“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
Disclosure:
• I have no commercial interests.
• I have best patient care interests.
• I believe we can all put efforts into
providing the best care.
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
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
What are cardiac patients and families
so afraid of?
• Dying
• Burdening their family (cardiac cripple)
• Cost of medications
• Quality of life
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
http://www.cdc.gov/chronicdisease/resources/publications/AAG/dhdsp.htm
Coronary Heart Disease
$108.9 billion
Hypertensive Disease
$93.5 billion
Stroke
$53.9 billion
Heart Failure
$34.4 billion
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
http://jme.bmj.com/content/29/2/103.full.html
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
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…
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
Scenario #1
Admission@ 0220 on cardiac telemetry
• 30 y.o. pt. recovering from n/v= flu-like
symptoms
• NSR on the monitor
• IV of NS @ 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
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???
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?
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.
• 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.
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???
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.
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
• 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
• 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???
Digoxin Toxicity
• Abdominal pain with n/v
• Dizziness
• Visual disturbance
• Digoxin held X2 days and dose lowered
• Repeat digoxin level in seven days
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: 38.8 -78 – 16 - 210/100
• 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
• BCs X2 drawn
• Started on IV of NS @ 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???
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
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
• IV antibiotics started, troponin #2- 1.010
• Insulin drip started for repeat glucoses in the
300-480 range
• Consults to nutrition, social work, chaplain
• VTE prophylaxis ordered
Day 2
• Pt. begins to have positive stools
• GI consulted & EGD/colonoscopy completed –
showed duodenal ulcer with large amount of
irritated/inflamed tissues, scant bleeding @ time
of scope
• Vs: 37.2- 108- 24- 112/54
Day # 3
• Respirations elevate to 32/min., using accessory
muscles
• Stat CXR = LLL infiltrate
• IV antibiotics changed
• Intubated
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???
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
http://clinicalcases.org/2005/07/cardiology-cases.html
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
• Comprehensive long-term program
• Medical evaluation
• Prescribed exercise
• Cardiac risk factor modification
• Education
• Counseling
• 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
• 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
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
http://content.onlinejacc.org/article.aspx?articleid=1138393
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
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
Nina Swan, MSN, RN, CMSRN, CNL
Director of Critical Care and Two North Telemetry
Iredell Memorial Hospital
nina.swan@iredellmemorial.org