Identifying these patients when they hit the ED doors is vital to their treatment. Getting a throrough history can help to determine their treatment and subsequent recovery plan.
- Determine cause of acute exacerbation
- Right or Left Sided failure?
- Determine interventions
- Try to determine cause:
- Acute coronary syndrome
- Uncontrolled hypertension
- Vavular dysfunction
- Cardiac infections
- Noncompliance with diet and medications (that darn chinese food!)
- Right Sided Exacerbation
- Peripheral Edema
- Jugular Venus Distention (JVD)
- Nausea secondary to abdominal venus congestion
- Left Sided Exacerbation (more common)
- Shortness of Breath
- S3 Heart Sound
- Pulmonary Edema
- ABCs are always first priority
- Admin supplemental O2
- IV access
- IV Meds
- Loop diuretic (Lasix)
- Nitroglycerin or Nitroprusside
- Ace Inhibitors
- Continued monitoring
- Lung Sounds
- BP and HR
- Urine output
- Clinical Judgement
- Gas Exchange
- Emphasize importance of tasking prescribed medications
- Review proper dietary restrictions (low sodium!)
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Hello everyone and welcome to today’s lesson on heart failure exacerbations. Specifically what to do when they come into the ED.
Most heart failure exacerbations are due to chronic heart failure. Its rare, not impossible, but rare for a patient to come in in acute heart failure who hasn’t had some signs of it prior. That being said, if these patients present to us, they usually require some quick thinking and immediate interventions.
When we assess these patients, one of the first things we want to try to figure out, is why the exacerbation is occurring. Is it related to comorbidity like acute coronary syndrome where blood supply is being cut off from the coronary circulation? Is it related to uncontrolled hypertension? Are cardiomyopathies preventing the pumping of blood out of the heart to where it needs to go. Are the valves malfunctioning and causing backflow. Is cardiac infection-causing arrhythmias that are altering the pump? Or, and this is one I see most commonly, is the patient noncompliant with their medications or their diet. It is amazing what a little Chinese food can do to grandma’s heart. Do you guys have any idea how much sodium is in that stuff?
Now, from looking at our patient, we can usually determine if this is right sided or left sided heart failure. If you guys want, there are some great lectures all about heart failure on NRSNG.com in the med-surg, cardiac units. If you need some more in-depth info on heart failure, please go check those out.
Now if we see things like swelling in the legs and feet, jugular venous distention, that ascites, you know that swelling in the belly, or nausea, which is caused by the venous congestion in the abdomen, we can think more right sided failure. Left sided failure can be suspected if our patient is having shortness of breath or dyspnea, and when we auscultate the lungs, we will hear those crackles. It’s a little harder to assess that S3 heart sound, but any good ER nurse can pick up crackles like they can pick up a pen off the desk. Those sounds are all related to the fluid that is building up in the lungs.
When we go to treat these patients, remember, it’s the ED, always ABCs. So, to that end, we have to help them breathe. Were going to apply supplemental O2, usually start with a non-rebreather. Get an IV going, and i’ll tell you why in a sec. We might want to use our BiPap machine to push the fluid out of the lungs with that positive pressure ventilation. This is often done before we think if intubating the patient and in fact, can keep us from needing that step. Now…that IV we put in, time to give some medications. We want to open up the vasculature and get rid of the fluid. So…Lasix to bring out the fluid and things like MOrphine and nitro to open up those vessels. The nitro also helps to decrease the preload and afterload and decrease the myocardial oxygen demand. Ace inhibitors can be given to help minimize fluid retention. How do they do that…well think back to nursing school. Do you all remember that renin angiotensin cycle? (I know…everyone just got a little migraine). Well the ACE inhibitors actually interrupt that cycle and help to minimize the fluid retention.
Of course, after performing out interventions, we need to monitor our patients. Check the lung sounds, as we want them to become nice and clear. Keep them on a monitor to watch the blood pressure and heart rate. Keep checking that level of consciousness and of course, if we are giving diuretics, we need to monitor the urine output. Whether this is done with a foley cath or not is up to your facility protocols.
Heart failure directly affects how a patient breathes. We need to watch not only their pulse ox but their capnography if you have it. Remember your ABC’s and remember that breathing is pretty darn important for these patients. It is top of your list of things you wanna fix here.
A few key points. We know ABC’s are always the top of our assessment tree. Check there breathing first and address it. Using Bipap is a great way to avoid intubation. These patients are almost drowning in their own fluids. There is no life preserver but… there are some great medications to help them like our diuretics and our vasodilators. And remember, if you do something, you have to see what that thing does to your patient. Make sure we are monitoring them.
Thank you for joining us for today’s lesson. Please check out our other emergency medicine lessons here on NRSNG and as always, HAPPY NURSING!