The Cat Story : Building the Cardiac Patient Relationship from Admission to Rehabilitation

Transcription

1 The Cat Story : Building the Cardiac Patient Relationship from Admission to Rehabilitation Nina Swan, MSN, RN, CMSRN, CNL 2015 Cardiovascular Forum Statesville Civic Center April 29, 2015

2 Disclosure: I have no commercial interests. I have best patient care interests. I believe we can all put efforts into providing the best care.

3 Objectives: Understand topics to motivate cardiac patients to better care during acute stay and as an outpatient Recognize symptoms to avoid failure to rescue events Explain and encourage the importance of cardiac rehabilitation #1- Build great relationships with cardiac patients and families

4 How would you describe your cardiac patients and families??? Repetitive Unable to follow medical advice Knowledge deficits Scared/worried Infallible (it can t happen to me ) Depressed

5 What are cardiac patients and families so afraid of? Dying Burdening their family (cardiac cripple) Cost of medications Quality of life

6 The Cost of Heart Disease and Stroke More than 1 of 3 (83 million) U.S. adults currently lives with one or more types of cardiovascular disease. An estimated 935,000 heart attacks and 795,000 strokes occur each year. Nearly 68 million adults have high blood pressure, and about half do not have this condition under control. =$444 billion

7 Coronary Heart Disease $108.9 billion Hypertensive Disease $93.5 billion Stroke Heart Failure $53.9 billion $34.4 billion

8 What do patients really want? Respectful and organized treatment Tests and procedures performed on time/ delays explained One doctor in charge Understandable answers from physicians and nurses Discussion of their fears and what could go wrong Explanation of how they return to their life

9 Get them up and moving Decreases the workload of the heart Decreases edema Maintains muscle mass and strength Decreases risk of a blood clots Improves affect and independence

10 Motivation of Cardiac Patients and Families Caring = build the relationships Honesty give them facts Listen to their fears and encourage them to conquer them Ask about their history: work, family, what do they do day to day when not inside the hospital Find the cat story

11 Cardiac Complications and Failure to Rescue Signs of deterioration develop 6-8 hours before cardiac arrest As many as 17% cardiac arrests occur on patients in the wrong setting 60% of cardiac arrests could have potentially been avoided with patients in the correct setting

12 Scenario # on cardiac telemetry 30 y.o. pt. recovering from n/v= flu-like symptoms NSR on the monitor IV of 150 ml/hr Labs: Na 135, K 3.2, BUN 27, Creat. 1.4, FBS 100 Up to the bathroom w/o assist Steady gait

13 Day 2 Ambulating in hallway Occasional PVCs Seen by hospitalist and cardiologist Plan to discharge later that day All of a sudden. What happened? What did we miss???

14 Hypokalemia K+ = 3.2 and was never corrected in an already compromised system trying to recover from the flu IV KCl 40 meq given Does he need any further workup?

15 Scenario #2 A 39-year-old African American female (AAF) with past medical history (PMH) of diabetes mellitus type 1 (DM1) was admitted to the hospital with an infected right diabetic foot ulcer. She needed intravenous access (IV) access for Unasyn and laboratory work, and failed several peripheral line (X8) attempts.

16 A right internal jugular (IJ) central line was placed. Immediately after the catheter was placed, she complained of shortness of breath (SOB) and palpitations. Her oxygen saturation (SpO2) was 100% on room air, and breath sounds were equal and clear bilaterally.

17 What happened? Is it a pneumothorax? A stat CXR and EKG ordered CXR = clear, EKG shows Atrial fibrillation with RVR What do we do? What did we miss???

18 Procedural A repeat CXR showed that the triple lumen catheter (TLC) was at the level of the right atrioventricular (AV) junction (not reported in the initial CXR results because the order was for SOB not line placement). The TLC was withdrawn 5 cm. The conversion to normal sinus rhythm followed immediately and there were no further issues.

19 Scenario #3 A 96-year-old African American female was admitted from a nursing home with c/o abdominal pain, nausea and vomiting (N/V), dizziness, confusion and double vision for 5 days. She was discharged from the hospital just 4 days ago. Clear S1 and S2, irregularly irregular rhythm, HR 101 bpm

20 PMH: hypertension, atrial fibrillation, coronary artery disease, stroke, congestive heart failure Medications: Metoprolol, digoxin, ASA, lisinopril, furosemide, Coumadin, esomeprazole Started on IV Diltiazem and HR down to the high 90s, appears comfortable

21 Pt. states that she is not seeing well RN checks pupil response equally reactive RN completes a full neuro assessment Pt. gets up to bathroom and falls stating she was dizzy What happened? What did we miss???

22 Digoxin Toxicity Abdominal pain with n/v Dizziness Visual disturbance Digoxin held X2 days and dose lowered Repeat digoxin level in seven days

23 Scenario #4 An 81-year-old African American female with a PMH: HTN, DM, CAD S/P MI X5 yrs ago, & chronic abdominal pain for 2 years without a clear reason admitted to the hospital with a worsening of the same abdominal pain for 2-3 days. Vs: /100

24 Abdomen: RLQ tenderness, no rebound, soft, +BS X4. The rest of the examination was not remarkable. CBCD, CMP, Amylase, Lipase, UA = all normal, KUB was nonspecific, CT of abdomen showed a dilated stomach, stable 3.6 cm AAA (the same size as 2 yrs ago) and old renal cysts

25 BCs X2 drawn Started on IV of 100 ml/hr, Zosyn, and pain meds prn ECG ordered showed evidence of old MI by deep Q waves in the inferior leads Resting comfortably after pain meds What happened? What did we miss???

26 NSTEMI Awoke with more n/v and worsening abd. pain two hours after pain meds given Stat troponin ordered = 2.32 Cardiac catheterization showed 99% occlusion of one of the branches of the circumflex artery and 90% occlusion of the right coronary artery stents X3 placed and pt. discharged on day 3

27 Scenario #5 A 67 y.o. male admitted with chest pain, SOB, acute renal insufficiency Labs: WBC- 17.6, Hgb- 8.1, Bun- 32, Cr- 2.94, K+- 5.6, Troponin- 0.82, Glucose- 348 Stat dialysis ordered and pt. is extremely upset but understands necessity

28 IV antibiotics started, troponin # Insulin drip started for repeat glucoses in the range Consults to nutrition, social work, chaplain VTE prophylaxis ordered

29 Day 2 Pt. begins to have positive stools GI consulted & EGD/colonoscopy completed showed duodenal ulcer with large amount of irritated/inflamed tissues, scant time of scope Vs: /54

30 Day # 3 Respirations elevate to 32/min., using accessory muscles Stat CXR = LLL infiltrate IV antibiotics changed Intubated

31 Day #10 Recovered from acute renal failure, GI bleed, post extubation on day #7, transfer to floor on day #8 All physicians signed off and stating pt. is ready for discharge What happened? What did we miss???

32 No Cardiac Workup Pt. had originally ruled in and had so many complications a cardiac workup was overlooked Cardiac catheterization = 95% RCA occlusion and 90% CX occlusion Discharged on day #12 Agreed to cardiac rehabilitation

33 The Importance of Cardiac Rehabilitation Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with UA/NSTEMI, particularly those with multiple modifiable risk factors and those moderate- to high-risk patients in whom supervised or monitored exercise training is warranted

34 Comprehensive long-term program Medical evaluation Prescribed exercise Cardiac risk factor modification Education Counseling

35 Designed to limit the physiological & psychological effects of cardiac illness Reduce the risk for sudden death or reinfarction Control cardiac symptoms Stabilize or reverse the atherosclerotic process Enhance the psychosocial & vocational status of selected patients

36 Existing community studies reveal that < 1/3 of patients with MI receive information or counseling about cardiac rehabilitation before being discharged from the hospital Physician referral was the most powerful predictor of patient participation in a cardiac rehabilitation program

37 Reasons Patients May Not Attend Cardiac Rehabilitation Affordability of service Insurance coverage/noncoverage Social support from a spouse or other caregiver Gender-specific attitudes Patient-specific internal factors such as anxiety or poor motivation Logistical & financial constraints

38 What Can We Do As A Team? Make the process easy = 100% referral rate Get commitment once the MI has been diagnosed & get the family members commitment See it as a team effort

39 Wrap Up Build relationships- that s our job & why we love what we do Look for more causes than what s in front of you, go over every symptom and don t beat yourself or the team up when things are missed = human Instruct, encourage, and get commitment from patients and families to attend cardiac rehabilitation

40 Nina Swan, MSN, RN, CMSRN, CNL Director of Critical Care and Two North Telemetry Iredell Memorial Hospital