Interdisciplinary Care: Heart Failure Patient

Background Information

Summary

P. R. is a 63-year-old Caucasian male with no known allergies, his preferred language is English and there is no family present at bed side. Patient is a full code. P. R. presented on the unit following insertion of a Left Ventricular Assist Device, HeartWare H-VAD which was placed on September 18, 2018 and is currently on the heart transplant list. P. R. was admitted to the hospital with medial diagnoses of nonischemic cardiomyopathy, congestive heart failure, and moderate protein malnutrition. Before the insertion of the H-VAD, P. R. states that over the past few months he has had frequent defibrillator shocks despite taking his medication appropriately, at least once a week. P. R. state he was doing dishes in his kitchen when he felt that his defibrillator would go off so he sat down to receive the shock then was brought into the E. R for further evaluation.

Upon evaluation in the E. R. patient P. R. was advised admission to the hospital for stabilization of his cardiac status. Patient P. R. has a medical history that includes aortic valve disorder, ventricular tachycardia, atrial fibrillation, benign hyperplasia of prostate with urinary obstruction, benign neoplasm of the colon, cardiomyopathy, congestive heart failure, drop foot gait, hypertension, mitral valve disorder, vascular disease with left renal artery aneurysm and thrombosis post stinging. His surgical history includes colonoscopy, multiple cardiac ablations, cardiac defibrillator placement, two pace maker placements, sinus surgery, and vascular surgery with a left renal artery stent. Family history includes maternal arthritis and paternal heart disease and hypertension. Patient P. R. is a former cigarette smoker who quit smoking in January 2017. He has also quit drinking alcohol and smoking marijuana about six months ago.

On physical assessment, patient P. R. is a well-developed gentleman. He has no acute distress but is frequently lethargic. Patient’s vitals are as followed: oral temperature of 97. 9 degrees Fahrenheit, pulse 80 beats per minute, blood pressure 87/69, weights of 88. 7 kilograms, respirations 18 breaths per minute and oxygen saturation 98% on room air. Patient is sitting in bed, calm and cooperative. HEENT: head is normocephalic and atraumatic; eyes PERRLA with pink conjunctivae; throat has moist mucosa; neck is supple with no signs of JVD, no carotid bruits, and no thyroid enlargement. Respiratory: respirations are regular, even and unlabored; scattered basilary rales noted with the left being greater than the right; capillary refill is less than 2. Cadiovascular: S1 normal without palpable pulse and positive LVAD hum or tone; no S2; no edema; no JVD. Gastrointestinal: abdomen softly distended with no tenderness and positive bowel sounds in all four quadrants.

Genitourinary: continent with clear yellow urine. Skin: no rashes, no petechiae, multiple well-healed incisions on chest; VAD exit site with no redness or drainage; extremities warm to touch with 1+ pulses felt in all 4 extremities. Neurological: oriented x3; normal strength with positive tremors. Telemetry monitor shows ventricular paced, atrial fibrillation, and occasional premature ventricular contractions. VAD parameters: Flow- 4. 5 Speed- 2600 PI-6. 4/3/2 and Power-3. 0Laboratory and Diagnostic Tests Lab Normal Range Result Rationale Sodium 131 mg/dL 135-145 mg/dL Low but stable due to heart failure, which impairs the ability to excrete water, which will decrease the amount of available sodium as well as from the use of the loop-diuretic (furosemide) which inhibits the reabsorption of sodium. Chloride 94 mmol/L 95-105 mmol/L Low because of the loop-diuretic (furosemide), which inhibits the reabsorption of chloride. Calcium 8. 3 mg/dL 9-11 mg/dL Low due to the loop-diuretic (furosemide), which excretes calcium. Albumin 2. 5 g/dL 3. 5-5 g/dL Low because of the patient’s malnutrition status. AST 32 U/L 8-20 U/L High due to heparin therapy and metoprolol. ALT 48 U/L 8-20 U/L High due to heparin therapy and metoprolol. WBC 11. 88/nL 5,000-10,000/nL High due to post surgery status, which increases which, is natural response right after surgery. If the WBC level continues to elevate then that would be more of a concern. HGB 9. 3 g/dL 12-15 g/dL Low level indicates anemia possibly due to post surgery status and the medication quinidine. HCT 29% 36-45% Low level indicated anemia possibly due to post surgery status and the medication quinidine. INR 19. 8 seconds 10-14 seconds High results mean that the patient’s blood is not clotting quickly enough because he is receiving heparin therapy. PTT 73. 8 seconds 60-70 seconds High results mean that the patient’s blood is not clotting quickly enough because he is receiving heparin therapy.

Diagnostic Procedure Result Rationale Electrocardiogram

Ventricular-paced with atrial fibrillation and occasional premature ventricular contractions. Patient is on continuous cardiac monitoring due to his chronic heart conditions and placement of the LVAD Chest X-Ray Improving premature ventricular contractions and left haziness with elevated diaphragm. To view placement of pacemaker, defibrillator, LVAD, and see any abnormalities of the heart, lungs or other internal structures. VAD interrogation No significant alarms noted; Flow= 4. 5 Speed 2600 PI= 6. 4/3. 2 Power= 3. 9; no redness or drainage from VAD exit site; driveline is secure and immobilizer is in use To review the patient’s VAD function. Medications Acetylsalicylic acid (Aspirin) is an antipyretic and nonopioid analgesic used for mild to moderate pain, fever, and prophylaxis of stroke and myocardial infarctions. Adverse effects include tinnitus, dyspepsia, epigastric distress, nausea, gastrointestinal bleeds, and increased bleeding time.

This patient is receiving 325-milligram tablets orally daily to reduce the risk of blood clots due to his atrial fibrillation. Nursing implications include: monitor for gastrointestinal bleeds, ulcers or rashes; assess client for asthma, allergies, and nasal polyps; assess pain and fever. Furosemide (lasix) is a loop diuretic used to treat hypertension or edema related to heart failure, and removes excess fluid from the body. Adverse effects include Stevens-Johnsons syndrome, hypocalcemia, hypochloremia, hypokalemia, hypomagnesmia, hyponatremia, hypovolemia, hypotension, blurred vision, dizziness, and aplastic anemia. This patient is receiving 80-milligrams intravenously twice a day to reduce his blood pressure and edema due to his heart failure. Nursing implications include: asses fluid status monitoring daily weight notifying provider of dry mouth, lethargy and hypotension; monitor electrolytes and renal and hepatic function. Heparin (Hep-Lock) is an anticoagulant used as prophylaxis or treatment for multiple thromboembolic disorders. Adverse effects include drug-induced hepatitis, rash, urticaria, bleeding, anemia, and pain at injection site. This patient is receiving 0-2,000 units titrated infused intravenously to reduce his risk of blood clots from surgery and his atrial fibrillation.

Nursing implications include: assess for signs of bleeding and hemorrhage and notify health care provider; observe injection sites for signs of inflammation, ecchymosis, or hematomas; monitor apt (activated partial thromboplastin time) and hematocrit pre and intra-administration; draw apt 30 minutes before each dose during intravenous therapy; Monitor platelets every 2-3 days during therapy; May increase AST and ALT levels; Give protamine sulfate as antidote. Metoprolol tartrate (Lopressor) is a beta- blocker used as an antianginal and antihypertensive. Adverse effects include fatigue, weakness, erectile dysfunction, and mental status changes. This patient is receiving 12. 5-milligram tablet orally every 12 hours due to his hypertension and heart failure. Nursing implications include: monitor blood pressure, electrocardiogram, and pulse often usually every 5-15 minutes; administer atropine if heart rate is less that 40 beats per minute; monitor input and output as well as daily weights; may increase AST and ALT. Mexiletine (Mexitil) is an antiarrythmic used as prophylaxis and treatment of serious ventricular arrhythmias like ventricular tachycardia and premature ventricular contractions. Adverse effects include dizziness, heartburn, nausea and vomiting, and tremors. This patient is receiving 150-milligram capsules orally every 8 hours to treat his ventricular tachycardia and premature ventricular contractions. Nursing implications include: monitor heart rate, electrocardiogram, and heart sounds; assess for peripheral edema and tremors. Quinidine (Quin-G) is an antiarrhythmic use to treat atrial fibrillation or flutter and prevent ventricular arrhythmias.

Adverse effects include dizziness, anorexia, abdominal cramping, diarrhea, nausea and vomiting, and hemolytic anemia or thrombocytopenia. This patient is receiving 150-milligram capsules orally every 8 hours to treat his atrial fibrillation and ventricular tachycardia. Nursing implications include: monitor heart rate, electrocardiogram, and heart sounds; assess blood pressure and report low blood pressure; assess for dizziness and ataxia. Spironolactone (Aldactone) is a potassium-sparing diuretic used to manage edema due to heart failure and manage hypertension. Adverse effects include hyperkalemia, hyponatremia, agranulocytosis and arrhythmias. This patent is receiving 25-milligram tablets orally daily to manage his heart failure. Nursing implications include: monitor fluid and electrolyte imbalances; assess heart rate, electrocardiogram, and heart sounds; assess blood pressure. Tamsulosin (Flomax) is an antiadrenergic used to manage outflow obstruction due to hyperplasia of the prostate by relaxing muscles making it easier to urinate. Adverse effects include dizziness, headache, and orthostatic hypotension. This patient is receiving 0. 4-milligram capsules orally daily to manage his benign prostatic hyperplasia. Nursing implications include: advise patient to move slowly when sitting upright; increase fluid intake to prevent fluid loss.

Nursing Diagnoses

Nursing Diagnosis: Decreased cardiac output related to decreased cardiac contractility as evidence by increased heart rate, dysrhythmias and EKG changes. Outcomes:

1. Patient displays acceptable vital signs with controlled or absent dysrhythmias.
2. Patient reports no symptoms of heart failure including angina, dyspnea and a stable weight with no edema.
3. Patient does not show any signs of change in mental status and remains oriented to person, place and time accordingly

Interventions:

1. Assess patient’s heart rhythm continuously on monitor to reveal whether dysrhythmias occur or if they increase or change.
2. Administer antidysrhythmics as prescribed to manage dysrhythmias.
3. If serious dysrhythmia occurs, stay with the patient and provide support and reassurance wile providing care to reduce stress which will decrease the dysrhythmias.

Collaborative Interventions:

1. Consult with cardiology and notify them of any EKG changes.
2. Consult with pharmacy to receive all prescribed medications and manage correct dosage and provide any questions you may have regarding medications.
3. Consult with a chaplain if patient or family seems to be having a difficult time coping with the physical and mental health from this medical condition.

Diagnosis: Impaired gas exchange related to inadequate cardiac output and fluid accumulation in the alveoli secondary to heart failure as evidence by rales heard in lower lung field and activity intolerance.

Outcomes:

1. Patient maintains clear lung fields, shows no signs of respiratory distress, and tolerates walk down hallway adequately.
2. Patient’s gas exchange improves as evidence by normal arterial blood gas levels.
3. Patient maintains normal respiratory rate at 12-20 breaths per minute and a pulse oximetry reading of greater than 95%.

Interventions:

1. Assess all lung fields for breath sounds and monitor oximetry and ABG values to monitor patients response to treatment and assess for respiratory distress.
2. Position patient in high Fowler’s position with head of bed up 90 degrees to decrease work or breathing which reduced cardiac workload and promotes gas exchange.
3. Administer diuretics as prescribed to reduce fluid accumulation and blood volume.

Collaborative Interventions:

1. Consult with laboratory to receive arterial blood gas levels promptly.
2. Consult with respiratory therapy if patient requires oxygen therapy.
3. Consult with physical therapy to see how patient is tolerating physical activity.

Diagnosis: Risk for impaired skin integrity related to decreased tissue perfusion as evidence by interrupted blood flow due to decreased cardiac output.

Outcomes:

1. Patient’s skin remains intact and meets nutritional needs.
2. Patient verbalizes and demonstrates techniques to prevent skin breakdown including frequent positional changes and passive range of motion exercises.
3. Patient understands to report any change in sensation or pain and to begin to become more active with physical therapy.

Interventions:

1. Assess patient’s nutritional status because inadequate nutritional intake can place the patient at risk for skin breakdown. Also educate the patient on adequate nutrition and hydration.
2. Check placement of patient and medical equipment every 2 hours because most issues involving the skin in a hospital setting is related to external forces.
3. Encourage use of pillows and foam wedges to prevent pressure injuries while patient is immobile and inactive.

Collaborative Interventions:

1. Consult with nutritionist to institute dietary recommendations or supplements if needed. A high protein and high calorie meal is needed to promote healing.
2. Consult with physical therapy to promote physical activity which will increase circulation and get the patient out of bed which will decrease the risk of impaired skin integrity.
3. Consult with wound care if a skin injury occurs.

Interventions

Routine Nursing Management Patient P. R. was on a Ventricular Assist Device, which required a lot of attention from the nurse. The nurse and I checked on the patient often to make sure that all of the parameters were within normal limits. With the nurse I also reviewed the patient’s EKG on the monitor to make sure that he had no arrhythmias and that his pacemaker was working properly. We also made sure that the patient, who was very lethargic was able to be aroused and get up to eat which he needed to do due to him malnutrition. Another routine nursing task that was needed for this patient was obtaining a blood pressure, which only the nurse was able to do due to his VAD status. Patient’s who have VADs so not typically have pulses because the VAD is continually flowing blood so a blood pressure needs to be obtained using a Doppler and manual blood pressure cuff. Medication administration was also a big task for this patient because of the amount of medications he was on.

The nurse and I had to make sure that all of his correct medications were given at the appropriate time with the right dose. We also have the opportunity to ambulate the patient for the first time after his VAD placement surgery with cardio-physical therapy. The patient was hesitant to get up and move because he has been so tired but we were able to communicate with him and get him to walk down the hallway, and he did a great job.

Collaborative Management

Collaborative care and management in a patient with heart failure is extremely important due to the complexity of the diagnosis. Professionals who provide care for heart failure patients include but are not limited to a primary care provider, cardiologist, heart failure nurse, home care, internist, dietician, pharmacist, social worker, psychologist, and physical therapist (Jaarsma, 2005).

During my time with this particular patient I personally witnessed his care provided by a cardiologist, physical therapist, social worker, pharmacist, nursing assistants, and of course the nurse. Some other interprofessional team members for this member included cardiac surgeons, VAD specialists and most likely other doctors and residence. The roles of these team members were to perform the VAD surgery and manage the VAD if something was complicated. The nurse’s main priority and role in this patient’s case was education related to his diagnosis and care for his LVAD when he is discharged home. When a patient with an LVAD is discharged home, or to a facility, the patient, family and care providers must go through classes to educate them on the LVAD device. The nurse was also responsible for educating the patient on their medications, which was also an important role of the pharmacist. Pharmacists are also responsible for providing advice to physicians on the appropriate dosages and regimen for a particular patient (Jaarsma, 2005).

The nursing assistant’s duties were to help the nurse in any tasks that may be needed to be done like obtaining vital signs or helping the patient with activities of daily living. Social work was involved with this patient’s care to facilitate where the patient will go and be cared for once they are discharged from the hospital. Physical therapy had the patient up, out of bed and ambulating to see how their heart tolerated daily activities. Physical therapists are involved in reconditioning and training heart failure patients to improve their quality of life and can be in a cardiac rehabilitation center, in hospitals, or in the patient’s home (Jaarsma, 2005). Dieticians may also be involved in the care of heart failure patients to evaluate, formulate and educate the patient on the appropriate diet. Healthy body weight is extremely important for these patient’s and being over or underweight are of serious concerns (Jaarsma, 2005). Weight reduction in obese patients is especially hard to manage because their heart is so fragile and they may not be able to tolerate exercise so diets becoming of the upmost importance. Heart failure is a very scary thing so patients and their families may need help in coping with their diagnosis so that is another job of a social worker and psychologist. The use of inter-professional and collaborative care, especially in heart failure patients, has greatly improved patient outcomes including quality of life, decrease in readmissions, and decreased mortality and morbidity.

Therapeutic Modalities

This patient was on a Left Ventricular Assist Device which is a therapeutic modality that is surgically implanted into the patient’s chest to function of the heart and support blood flow. The nurse I was following would check on this patient more than any of her other patient’s to make sure that the Ventricular Assist Device was doing its job. We would go into the room and make sure that there was at least one full battery on the charging port, along with multiple others, and we would check all of the parameters of the VAD.

Ventricular Assist Device functions include pump speed, flow, power, revolutions per minute, and pulsatility index (PI). To assess the patient’s VAD function as well as fluid status, the nurse should monitor the PI, flow, and RPMs extremely closely. If the nurse found that any of these parameters were off she would need to contact the cardiologist and VAD team to come and change the settings or troubleshoot the VAD. Care for patients with VADs is a complex task and quite a bit of training and protocols as involved. Other therapeutic modalities that were used with this patient included his cardiac defibrillator and pacemaker. The nurse only monitored these modalities by viewing the telemetry monitor to make sure they were working properly. We viewed a spike on the electrocardiogram rhythm strip right before the P wave, which indicated that the patient’s pacemaker was ventricular pacing correctly.

Nursing Role Reflection

Through working with the nurse in the critical care setting I have learned even more so that communication is very important in facilitating patient care and easing the patient’s and families anxiety in this stressful time. “Effective communication between health care providers and their patients is increasingly recognized as a critical component of patient rights, patient-centered care, patient engagement, patient safety, positive patient outcomes, patient satisfaction, and value-based care” (Blackstone & Pressman, 2016). Nurses and health care providers must speak to patients and their family in laymen’s terms in order for them to understand fully. Not only do health care providers need to communicate accordingly to the patient but also they must communicate effectively with other health care providers so everyone is on the same page. This is where I noticed a few barriers in providing care to the patients. Words can be lost in translation especially when you are working with a team of health care professionals from multiple disciplines. Communication breakdown unfortunately happens quite too often in the health care setting negatively influencing patient safety, outcomes, and satisfaction.

There is actually communication training that is offered to better aid in diminishing this health care related barrier. SPEACS-2 is a mini, online, self guided course available to nurses that focuses on patient-provider communication in the intensive care setting (Blackstone & Pressman, 2016). I believe this is a great addition to nursing education but also should be available to other health care providers. With this learning communication tools can help to improve communication between interdisciplinary providers, which will in turn improve the communication with the patient, family, and caregivers. Even though my patient had no difficulty communicating verbally, I can see that a lot of patients in a critical care setting may have a hard time communicating to health care providers verbally which can definitely impact their care negatively. A great way to bridge this barrier I found in my research was in Italy where a nurse developed a small expandable card that represented words and pictures to communicate about pain, physical and cognitive needs, and comfort to name a few (Blackstone & Pressman, 2016). I believe this would be a very useful tool because patients who are intubated or cannot verbally express their thoughts or feelings due to a medical condition, still need to be able to express these things to health care provided in order to receive the best care.

Throughout my clinical experiences as a nursing student I have seen and learned of new and better ways to communicate with health care team members, patients, and their families. I have learned to treat each patient as an individual and meet his or her individual needs accordingly. For example with this particular patient, he required more attention than other patients did from the nurse due to his medical condition and medical equipment so the nurse was sure to balance out her schedule appropriately. I will be sure to evaluate the patients that I have each day to see what needs have to be met per each patient and communicate with them on a level that they understand and with everything that I can to my knowledge. I will also use all of my resources available to better my communication skills and nursing skills.