Cardiopulmonary Assessment of the Post Partum Patient

1. Cardiopulmonary Assessment of the Post Partum Patient Self-Learning Packet

2. Activities Include: Pre-test (which is done anonymously to assess your current knowledge on the subject). PowerPoint presentation with printable handout Small group discussion Hands-on simulation activity Fun word search Fish Bowl Questions Post-test (which is done anonymously to assess knowledge gained from this program)

3. Pre-test The pre-test has been sent to you as an attachment to the original e-mail. Please complete the pre-test before continuing with this module. The pre-test will only be used for information gathering—in order to assess your current knowledge on the topic. You will not be rewarded or punished in any way in conjunction with this test.

4. Background Cardiopulmonary (CP) assessment is an essential part of the head-to-toe physical assessment of any patient—including the post partum patient. A woman may develop a cardiopulmonary complication without having prior history of cardiopulmonary diagnoses or risk factors (Leslie, 2004). Accurate assessment skills and quick intervention may save the life of a woman who develops a post partum cardiopulmonary complication.

5. Complications • The most prevalent cardiopulmonary complications in the post partum patient population include, but are not limited to: • Heart failure • Pulmonary edema • Pulmonary embolism *Sciscione, 2003

6. Heart Failure Heart disease is the leading cause of maternal death during pregnancy (Barker, 2006). Peri partum cardiomyopathy (PPCM)can be defined as: left ventricular dilatation and dysfunction during the last month of pregnancy or the first five months of the post partum period—in the absence of pre-existing heart disease (Leslie, 2004). 25-50% mortality, half of these die within the first 3 months. In survivors, 50% will recover “normal” or “near normal” LV function (Leslie, 2004).

7. Think About This… Can you name some of the signs and symptoms of heart failure?

8. Heart Failure (continued) • Signs and Symptoms of PPCM: • Dizziness • Shortness of breath • Crackles in the lungs • Tachypnea • Tachycardia • Orthopnea • 3rd heart sound (S3) • Cardiomegaly • EKG showing left axis deviation and flat T waves *Leslie, 2004

9. Heart Failure (continued) There is an increased risk of thromboembolism in PPCM. Future pregnancy for a woman who has had PPCM carries a significant risk of clinical deterioration and death; therefore future pregnancy in this population should be strongly discouraged. *Leslie, 2004 Future pregnancy

10. Pulmonary Edema Pulmonary edema is defined as the accumulation of fluid in the pulmonary interstitial spaces and alveoli, which prevents the adequate diffusion of both oxygen and carbon dioxide (Sciscione, 2003).

11. Think About This… Can you name common therapies that we use in our patient population which may lead to or exacerbate symptoms of pulmonary edema?

12. Pulmonary Edema (continued) • The most common causes of pulmonary edema are the use of tocolytic agents (including magnesium sulfate and terbutaline), underlying cardiac disease, fluid overload, and preeclampsia (Sciscione, 2003). • As a high-risk hospital, we see many patients who are or have recently been on tocolytic therapy for preterm labor or magnesium sulfate used in the treatment of preeclampsia.

13. Pulmonary Edema (continued) • Signs and Symptoms: • SOB or feeling of drowning • Wheezing or gasping for breath • Anxiety or a feeling of apprehension • Cough that may produce frothy sputum, possibly blood-tinged • Excessive sweating • Pale skin • Chest pain • Palpitations and/or tachycardia *Mayo Clinic, 2009

14. Pulmonary Embolism Pulmonary embolism is a condition that occurs when one or more arteries in your lungs become blocked. In most cases, pulmonary embolism is caused by blood clots that travel to your lungs from another part of your body — most commonly, your legs. *Mayo Clinic, 2009

15. Pulmonary Embolism (continued) The incidence of thromboembolic disease in pregnancy has been reported to range from 1 case in 200 deliveries to 1 case in 1400 deliveries. The risk of pulmonary embolism is increased in pregnancy and during the postpartum period. Approximately 10% of patients who develop pulmonary embolism die within the first hour, and 30% die subsequently from recurrent embolism. *Kamangar, 2009

16. Pulmonary Embolism (continued) • Signs and symptoms: • Dyspnea, tachypnea • Pleuritic chest pain • Cough—possibly with hemoptysis • Hypotension • Tachycardia • Poor perfusion to extremities • S3 or systolic murmur • Crackles and/or diminished breath sounds • Weakness • Oliguria • Sweating • Possibly low-grade fever *Kamangar, 2009

17. Cardiopulmonary Assessment An overview

18. Cardiopulmonary Assessment • Respiration: • Respiratory rate should be 12 to 20 respirations per minute. • Note the pattern of respiration (should be even and regular) and chest movement (should be symmetric). * Seidel, 2006

19. Think About This… What signs can you see, just by looking at the patient, that may indicate that they are having cardiopulmonary complications?

20. Cardiopulmonary Assessment (continued) Observe lips and nails for cyanosis, the lips for pursing and the nares for flaring—all indicators of poor respiration and oxygenation.

21. Cardiopulmonary Assessment (continued) • Auscultation: • With the patient sitting upright when possible, auscultate all lung fields. If the patient may have heart failure, begin auscultation at the base of the lungs in order to detect crackles that may disappear with continued exaggerated respiration. • Crackles—sometimes called rales, heard more often during inspiration—may be fine or coarse. You can hear crackles by following this link: http://www.med.ucla.edu/wilkes/cracklesmain.htm **Note: if link does not open when you click on it, right click On the link and click “Open hyperlink”.

22. Cardiopulmonary Assessment (continued) • Rhonchi— loud, low, coarse sounds like a snore. Most often heard continuously during inspiration or expiration. Coughing may clear sounds. • Wheeze— musical noise sounding like a squeak; most often heard continuously during inspiration or expiration; usually louder during expiration. http://www.wilkes.med.ucla.edu/lungintro.htm • Assess cough • Describe the cough according to its moisture, frequency, regularity, pitch and loudness, and quality. *Seidel, 2006

23. Cardiopulmonary Assessment (continued) • Cardiac Auscultation: • Should be auscultated with the patient in the following positions: • Sitting up and leaning slightly forward—this is the best position to hear high-pitched murmurs with the diaphragm of the stethoscope. • Supine • Left lateral recumbent—this is the best position to hear the low-pitched filling sounds in diastole with the bell of the stethoscope.

24. Cardiopulmonary Assessment (continued) • Should be performed in each of the five cardiac areas, using first the diaphragm and then the bell of the stethoscope. • Second right intercostal space • Second left intercostal space • Third left intercostal space • Fourth left intercostal space • Fifth left intercostal space • Normal heart sounds are S1 and S2 • Results from closure of the AV valves. *Seidel, 2006

25. Think About This… Why would a prominent S3 or S4 indicate cardiopulmonary complications?

26. Cardiopulmonary Assessment (continued) • Abnormal Heart Sounds: • S3-- an S3 may be heard if the volume of fluid/blood is abnormally large (as in pulmonary edema or heart failure). It sounds like a gallop, resembling the rhythm of pronouncing the word Ken-TUCK-y or SLOSH’-ing-in. It is best heard with the bell placed at the apex with the patient in the left lateral recumbent position. An S3 may be normal in pregnancy and children. • S4—an S4 may be heard if the ventricle is stiff and non-compliant, as in ventricular hypertrophy due to long-standing hypertension. It is heard best with the bell of the stethoscope at the apex. When it is heard, it resembles the rhythm of pronouncing the word TEN-nes-see or a-STIFF’-wall. A prominent S4 is always abnormal. http://www.wilkes.med.ucla.edu/Rubintro.htm *Cable, 1997

27. Interventions What do I do?

28. What Do I Do First? • In the event of a patient displaying signs of clinical decompensation, action must be taken immediately. • It is important to stick to the ABC’s of Basic Life Support when assessing your patient: • Airway—is the airway open. One common position found with the hospital patient is slumped down in the bed with the chin in toward the chest. This does NOT facilitate an open airway. Get the patient pulled up in the bed or lie the bed flat if necessary. • Breathing—is the patient breathing? Look, listen, and feel • Circulation—does the patient have a pulse?

29. Next… It is always a good idea to call the Rapid Response Team when in doubt about a patient’s condition. If necessary, Dial ‘22’ to call a Code 90 (at WPH). Call out to other team members to help you assess the situation. Call the doctor to relay information or to ask that he/she come an assess the patient as well.

30. Also… • While calls are being made and help is on the way, it might be beneficial to: • Initiate oxygen if the patient is not already on it. • Make sure you have recent vital signs, intake and output measurements (including IVF’s), and oxygen saturation. • Ensure that the patient has adequate IV access. • If the patient speaks a language other than English (or another language that you speak), locate a translator or language line when appropriate. • Make sure that you have accurate documentation of recent medications that the patient has received. • Re-assure the patient and family that you are taking the necessary steps to help them get well again.

31. Small Group Discussion Mini Case studies

32. Small Group (continued) Pick a partner and discuss one of the following scenarios, addressing possible assessment findings and interventions which would be appropriate in order to prevent further decompensation of your patient.

33. Scenario #1 Mrs. Smith is a 33-year-old who delivered a 34-week infant via cesarean section 7 hours ago. She has a history of chronic hypertension with superimposed pre-eclampsia and chorioamnionitis. She has been on magnesium sulfate for both preterm labor and seizure prophylaxis for approximately 36 hours. Mrs. Smith’s urine output has been steadily decreasing post-operatively and she is reporting shortness of breath. She is slightly tachycardic, has a low grade fever, and blood pressure 158/92. When you assess her you notice that she has capillary refill > 3 seconds and her O2 saturation is 88%. What are some possible differential diagnoses? What would your course of action be at this point? What orders could you expect to receive from the physician?

34. Scenario #2 Mrs. Black is a 52-year-old who had a robotic laparoscopic total hysterectomy this morning. She has a history of high cholesterol, anemia due to fibroids and menorrhagia; however, she reported that before this week she hadn’t been to the doctor in about 5 years. During surgery she received 3,500 ml of IVF and 2 units of PRBC’s. She is about 8 hours post-op when she suddenly starts complaining of chest pressure, severe shortness of breath and feeling like she is going to die. Discuss possible differential diagnoses as well as your immediate interventions for this patient.

35. Hands-on/Simulation/ Demonstration Practice time

36. Stan the Sim-Man For extra practice you may contact the Orlando Health Education department to inquire about setting up a time to go practice assessment skills on “Stan the Simulator Man”. Stan has the capability to have normal to adventitious lung sounds, normal to abnormal heart sounds, as well as specific scenarios to help you critically think what you would do in different scenarios.

37. If you can’t get a date with Stan… Take time to practice listening to normal (on a friend) or abnormal (perhaps on a friend or a patient) lung sounds. Utilize the links provided in this presentation to hear abnormal sounds. Practice auscultating at the different cardiac assessment points and identify the different heart sounds. If you, or another team member, have a patient with an out-of-the-ordinary assessment, encourage others to listen—with the patient’s consent, of course.

38. Fun Stuff Word Search

39. Complete at your leisure… Attached to your original e-mail you will find a word search composed of terms related to pulmonary edema, pulmonary embolism and heart failure

40. Your Input Please evaluations

41. Fish Bowl Questions Please take the time to write down a question that you might have--that was not answered or not explained well enough by this self-learning module—and drop it in the container placed in the lounge. Chances are, if you are wondering, someone else is too! As I receive questions in the “fish bowl”, I will answer them in the form of a small, one-page poster presentation.

42. Post-test Please complete the post-test that is attached to your e-mail. It is identical to your pre-test, and will be used to gather information as to whether or not the material covered here was adequate to improve your knowledge of the subjects. Answers can be requested via e-mail. Please send the request to stacey.raimundo@orhs.org. Once you have checked your answers, please drop your pre-test and post-test (stapled together) into my mailbox—you do not have to include your name.

43. Program Evaluation Attached to your original e-mail you will find a summative evaluation form. Please take the time to help ensure that I can make proper adjustments to the module for future use. Your input is very important to me!

44. References: American Heart Association. (2009). BLS healthcare provider. Retrieved electronically November 29, 2009 from http://www.americanheart.org/presenter.jhtml?identifier=3019553 Barker, D., Lewis, N., Mason, G., & Tan, L. (2006). Maternal cardiovascular medicine: Towards better care for pregnant women with cardiac disease. The British Journal of Cardiology, 13(6), 399-404. Bastable, S. B. (2008). Nurse as educator: Principles of teaching and learning for nursing practice. (3rd ed). Sudbury: Jones and Bartlett. Billings, D. M. & Halstead, J. A. (2009). Teaching in nursing: A guide for faculty. (3rd ed). St. Louis: Saunders Elsevier. Cable, C. (1997). The auscultation assistant. Retrieved electronically on November 30, 2009 from http://www.wilkes.med.ucla.edu/inex.htm Discovery Education. (2008). Puzzlemaker. Retrieved electronically November 29, 2009 from http://puzzlemaker.discoveryeducation.com/code/BuildWordSearch.asp Kamangar, N., McDonnell, M. S. & Sharma, S. (2009). Pulmonary embolism. Retrieved electronically November 30, 2009 from http://emedicine.medscape.com/article/300901-overview Leslie, S. J., Emmanuel, Y., Francis, C. M., & Flapan, A. D. (2004). The treatment of peripartum cardiomyopathy. The British Journal of Cardiology, 11(5), 393-396.

45. References (continued): Mayo Clinic. (2009). Pulmonary edema. Retrieved electronically November 30, 2009 from http://www.mayoclinic.com/health/pulmonary-edema/DS00412/DSECTION=symptoms Mayo Clinic. (2009). Pulmonary embolism. Retrieved electronically November 30, 2009 from http://www.mayoclinic.com/health/pulmonary-embolism/DS00429 Morrison-Shetlar, A. (2007). Interactive teaching and active learning with and without technology in any size class. Retrieved electronically November 29, 2009 from http://www.undergraduatestudies.ucf.edu/ morrison/handouts.html Schafersman, S. D. (1991). An introduction to critical thinking. Retrieved electronically November 29, 2009 from http://www.freeinquiry.com/critical-thinking.html Sciscione, A. C., Ivester, T., Largoza, M., Manley, J., Shlossman, P., & Colmorgen, G. H. C. (2003). Acute pulmonary edema in pregnancy. Obstetrics and Gynecology, 101(3), 511-515. Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2006). Mosby’s guide to physical exam. (6th ed). St. Louis: Mosby Elsevier. Webster University: Institute for Excellence in Teaching and Learning-Faculty Development Center. (2009). Active learning handbook. Retrieved electronically November 29, 2009 from http://fdc.webster.edu/wp-content/uploads/2009/09/active-learning.pdf

46. Thank-you for taking the time to participate in this learning experience!I appreciate your time and effort!