And Then There is Failure

Heart Failure And Then There is Failure Heart Failure Brenda Phipps BSN Nurse Educator Minneapolis VA Tina Wright MSN Clinical Nurse Leader Minneapolis VA Symptoms SOB, use of accessory muscles Crackles, Edema Weight, I/O Results in inadequate tissue perfusion Fatigue or poor exercise tolerance Perfusion/color, cold extremities Contributing Factors HTN CAD Smoking Diabetes Valvular Disease Arrhythmias SVT, A-fib, SB 1 2 Right Sided *Rest of Body Congestion of peripheral tissues Dependent edema Ascites Anorexia, GI distress Weight loss Right vs. Left Left Sided *Lungs Pulmonary congestion Decreased cardiac output Activity intolerance and decreased tissue perfusion Impaired gas exchange (cyanosis, signs of hypoxia) Orthopnea (pink frothy sputum, paroxysmal nocturnal dyspnea) Compensatory Pathophysiology: Neurohormonal Activation Renin-Angiotensin-Aldosterone System (RAAS) Sympathetic Nervous System Endothelin Ventricular Remodeling 3 4 Neurohormones ANP-Atrial natriuretic peptide BNP- Brain natriuretic peptide Neurohormones BNP Test is used for patients that present to Emergency Room with shortness of breath Helps differentiate between HF and Respiratory (COPD, PNA) Results in 15 minutes BNP< 100 pg/ml, not heart failure BNP 100 250 pg/ml. probably heart failure, compensated BNP > 500 decompensated heart failure BNP > 1000, only due to heart failure 5 6 1

What is Tele Telling You? C/O SOB sats 89% RR 26 HR 70s with PVC B/P 92/ 70 CVP 14 PVC from hypoxia and ventricular remodeling Ultra filtration 7 8 Indication >8 Hours ultrafiltration treatment of patients with fluid overload who failed diuretics therapy and require hospitalization Fluid overload Excessive fluid Na and water = wt. gain Peripheral Edema Ascites (abdomen) Anasarca ( generalized ) Pleural effusion ( lungs) Causes Excessive fluid and sodium intake due to: Disease Heart failure Nephrotic syndrome Liver cirrhosis IV administration during surgical operations Afib ablations Valve repair or replacement Cardio or thoracic procedures 9 10 Treatments: Ultrafiltration Therapy to remove excess salt and water from patients with fluid overload. Adjunct to diuretics or when diuretics fail to work effectively. (Hold diuretics during the procedure.) Removes isotonic fluid therefore removes more sodium than diuretics. Left sided failure 250 cc/hr for 24 hours Right sided failure 100 cc/hr 11 Ultrafiltration What s Needed? Transportable console with simple operator interface Disposable single-use extracorporeal blood circuit Venous access that can provide 10 40 ml/min of blood Needs two venous access devices 12 2

BREAK Standup Do the Hokey Pokey Brenda Phipps BSN, Nurse Educator Tina Wright MSN, Clinical Nurse Leader Minneapolis VA health care system 13 14 Elements of a brief respiratory assessment Elements of a brief respiratory assessment Level of Consciousness Respiratory rate / pattern Alert, Oriented, Cooperative Normal, relaxed Follows commands Intermittent distress Disoriented Dyspnea on exertion, Obtunded, uncooperative irregular, dysynchronous comatose RR>30 bpm SOB at rest, use of accessory muscles, no spontaneous RR 15 (continued) Lung sounds / Breath sounds Clear and equal Decreased throughout Decreased bilaterally, crackles Wheezing, absent breath sounds Rhonchi Assessment of Cough: Is cough weak? Is cough loose? Is patient able to cough up sputum? Secretion Clearance / Cough Effective non-productive cough. Suction: scant thin secretions Effective cough with production. Suction: mod. Amounts Weak, Congested. Suction: Frequent and large amount. Unable to cough, requires suction. Suction: copious secretions of plugs. 16 Secretions Dehydrated Thick Tenacious Over hydrated Thin Frothy Clear or white Normal secretions Yellow green, or tan: Infection Pink: pulmonary edema Black: smoking, cancer Blood: Bleeding What are the Signs of Respiratory Failure? 18 17 3

Respiratory Failure Respiratory Failure Signs of Poor Oxygenation Tachycardia Decreased sats Decreased PaO 2 Increased work of breathing Increased B/P Anxiety Cyanosis Signs of Poor Ventilation Increased PCO 2 Decreased ph Respiratory acidosis Lethargy Shallow respiratory pattern 19 Treatment of Poor Oxygenation Increase FiO 2 BiPAP FiO 2 PEEP/ CPAP Treatment of Poor Ventilation BiPAP and ventilatory support Minute volume = RR x TV EPAP IPAP 20 Normal ABGs ABG Respiratory Failure Assessment ph PCO 2 PaO 2 HCO 3 SaO 2 7.35 7.45 35 45 80 100 22 26 95 100 21 Oxygenation PO 2 Decreased SaO 2 Decreased Ventilation ph Decreased PCO 2 Increased 22 ABG Compensatory Mechanisms The body will try to compensate to get back to JUST normal PCO 2 quick to change HCO 3 is slow to change If HCO 3 is 28 32, can assume the PCO 2 has been high for long time (e.g., pt with COPD who is a CO 2 retainer) 24 Try to match support settings so you don t over correct 23 4

Is it an oxygenation or a ventilation problem? 25 ABG Interpretation 7.39 41 92 22 98 7.42 40 54 23 85 7.26 68 88 23 94 7.31 54 58 22 88 7.30 31 116 15 98 Normal Oxygenation Ventilation Oxygenation & ventilation Neither: metabolic with compensation 26 Physiologic Goals of Mechanical Ventilation: Bi PAP Improves gas exchange EPAP Increase lung volumes IPAP Reduce the work of breathing Rest Support the cardiovascular system Oxygen delivery How does Bipap help to improve the respiratory status? Improve oxygen Increase FiO 2 E PAP (PEEP) = positive end expiratory pressure Improve ventilation Increasing respiratory rate Increasing tidal volume or IPAP Minute volume = RR x TV 28 27 Positive End Expiratory Pressure (PEEP) EPAP Increases surface area decreasing risk of atelectasis 29 ABG Interpretation 7.39 41 92 22 98 7.42 40 54 23 85 Normal Oxygenation FiO 2 or EPAP 30 Increases PaO2 Improves alveolar expansion 7.26 68 88 23 94 7.31 54 58 22 88 Ventilation MV Oxygenation and ventilation FiO 2 /EPAP Increase MV 5

Indications for Mechanical Support Hypoventilation with respiratory acidosis Acute ventilatory failure Impending respiratory failure Severe oxygenation problems Pulmonary edema Hypoxemia RR Increased / Decreased Irregular breathing pattern Retractions of intercostal muscles / use of accessory muscles HR Decreased / Increased BP Decreased / Increased Acute chest pain Acute change in mental status 31 Administration of Aerosolized Medication Albuterol Beta-2 adrenergic agent that dilates small airways Atrovent Anticholinergic synergistic effect with Albuterol Combivent Albuterol + Atrovent, combination effect Aerobid Steroid which reduces airway inflammation 32 Alarms Interventions An Emergency is NO Time to Panic Best back-up ventilator trained clinician with a resuscitation bag Mask must be with the ambu 34 Cardiac Arrest Immediate intervention Multiple roles Role expectation Key Roles Code Chief/Team Leader Assess team responsibilities and data, direct treatment, set priorities, triage Bedside Nurse/Rapid Response Nurse Check pulses obtain vital signs, place defibrillator pads, place pulse oximeter, places IV, assess patient IVs, push medication, blood glucose, CPR Anesthesia/Respiratory Airway access/management 35 36 6

Crash cart Prepares medication, deploy equipment, bag valve mask, back board, defibrillating pads Medication Recorder Support Roles Runner IV Team Gate Keeper/Crowd control Clerk Supervisor 37 38 Staff Anesthesia Open airway equipment assess and assist ventilation, intubate, check pulses Respiratory Therapist Assist airway manager, set up oxygen and suction equipment, suction as needed Aid Bring capillary blood sugar machine and patient chart to bedside, transport lab samples Medical Student Check pulses, perform chest compressions Supervisor Clerk 39 Character Change Post emergency custodian 40 7