Is your patient short of breath? Don't miss CHF
Appearances can be deceiving
A patient complaining of shortness of breath may "look good," but the history and pulse oximetry reading may tell a different story, warns Angela Westergard, RN, manager of emergency services at Mercy Medical Center in Oshkosh, WI.
"There is also the possibility that an inexperienced nurse could miss subtle cues," she says.
Patients often are able to compensate for their difficulties and don't appear in distress, notes Westergard. "But in reality, the situation can be ominous," she says. For example, a patient who is in status asthmaticus may not have noisy breath sounds because they are moving very little air, but this is a life-threatening situation that needs to be addressed immediately.
If a patient's condition developed over several days, the ED nurse may not take the time to assess for additional symptoms such as cardiac arrhythmias, chest pain, or other more acute problems, says Westergard. When a patient comes in complaining of shortness of breath, immediately think of heart or lung problems, says Nancy Bennett, MSN, RN, educator for the ED at Hospital of Central Connecticut in New Britain. "Our goal is to get the patient into a room ASAP, before they decompensate," she says.
Ask these questions at triage
Ask these questions at triage to determine if the patient is in congestive heart failure (CHF), says Bennett:
- How long have you been short of breath? When did it start, and what were you doing at the time?
- Do you have heart or lung problems? "If the patient states he has COPD [chronic obstructive pulmonary disease], we ask if he has used his inhaler today and, if so, how many times," says Bennett.
- Have you been in the hospital before for this?
- What medications do you take?
- Does the shortness of breath get worse when you do any physical activity? If so, what activity exacerbates it? "Some people have episodes where they're doing fine, but any kind of physical activity makes it harder for them to catch their breath," Bennett explains. "The fluid starts accumulating in the lungs, their air exchange is inefficient, and they become more short of breath."
- Do you have any chest pressure, pain, or palpitations associated with the shortness of breath?
- Have you noticed any swelling of your feet, ankles, or lower legs?
- Have you had to use two or more pillows to sleep at night? "People in CHF usually have a hard time lying flat, so they raise themselves up to sleep," says Bennett.
At triage, nurses take an oxygen saturation level along with other vital signs, says Bennett.
"If the patient states they have COPD, we listen to their lung sounds," says Bennett. "If they state they have asthma and they're severely short of breath, we call our respiratory therapist for a stat breathing treatment if there's going to be some delay in getting them into an ED bed."
Patients are immediately put on a cardiac monitor and supplemental oxygen, either by face mask or nasal cannula, depending on their oxygen saturation level.
Nurses check the patient's lungs, check their fingers for capillary refill and color, obtain an electrocardiogram (EKG), insert an intravenous line, draw labs, and order a stat chest X-ray.
If pneumonia is suspected, blood cultures are drawn and a chest X-ray is obtained. Patients are asked if they're coughing and expectorating sputum and, if so, what color, Bennett says. They're also asked whether they have been running a temperature at home, she says.
First, do a quick "eyeball assessment" of your patient, says Westergard. "What does the patient look like? Is he or she able to speak and answer questions?" she says. "If the answer to these questions is that the patient appears to be in distress, he goes right back to a room for evaluation."
If the patient doesn't appear to be in distress, ask about past medical history, medications taken, what they were doing when the symptoms started, how long they have been short of breath, and whether they have other symptoms such as chest pain or ankle swelling, says Westergard.
If the pulse oximetry is over 90, the patient goes right back to a room, says Westergard. "If the level is over 90 and the ED is busy, the patient has a full set of vitals taken and a more thorough assessment is done at triage," she says. "If the vitals are of concern, the patient goes right back to a room."
Mercy's ED nurses also have standing orders for the following interventions, based on the patient's presentation:
- Obtain a pulse oximetry reading.
- Give two liters of oxygen per nasal cannula if the oxygen saturation level is less than 92%.
- Place a saline lock.
- Obtain a peak flow reading, if the patient is able to.
- Give a single dose of ipratropium bromide per hand-held nebulizer.
- Order a chest X-ray.
"This can save several minutes when the ED physician is busy evaluating other patients and can help prevent the patient from further deteriorating," Westergard says. "The earlier we can get the airway open and working, the better the outcome."
Sources
For more information about patients with shortness of breath, contact:
- Nancy Bennett, MSN, RN, Educator, Emergency Department, Hospital of Central Connecticut, New Britain. Phone: (860) 224-5900, ext. 2664. E-mail: [email protected].
- Angela Westergard, RN, Emergency Services, Mercy Medical Center, Oshkosh, WI. Phone: (920) 223-0567. E-mail: [email protected].
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