Pulmonary Edema: Assessment (Nursing)

00:01 Now as a nurse, what are the things like I could expect, likehow do I watch for this? because hey listen, you're right in the trenches.

00:08 You're the one who can actually pick up pulmonary edema before anybody else.

00:14 Okay, so that's really cool.

00:16 In fact, if you stay on top of this with the patient you do the appropriate assessments, you will catch pulmonary edema before anyone else.

00:23 The quicker we catch it the quicker we can intervene and prevent a really bad outcome.

00:29 so what are some common overall test that we'll do as a healthcare team? We'll likely order a chest x-ray, you can see pulmonary edema on a chest x-ray.

00:38 We'll do a pulse ox, remember that's a little clip you could put on a finger, there's other places you can put it but you put it on the finger, it's got a red light at the top, red light in the bottom and I'll help you tell how the oxygenation is doing of the patient.

00:52 Now a pulse oximetry is not as accurate as an ABG but it will give us a pretty good estimate.

00:59 Just be sure the patient doesn't have some type of Raynaud's disease or severe problems with circulation in their fingers.

01:05 If they do, you need to find an alternate placement so it's accurate.

01:09 Now we might look at a 12-lead.

01:10 Well, excuse me what is a 12-lead EKG have to do with pulmonary edema? Well remember a 12-lead, normally we hook a patient up in a critical care unit or a telemetry, we've got 5-leads.

01:22 But a 12-lead, gives me like this whole picture of the heart.

01:26 It's looking at the heart from all angles.

01:29 It's what would we would look at for signs of a myocardial infarction.

01:32 We know if the heart's taken a hit, then that could lead to problems with pulmonary edema.

01:37 So that's why you do a 12-lead EKG.

01:40 Now they might also consider an echocardiogram or cardiac cath.

01:45 That's gonna give us more precise information than even the 12-lead EKG.

01:50 The echocardiogram especially trained bachelor's-prepared tech will come in and what they do might look easy but it's really complex.

02:00 They are high-level, they're really professionals in what they do.

02:04 They'll put some gel on, they use echocardiogram one and they take a look at the patient's heart and the chambers.

02:10 They can estimate what the ejection fraction is, are there any problems are with the heart's actual function.

02:16 So that could be really helpful if we suspect that.

02:19 Now cardiac catheterization is very invasive, must be done by a physician and they'll go in and cath, they can do it through the arms and the leg, and they'll shoot dye and they'll take a look at the blood flow of the heart and how things are functioning that way.

02:31 So each one of those bring something different to the table.

02:35 It will depend on how severe the patient is experiencing pulmonary edema and if they can figure out what causes the pulmonary edema.

02:43 Now lab work you should watch for, the first one is BNP brain natriuretic protein (peptide).

02:48 That's a weird name, what are we dealing with, how come it started with the brain? what' s up with, okay don't let that bother you, just know when BNP is released that that can end up, that's an enzyme that tells us the heart is in trouble.

03:00 So when a BNP is elevated, that's an indication of congestive heart failure.

03:06 So think of us as like we're investigators, right? We're detectives, we're trying to figure out like we know pulmonary edema is bad.

03:12 We're trying to figure out what the cause of the pulmonary edema is so that we can help plan for the most effective treatment plan.

03:19 So BNP would be a sign that, wow you're in congestive heart failure that heart is overworked.

03:25 That might be because of an event or it might be something that becomes chronic for the patient.

03:29 Be aware of that when you're looking at BNP levels.

03:32 ABG, there is one you know there is an old friend, that's an arterial blood gas.

03:39 Remember that requires a blood sample that has to be taken from an artery, ouch! That's a lot harder for your patient.

03:46 If they have an art line - an arterial line, then you can just turn the stopcock, get the blood supply out and the patient doesn't even feel it.

03:53 But they probably felt that ABG, the arterial line being inserted.

03:57 Most patients don't have an arterial line, they must have been in critical care to have one of those.

04:03 Regular ABGs are just drawn by sticking in artery and that's why I said it's kinda difficult for your patient because an arterial stick is much more uncomfortable than a venous stick.

04:14 Now renal function, we'll probably do some lab works, right? We'll look at their creatinine.

04:18 If they're elderly, we'll look at their creatinine clearance, we'll look at their BUN, look at their GFR.

04:23 Those are common labs that we would look out to assess, hey are their kidneys functioning? Again, why are we messing with the kidneys? Remember, we know the kidneys play a major role in fluid-volume balance so we'll want to see how are your kidneys functioning because not just one cause of pulmonary edema, a patient may come in with multiple causes of pulmonary edema.

04:44 We'll also look at cardiac troponins, that's gonna tell us if the heart, boom! has taken a hit.

04:50 We use that lab work to see if the patient's had an MI.

04:53 We take a series of cardiac troponins, you do them over in a probably 24-hour period.

04:58 They'll do that least three of those to see if those are rising and that would indicate myocardial infarction or damage to the heart wall Now here's the part, those are all tests that are ordered by a healthcare provider.

05:13 Now I want to talk about what you do, how do you figure out? How are you the first person to recognize this patient's developing pulmonary edema? Well you're gonna listen to words.

05:23 Your patient will either tell you they're feeling kind of short of breath or they're having a hard time catching theire breath or you may pick it up on an assessment.

05:31 So you listen to the lung sounds anterior and posterior.

05:37 So look at the graphic that we have here which shows you the different spots that you should listen anteriorly and posteriorly.

05:45 Now if you've already been to clinicals, you're gonna look at me like, "I don't see most nurses listen in the back".

05:52 That's true but we want you to practice differently because you understand that listening in the back and the bases is the first place pulmonary edema will develop and that's when you want to catch it - when it's first developing.

06:06 So look at our graphic that shows you the places to place your stethoscope.

06:10 just to refresh yourself on the proper way to assess and auscultate someone's lungs.

06:15 You're listening for coarse crackles that shouldn't clear with coughing - that's a sign of pulmonary edema.

06:21 So ask the patient if they haven't told you, "Hey do you feel like having a hard time catching your breath or do you feel more short of breath than usual?" Also,look for edema in the extremities, look at the tissue over their shin bone, look at their feet, look at their toes, look at their hands and see if they have what we call peripheral edema or edema in the extremities.

06:42 These are all clues that great nurses watch for so you can advocate for your patient, intervene early and have the best possible outcome for your patient.

06:53 Now let's talk a little bit more about how your patient will feel with pulmonary edema.

06:58 They can have mild to severe shortness of breath.

07:01 When we say severe shortness of breath, everybody can see what that looks like but mild is sometimes harder to assess because some patients are hesitant to tell you, they just think, "Ohl I'm just tired or it's just because I'm not feeling well".

07:16 So the more questions you ask in a casual manner, hopefully they'll give you that information early.

07:22 Now they're unable to lie down without increased shortness of breath is a classic sign of pulmonary edema.

07:30 In fact with congestive heart failure patients, a very common question that we ask them is, "hey where are you sleeping at night?" Sounds like an interesting question well and it is, it's not devious but we ask them though, "where do you sleep at night?" because if they tell you, "Oh I always sleep in my recliner".

07:45 ding, ding,ding, ding, ding, ding! that's something you want to look for because somebody in pulmonary edema cannot lay down without feeling smothered So if a patient can't lay down at night to sleep in their bed or ask them, "do you have to use multiple pillows at night and where do you use them?" They might say, "oh yeah, I use it on my knee because it gets really kind of uncomfortable".

08:06 But if they tell you they put them under the back of their head so they're elevated, that's another classic symptom of them having pulmonary edema.

08:14 So a patient may be completely unaware that they're in pulmonary edema but you're not because you know the right questions to ask, you know the right assessment to do to figure it out.

08:25 Now when they're suffering with pulmonary edema, they're not oxygenating as well that's why they feel tired.

08:31 It's also kind of irritating which is why they will cough.

08:34 They may even have some chest pain.

08:37 So the patient may be unaware that all these things together could be pointing towards pulmonary edema.

08:42 Again, not you.

08:44 You're not fooled by that because you know these are symptoms that are often associated with pulmonary edema, so it's a great thing to teach your patient.

08:54 Hey we want to keep you safe at home so if you noticed your shortness of breath gets worse when you try and lay down, oh call us, we wanna know that.

09:03 If you notice that you're more tired than usual, if you notice this kind of annoying cough or obviously you start having chest pain, call us right away because we want to see you, we want to catch this early so you don't have any big problems with that.

09:17 See we are the ones with the patient who can think of the impact you could make.

09:22 If a patient understood these symptoms and you, "oh no, know come see us early so we can help you", everyone would have a much better outcome.