Nurses: Try these tips for CHF management
Congestive heart failure (CHF) patients can become fluid overloaded, quickly decompensate, and arrive in the ED in respiratory distress, notes June Howland-Gradman, RN, MS, clinical director of cardiac services at the University of Chicago Hospital.
"The ED nurse needs to be prepared to handle a cardio/pulmonary emergency," she emphasizes. Here are some things to consider when managing CHF patients:
• Use pulse oximetry.
Pulse oximetry has become standard of care over the last few years. "Pulse oximetry has become the fifth vital sign, especially in someone having difficulty breathing," says David Wilcox, MD, FACEP, medical director for ConnectiCare, an HMO in Farmington, CT, and associate professor of emergency medicine at University of Massachusetts Medical School in Worcester.
EKGs are a snapshot in time, but when a patient is monitored, you can detect how things change over time, Wilcox notes. "This is the same thing we are now doing with pulse oximetry and oxygenation," he says. "If the patient is getting worse, we want to know that so we can step up their therapy."
• Sort out CHF from other conditions.
Other types of respiratory problems can be tricky and confusing to sort out from CHF, such as asthmatic attacks or chronic obstructive pulmonary disease (COPD), Wilcox says. "The symptoms may be the same, but in CHF, the source of the respiratory problem is the heart, not the lungs," he notes.
Asthmatics have characteristic wheezing in the chest, but some CHF patients also do, says Wilcox. "Just as CHF patients get fluid in their lungs, they also get fluid in their body, so the hands and feet are often swollen," he explains. "That is a tip-off you’re dealing with a CHF patient, not an asthmatic."
CHF usually comes on gradually, not suddenly. "Patients may feel fatigued and short of breath, and now the symptoms are getting worse," says Wilcox. "If it’s the first episode, the patient may not know what’s going on. They won’t pick up on the fact that their hands and feet are swollen. They will probably think they’re getting a cold."
Also, because the patient has strain on the heart and not pumping fluid forward as much as should be, their neck veins start to stand out very prominently, because they get distended with extra fluid, Wilcox notes.
• Don’t overlook related conditions.
Sometimes there is more than one condition going on. For example, an elderly diabetic patient might be getting short of breath and have pneumonia, but that stress has brought on CHF, says Wilcox. "Or the patient may be a smoker who has COPD, so they have a lung problem," he says. "But smoking also affects the heart, so the two problems are exacerbating each other, and the patient is now in CHF."
You need to find out why the CHF occurred, and not just treat the exacerbation, cautions Wilcox. "This is especially true if they have had CHF for a while, but now this is worse," he says. "You need to figure out what has kicked this off." The source could be heat or humidity, a dietary indiscretion, or an infection, Wilcox says.
Treat the underlying problem to get rid of the exacerbation, Wilcox stresses. For example, the pneumonia patent will also need antibiotics, he says. "If we just treated the CHF but didn’t get a chest X-ray or notice the fever, the pneumonia is still there," Wilcox says. "If it’s not treated, we don’t take that stress off the heart, so the patient will stay in CHF."
• Find out what medications the patient is taking.
The majority of CHF patients have been through this situation before and are currently being treated, says Wilcox. "Sometimes the patient is so short of breath that they can’t actually give you any information," he says.
In that scenario, you may be the last person to see the family or paramedics. "So it’s important to get whatever information you can, such as medications they are on or details of the history," Wilcox advises.
Have they had heart attacks in the past? Or associated medical problems such as diabetes? "The few moments it takes you will speed the process of working the patient up," Wilcox says.
Those details can help narrow the diagnosis down to CHF. The eventual diagnosis is primarily based on the patient history, Wilcox stresses. "You may find an inhaler labeled albuterol, so you know the patients has a history of asthma, or you may find out that the patient has had three heart attacks," he says.
• When patients are exacerbated, never stop any medications they are on.
"If you are not familiar with the medication, you may be tempted to tell the patient to stop taking it and follow up with a physician, but that is a mistake," says Howland-Gradman.
It’s a long, tedious process to initiate and increase dosages of titrate beta blockers, Howland-Gradman explains. "Instead of stopping anything, go ahead and treat the exacerbation as appropriate, and adjust oral diuretics, if necessary. Do not stop beta blockers without discussing with the cardiologist," she recommends.
• Ask about changes in medications.
If patients have started new medications or increased dosages, this can give you clues to the severity of the condition, notes Wilcox. "Maybe the patient has been on a long downward spiral and the doctor has been gradually increasing their medications, which would indicate a worsening of the process," he says. "Or if they have changed a different medication, they could be having a bad reaction, causing the problem to get worse."
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