shortness of breath and slight limitation of his ordinary daily daily activity, activity, during during the the last last 2 2 months months as as well well as as slowly slowly progressing lower extremity edema progressing lower extremity edema ABG=arterial blood gas; ACS=acute coronary syndrome; ASA=acetylsalicylic acid; CCU=Coronary Care Unit; NIPPV=non-invasive positive pressure ventilation; p.o.=by mouth; RR=respiration rate; s.c.=subcutaneous; TnT=troponin T 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 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 Teaching Points Nurses Nurses have have to to be be familiar familiar with: with: indications indications for for NIV NIV monitoring monitoring of of patients patients with with NIV NIV available available protocols protocols regarding regarding NIV NIV NIV=non-invasive ventilation

Disposition Decision 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 Discussion and Conclusions Nurses Nurses are are the the health health professionals professionals central central to to the continuity of care. Careful evidence-based the continuity of care. Careful evidence-based protocols protocols for for nursing-led nursing-led NIPPV NIPPV implementation implementation and and maintenance maintenance is is important important Such Such protocols protocols must must be be developed developed in in a a way way to to

achieve achieve the the optimal optimal standardization standardization of of care care in in a relatively heterogeneous population. a relatively heterogeneous population. Importantly, Importantly, clear clear communication communication between between the the entire care team is critical entire care team is critical NIPPV=non-invasive positive pressure ventilation Home Case Introduction Case Details and Initial Triage Initial Diagnosis and Care Plan Diagnostic Results Revised Diagnosis and Care Plan Disposition Decision Supplemental 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

Recently Viewed Presentations

  • The Early 20th Century - WordPress.com

    The Early 20th Century - WordPress.com

    Roaring Twenties for 500 Name one event that demonstrated the importance of Christian Fundamentalism in the 1920s. 100 The Scopes "Monkey" Trial in which a teacher was convicted for teaching evolution in Tennessee The rise of radio evangelists (preachers) like...
  • INFRAINGUINAL PAD INTERVENSION JOURNEL REVIEW Presented by :

    INFRAINGUINAL PAD INTERVENSION JOURNEL REVIEW Presented by :

    For patients with chronic ischemia (> 14 days), surgical revascularization was more effective and safer than thrombolysis. Combining a treatment strategy of catheter-directed thrombolysis for acute limb ischemia with surgical revascularization for chronic limb ischemia offers the best overall results.
  • Access to Learning: Language and Academic Skills Support

    Access to Learning: Language and Academic Skills Support

    Access to Learning: Language and Academic Skills Support Available for International Students Gamu Matarira Siegrid Beck Xiangping Du HBS L&T Conference 2013
  • Diapositive 1 - ChezMaya

    Diapositive 1 - ChezMaya

    Ce magnifique texte a été écrit et m'a été offert par Pierrette Beaulieu. Les illustrations m'ont été offertes par ma petite sœur virtuelle Jeanne Turcotte. Je les remercie toutes deux chaleureusement. Musique : A.Rieu, fleurs de printemps. Jacky Questel, Bidos...
  • South Yorkshire Netball

    South Yorkshire Netball

    4th court added to the league - Sheffield Concord Sports Centre . Umpire Mentoring Programme. Shorter league to allow for Summer Competition to take place between May and July. Umpire Expenses - paid by teams on the evening. ... South...
  • TSX-V: CAD Colonial Coal International Corporation Western Canadas

    TSX-V: CAD Colonial Coal International Corporation Western Canadas

    The scientific and technical information relating to the Huguenot property has been derived from the Huguenot Technical Report dated September 23, 2013, a copy of which will be filed on sedar.com under Colonial Coal International Corp., copies of the technical...
  • LED - Why Such Interest?

    LED - Why Such Interest?

    OT 75 E -+ - DALI Colormix ... Available in white and other LED colors Plug and Play System with feeder an connector Easy assembly with brackets Modular system with highly integrated: 1. ... Arial Times New Roman Wingdings The...
  • Social Media and Emergency Management - FEMA

    Social Media and Emergency Management - FEMA

    Social Media and Emergency Management. The Year in Review 2011-2012: Lessons Learned, New Processes and Future Trends