Perform these interventions for congestive heart failure

Nurses should use standing orders

Congestive heart failure (CHF) patients often wait too long to seek medical treatment and arrive in the ED in an acutely exacerbated state, says Eileen Swailes, RN, nurse manager of the ED overflow unit at Good Samaritan Hospital Medical Center in West Islip, NY.

"Delayed recognition of acute events results in a more complicated length of stay and increases the chances of mortality," says Swailes. Here are three ways to speed care of CHF patients:

Recognize signs and symptoms.

"To avoid a delay in treatment for this population, it is imperative the ED nurse recognizes the signs and symptoms of CHF," says Swailes. In addition to shortness of breath, CHF patients may present with lower extremity edema, chest pain, cough, exhaustion, irregular heartbeats, or palpitations, she says.

Have the same index of suspicion for CHF whether the patient arrives via triage or ambulance, says Jennifer Zanotti, MS, RN, CEN, CCRN, ED clinical nurse specialist at Ronald Reagan University of California Los Angeles (UCLA) Medical Center. Zanotti says to look for dyspnea, orthopnea, fatigue, abdominal discomfort secondary to ascites or hepatomegaly, edema that is dependent, jugular venous distention, bilateral crackles, and S3 heart sound. "Recognize the patient populations at risk, then work to discover the primary precipitating event for heart failure," she says.

While your patient's CHF might be chronic and a symptom of underlying heart damage, it also might be a result of problems from a valve, acute coronary syndromes, hypertension, fever, acute respiratory distress syndrome, or certain medications, says Zanotti.

Use standing orders.

Madonna Scatena, RN, MSN, advanced practice nurse for the ED at Advocate Christ Medical Center in Oak Lawn, IL, says, "Standing orders are very useful in the ED setting, so the patient can be rapidly assessed and treated." If ED nurses at Advocate Christ suspect CHF, the patient is placed on a cardiac monitor, oxygen, and an intravenous (IV) site is started.

"Care should not be delayed in triage by taking a long medical history and documenting an extensive list of medications. This can be done at a later time," she says. "The CHF patient should be brought directly to the treatment room where care can be instituted without delay."

Ronald Reagan — UCLA's ED is working on a process for early identification of CHF, says Johanna Bruner, MS, RN, FNP, director of cardiology services. "Early recognition translates to earlier intervention and better patient outcomes," she says. "The ultimate long-term goal is to shorten length of stay and prevent readmission."

The triage nurse gives the patient an EKG within 10 minutes, followed by a chest X-ray. "Then, they grab the attention of the ED physician or a nurse practitioner, to get the proper medications started quickly," says Bruner. "The quicker you begin treatment, the sooner the load on the heart is reduced."

Consider the patient's baseline.

Zanotti says, "Patients with heart failure may also have other medical issues which can cloud recognition initially. "History is important. Is this an acute or chronic problem?"

If the problem is chronic, she says to "get a feeling of where the patient is vs. their baseline. Have the patient rate their shortness of breath or dyspnea to gauge where they are, based on their personal best. This also helps to know if interventions are working for the patient's symptom control." (See related stories on immediate interventions for CHF, subtle signs of CHF, and use of nitroglycerine, below.)

Sources

For more information on care of congestive heart failure patients in the ED, contact:

  • Johanna Bruner, MS, RN, FNP, Director, Cardiology Services, Ronald Reagan University of California Los Angeles Medical Center. Phone: (310) 794-7740. E-mail: JBruner@mednet.ucla.edu.
  • Caroline Lynn, BSN, RN, FNE, SANE, Shift Coordinator, Emergency Department, Clarian West Medical Center, Avon, IN. Phone: (317) 217-2789. E-mail: clynn@clarian.org.
  • Madonna Scatena, RN, MSN, Emergency Department, Advocate Christ Medical Center, Oak Lawn, IL. E-mail: Madonna.Scatena@advocatehealth.com.
  • Eileen Swailes, RN, Nurse Manager, Emergency Department, Good Samaritan Hospital Medical Center, West Islip, NY. Phone: (631) 376-3418. Fax: (631) 376-3411. E-mail: eileen.swailes@chsli.org.
  • Jennifer Zanotti, MS, RN, CEN, CCRN, Clinical Nurse Specialist, Emergency Department, Ronald Reagan University of California Los Angeles Medical Center. Phone: (310) 267-8482. E-mail: JZanotti@mednet.ucla.edu.

Must-do interventions for your next CHF patient

Cyanotic and unable to speak, unaware of her surroundings, barely responsive, with severe difficulty breathing. That was the condition of a 76-year-old female brought to the ED at Good Samaritan Hospital Medical Center in West Islip, NY.

"On arrival, physical inspection revealed bilateral pitting and peripheral edema to her lower extremities that had progressed to her groin," says Eileen Swailes, RN, nurse manager of the ED overflow unit. "Her pulse oximetry on room air was 82%." These steps were taken:

  • Oxygen was administered via 100% nonrebreather.
  • After the arterial blood gas results, the patient was placed on continuous positive airway pressure (C-PAP). "Her color began to improve immediately," says Swailes. "Intubation was considered, but it was decided to give the interventions a few minutes to take effect."
  • Two large-bore intravenous (IV) lines were placed, and baseline blood work was drawn, including a brain natriuretic peptide level.
  • Furosemide 100 mg was administered intravenously, and nitroprusside was hung at 10mcg/kg/min and titrated to blood pressure.
  • A EKG and stat portable chest X-ray were done, which showed bilateral infiltrates.
  • Auscultation of lung fields revealed bilateral lower lung field diminished breath sounds.
  • The patient was monitored closely as the nitroprusside was titrated every few minutes. "As the blood pressure came down slowly, the [furosemide] began to take effect," says Swailes. "Over the course of an hour, her mental status improved. She was able to identify that she was in a hospital, but could not recall what had happened to her."
  • The woman's respiratory status continued to improve. After a second arterial blood gas, she was removed from the C-PAP and placed on a venti-mask.

"The patient was admitted and continued to improve, although over the course of the next few days she became anemic and required a blood transfusion," says Swailes. "The family and patient agreed that the patient was noncompliant in managing her chronic CHF and that the lack of family support would increase the likelihood of this event occurring again. She was discharged to a nursing home and continues to do well there."

Immediate interventions

Obtaining a room air pulse oximetry, administering supplemental oxygen as needed, obtaining IV access to offload the fluid overload, obtaining baseline lab work, and administering diuretics. These things should all be done immediately for a CHF patient, says Swailes.

"The dose of the diuretic should be a higher dose than the patient is currently taking at home. It should be administered IV," adds Swailes. Here are other steps to take:

  • Call for a stat chest X-ray, arterial blood gas, and EKG. "Morphine can be given for anxiety, especially for those with accompanied high blood pressure," says Swailes.
  • Consider use of vasodilators. "Vasodilators such as [nitroprusside] lower blood pressure quickly and reduce preload and afterload. But these cannot be given to patients with acute CHF accompanied by reduced peripheral vascular resistance," says Swailes.

Patients who also present with high blood pressure should receive vasodilators as well as diuretics. "The irregular heartbeats may be a result of low cardiac output. In this case, inotropic agents would be beneficial," says Swailes.

  • Obtain an actual weight.
  • Place the patient on dietary sodium restrictions.
  • Perform good discharge planning.

"This includes follow-up in the community, as well as a nutrition consult in the ED," says Swailes. "This should be done as soon as the patient is well enough to understand the information."


Suspect CHF even with this vague complaint

A gradual progression of exertional dyspnea might not make you suspect congestive heart failure (CHF) immediately, but don't rule this condition out if your patient presents this way.

A 78-year-old man reported this condition to ED nurses at Clarian West Medical Center in Avon, IN. He added that he had been diagnosed with pneumonia two weeks ago, but was doing well on current treatment. He had no history of chronic obstructive pulmonary disorder (COPD) or CHF.

However, "a prompt nursing assessment was a key component to a quick diagnosis of CHF" for this patient, reports Caroline Lynn, BSN, RN, FNE, SANE, shift coordinator for the ED. ED nurses noted a mild increase in respiratory rate and effort, a pulse oximeter oxygen saturation of 84, scattered crackles to all lung fields per auscultation, and a complaint of generalized weakness. The patient immediately was placed on a cardiac monitor, a bedside EKG was completed, and a chest X-ray was ordered. A complete blood count, basic metabolic panel, troponin, and brain natriuretic peptide were obtained.

"The patient's complaints were vague, and he did not demonstrate any marked peripheral edema," Lynn recalls. "A quick diagnosis was made, due in part to our streamlined algorithm. The patient was admitted and discharged four days later." [The algorithm used by ED nurses is included.]


Clinical Tip

Titrate nitroglycerine more aggressively

Nitroglycerine should be titrated aggressively in your congestive heart failure patient, says Madonna Scatena, RN, MSN, advanced practice nurse for the ED at Advocate Christ Medical Center in Oak Lawn, IL.

"Many ED nurses seem to be reluctant to do this," she says. "The goal is a drop in the mean arterial pressure of 20% from the initial value. This requires frequent monitoring of the blood pressure and heart rate."