NURSING CARE IN PATIENT WITH ACUTE CARDIOGENIC PULMONARY EDEMA : CLINICAL CASE REPORT

Ayyu Sandhi School of Nursing, Faculty of Medicine, Universitas Gadjah Mada, Indonesia

Abstract Acute cardiogenic pulmonary edema is the life-threatening condition which is the common cause of acute respiratory failure. If it is not treated immediately, these conditions will also lead to the right-sided heart failure. Therefore the accurate and early intervention was needed. In Intensive Care Unit of Sdra lvsborgs Sjukhus we treated a man, 80 years old, who was taken to the hospital with clinical manifestation of acute cardiogenic pulmonary edema. The purpose of this paper is to identify the background factors and to explore nurses competence in performing the management of acute cardiogenic pulmonary edema. Critical thinking skills are developed as well as ethical consideration and lifeworld perspective. The data in this study case was gathered by in-depth interview, observations, and medical history. We found that acute cardiogenic pulmonary edema could be well treated by early interventions by following procedure and standard.

INTRODUCTION Acute cardiogenic pulmonary edema is accumulation of fluid in the alveoli that inhibits gas exchange by impairing the diffusion pathway between the alveolus and the capillary (Urden et al., 2006). It caused by left-sided heart failure, which the left side of the heart can not forward all of the blood it receives to the systemic circulation. As a result, its pressure is increased and blood backs up in the pulmonary circulation (Walsh, 2002). Symptoms of pulmonary edema may include coughing up blood or bloody sputum; orthopnea and tachypnea; feeling of "drowning"; crackles sounds in lung auscultation (Zieve and Hadjiliadis, 2011). The focus of the nursing intervention is to maintain patients airway and oxygen delivery. PROBLEM A man, 80 years old, arrived at the emergency room at 12.00 by ambulance with complaints of shortness of breath and chest pain. He has felt the complaints for 1 hour ago, and when these symptoms become heavier he decided to call an ambulance. When the ambulance arrived, he was still able to walk to the ambulance. During transportation the vital signs were: saturation (Sa) 80%, respiratory rate (RR) 28 x/m, heart rate (HR) 32 x/m, blood pressure (BP) 190/110 mmHg. In the ambulance he was unconscious for seven minutes and during that time, health workers could not measure his blood pressure. In the emergency room, he was given Furix 80 mg, Morphin 5 mg, Plavix 600 mg, Trombyl 320 mg, Pantoloc 20 mg. ECG showed a Left Branch Bundle Block. He showed short of breath and shallow breathing. Doctor diagnosed him acute myocardial infarction, thereby they provided mechanical ventilation therapy with CPAP oxygen flow 75%, Naloxon 0.25 ml, Clopidogrel 75 mg, ASA and Nitrolingual tablet 0.4 mg. Chest X-Ray showed pulmonary edema. Then he was moved 1

to the ICU to receive further treatment and monitoring. First hour in the ICU, his blood pressure rose to 140/90 mmHg and heart rate 90 x/m. The next hours blood pressure and heart rate tended to stabile. The first day in ICU, he was visibly tired, breathing shallowly, and had experienced episodes of confusion in which he could not answer the question of who he is and where he is now. His wife who accompanied him was calm, knowing with certainty the condition of her husband, and can receive the information given by health personnels. They have one daughter and two grandchildren who live far away from home. They have good communication, and always share if there is any family problem. OBJECTIVE The purpose of this paper is to identify the background factors and to explore nurses competence in performing the management of acute cardiogenic pulmonary edema. Critical thinking skills are developed as well as ethical consideration and lifeworld perspective. METHOD Subjective data obtained from in-depth interview with patient's relatives. Objective data obtained through observation of the clinical appearance of patients and medical documentation. RESULT From the previous medical history we found that in October 2011 he had suffered from postrenal kidney failure related to hyperplasia of the prostate gland and neuromuscular-bladder dysfunction. He also ever had gastric ulcer, anemia and diarrhea. He also suffered from diabetes. ECG showed a left branch bundle block and chest X-ray showed pulmonary edema. The results of echocardiography identified decreased movement of left chamber of the heart, with EF 40% and pulmonary-arterial pressure 10 mmHg. Laboratory results showed pH 7.1 (7.35-7.45), pCO2 10.48 kPa (4.6-6), potassium 6.4 mmol/L (3.5-4.4), creatinine 112 mmol/L (60-105), glucose level 18 mmol/L (4.2-6.3). Doctor agreed that the post-renal failure experienced by the patient caused the kidney could not properly dispose urine, so potassium accumulates in the blood. High levels of potassium affected the heart's electrical conduction system and eventually caused a buildup of fluid in the lungs. DISCUSSION Acute Cardiogenic Pulmonary Edema Acute pulmonary edema, the common cause of acute respiratory failure, is a life threatening disease, with a 12% in-hospital and 40% one-year mortality (Roguin et al., 2000). Acute pulmonary edema can be caused by left-sided heart failure. In left-sided heart failure, the left side of the heart can not forward all of the blood it receives to the systemic circulation. As a result, its pressure is increased and blood backs up in the pulmonary circulation. The pulmonary vessels become congested, the alveoli gradually filled with serous or serosanguineous fluid causes the impairment of respiratory gas exchange. (Walsh, 2002). There are two phases of the occurrence of pulmonary edema. The first phase is characterized by interstitial edema, enlargement of perivascular and peribronchial space, and increasing lymphatic flow. The second phase is characterized by alveolar edema due to fluid movement into the alveoli from the interstitial space (Urden et al., 2006).

If pulmonary edema continues, it can increase the pulmonary capillary pressure, increase right ventricular workload and oxygen demand, and eventually the right side of the heart begins to fail. These complications can be seen from the following clinical manifestations: leg edema, ascites, pleural effusion, and congestion and swelling of the liver (Nicholson, 2007). Symptoms of pulmonary edema may include coughing up blood or bloody sputum; difficulty breathing when lying down (orthopnea) and rapid breathing (tachypnea); feeling of "air hunger" or "drowning"; gurgling sounds with breathing or wheezing (Zieve and Hadjiliadis, 2011). Physical examination to listen to lung sounds will detect crackles in the lungs, called rales, and wheezing may be present. In addition to clinical manifestations, signs and symptoms of pulmonary edema can be seen from the results of ABG. As the edema progresses and pulmonary gas exchange becomes impaired, acidosis (pH less than 7.35) and hypoxemia ensue (Urden et al., 2006). In this case, in addition of those signs and symptoms, the patient's skin was also cold and cyanosis. This may be due to low cardiac output, peripheral vascular vasoconstriction and decreased arterial blood saturation (Urden et al., 2006). Respiratory Management Nursing actions should focus on maintaining patient's airway and oxygen delivery. The doctor will order oxygen therapy (10L/min). However, if the patient tends to be hypoxemic with arterial oxygen saturation lower than 90%, despite standard medical therapy, ventilator assistance may be needed (Bellone et al, 2006). First hours in the ICU, patient used noninvasive ventilation (NIV) with Assisted Spontaneous Breathing mode (ASB) with 50% oxygen flow that is slowly revealed as his respiratory status getting better. NIV is now routinely used during the emergency care of patients with acute pulmonary edema, with the aim of rapidly reducing the acute respiratory distress syndrome and the need for endotracheal intubation (L'Her, 2011). It can open collapsed alveoli and increase of the surface area for gas exchange (Urden et al., 2006). In addition to oxygen therapy, nursing interventions also aim to optimize ventilation by elevating his position into a position of high-Fowler or semi-Fowler, to promote diaphragmatic descent and maximal inhalation (Urden et al., 2006). The use of incentive spirometry 5 to 10 times/hour is also urgently needed to help reinflate (and to prevent) collapsed portions of the lung (Urden et al., 2006). In addition, as much as possible we do not heighten dypnea by provide rest period for the patient. Patient were rested at 11-13 o'clock, we set the atmosphere of the room, turn off the lights, close the curtains to optimize the rest of the patient. Circulation Management In this case, the doctor ordered Dobutamine 2 mg/ml to increase cardiac muscle contractility (Don Yi et al, 2000), decrease afterload and therefore increase the cardiac output (Morton et al., 2009); and Nitroglycerine 1 mg/ml to reduce afterload (Urden et al., 2006) and to mediate the volume of blood presented to the left ventricle, thus helping to control dyspnea (Morton et al., 2009). Nitroglycerine doses may be vary from the range of 3-9 mg (Bellone et al, 2006). The doctor also ordered the provision of Novorapid 1 U/ml regarding high blood glucose levels of the patient. Intravenous administration of insulin will drive potassium circulating in the blood back into the cell resulting in lower concentrations (Messina, 2011). 3

Fluid Management In this case, fluid management hold important key to improving respiratory function. Diuretics are administered to decrease preload and to eliminate fluid from the body (Urden et al., 2006). Doctor have ordered Furosemide 40 mg via infusion to produce urine output at least 100 ml/hour. Fluid balance was kept (-), and fluid intake was limited to maximum 500 ml in a day. In addition to observing the amount of urine output per hour, it is important for nurses to monitor laboratory results for the potassium. The second day in ICU, potassium values had dropped off at the rate 3.54 mmol/L. Patient and Family Lifeworld Perspective Sometimes, a disease more than just the symptoms, diagnosis and treatment. Disease can limit one's ability and disrupt the balance of relationship with the world. When healthy, a person will face the world without fear. But when sick, there will be fear, discomfort and helplessness (Dahlberg et al, 2008). Family plays an important role in caring for critically ill patients. By allowing family to visit, the patient will feel still connected to the world before he went to the hospital. Various studies have shown that the presence of family can lower intracranial pressure of the patient, reduce anxiety of patient and family, increase social support for patient, and let the patient control the situation recently (Morton et al., 2009). In this case, the patient's wife was calm. It may indicate she had been well-informed about her husband's condition. But in other cases where the family may not understand what was happening, they will more likely to become depressed. Here the role of nurses is to inform everything about the patient's condition, what action has been and will be done, orientate treatment room, and introduced the name of health care workers involved (Moore and Woodrow, 2004). Ethical View Four main ethical principles are autonomy, nonmaleficience, beneficience, and justice and fairness (Moore and Woodrow, 2004). Autonomy is the right of the patients to speak for themselves as to how they want to be treated their illnesses (Bernstein, 2011). The importance role of health workers here is how to convey information about the patient's condition clearly, so that patients and families can make right decision related to treatment that will be undertaken. Beneficence means always do the best and the right for the patient (Urden et al., 2006 ). We make sure to always check the instructions before the intervention and using standard procedures. Nonmaleficence means we keep prevent harming and keeping the patient safety (Urden et al., 2006). This can be done by performing a procedure with good preparation, double check to make sure that we are doing the correct procedure for the correct patient. Justice and fairness means treating everyone equally (Moore and Woodrow, 2004). CONCLUSION Acute cardiogenic pulmonary edema is the accumulation of fluid in the alveoli that impair gas exchange. It caused by left-sided heart failure. If it is not treated immediately, these conditions will also lead to the right-sided heart failure. These conditions encourage nurses to be able to perform accurate and precise interventions, taking into account the ethical principles and lifeworld perspective of patient and family.

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