18.4: Management of Impaired Cardiopulmonary Functioning
By the end of this section, you will be able to:
- Describe nursing actions for management of impaired cardiopulmonary functioning
- Understand interdisciplinary collaboration for management of impaired cardiopulmonary functioning
- Describe emergency interventions for impaired cardiopulmonary functioning
Nurses are involved in the management of cardiopulmonary care throughout the care plan, from assessment and planning through evaluation and reassessment. Nursing actions while caring for patients with impaired cardiopulmonary function are varied, from routine to emergent care. Patients with cardiovascular and/or pulmonary dysfunctions may be stable or suffering an emergency event, such as a deadly cardiac rhythm or a respiratory or cardiac arrest. Depending on the care setting, nurses have to be able to respond and act to patients’ changes in status, with interventions, patient education, and guidance regarding self-monitoring, through drug therapy (routine and emergent), defibrillation, and CPR. Nurses are also part of a healthcare team and as such work with other members from different disciplines. Interdisciplinary care provides a holistic approach to patients and their care and brings about positive outcomes.
Nursing Actions
Nurses are directly involved in patient care. From assessment to evaluation, nurses are creating, implementing, and evaluating their care plans based on the current status of their patients. Nursing actions relative to the cardiopulmonary system reflect particular actions designed for the respiratory system and those for the cardiovascular system. Some interventions, like O 2 therapy and behavioral modifications, are apt to benefit both components of the cardiopulmonary system. Even drug therapy in one category is prone to assist with symptoms or deficits in the other, as an improvement in ventilation , oxygenation, or perfusion can be expected to improve the others. In this section, specifics as to assessment, a variety of tools and techniques, medications, and topics for patient education are discussed. Additionally, interdisciplinary collaborative examples are explored as are emergency interventions specific to the respiratory and cardiovascular systems.
Respiratory Assessment
The evaluation of the respiratory system includes collecting subjective and objective data through a detailed interview and physical examination of the thorax and lungs. This examination can offer significant clues related to issues associated with the body’s ability to obtain adequate oxygen to perform daily functions. Inadequacy in respiratory function can have significant implications for the overall health of the patient.
Collect subjective data using interview questions, paying particular attention to what the patient is reporting. The interview should include questions regarding any current and past history of respiratory health conditions or illnesses, medications, and reported symptoms. Consider the patient’s age, gender, family history, race, culture, environmental factors, and current health practices when gathering subjective data.
A focused respiratory objective assessment includes interpretation of vital sign s; inspection of the patient’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds (Figure 18.24) using a stethoscope. The nurse must have an understanding of what is expected given a patient’s age, gender, development, race, culture, environmental factors, and current health condition to determine the meaning of the data that are being collected.
When certain findings indicate further exploration, palpation and percussion may be performed. An example is if on inspection the nurse finds apparent edema around one or both collarbones, especially if the patient was recently intubated with an ETT. Palpation can be used in such a situation to assess for subcutaneous emphysema (air in the subcutaneous tissue), as the tiny air pockets feel crispy ( crepitus ) to the fingertips. Percussion is helpful for the nurse to determine underlying structures in the pulmonary cavity, whether a region that should be air filled instead contains fluid or a solid mass. Refer to Table 18.4 for expected and unexpected assessment results.
| Assessment | Expected Findings | Unexpected Findings (Document and Notify Provider if a New Finding*) |
|---|---|---|
| Inspection |
|
|
| Palpation |
|
|
| Percussion |
|
|
| Auscultation |
|
|
|
*CRITICAL CONDITIONS
to report immediately |
|
Cardiovascular Assessment
The evaluation of the cardiovascular system includes a thorough medical history and a detailed examination of the heart and peripheral vascular system. Nurses must incorporate subjective statements and objective findings to elicit clues of potential signs of dysfunction. Symptoms like fatigue, indigestion, and leg swelling may be benign or may indicate something more ominous. As a result, nurses must be vigilant when collecting comprehensive information to utilize their best clinical judgment when providing care for the patient.
The subjective assessment of the cardiovascular and peripheral vascular system is vital for uncovering signs of potential dysfunction. To complete the subjective cardiovascular assessment, the nurse begins with a focused interview. The focused interview explores past medical and family history, medications, cardiac risk factors, and reported symptoms. Symptoms related to the cardiovascular system include chest pain, peripheral edema, unexplained sudden weight gain, shortness of breath (dyspnea), irregular pulse rate or rhythm, dizziness, or poor peripheral circulation. Any new or worsening symptoms should be documented and reported to the healthcare provider.
The physical examination of the cardiovascular system involves the interpretation of vital sign s, inspection, palpation, and auscultation of heart sounds. Jugular venous distension may be visible, especially as patients are repositioned. As the nurse is examining the patient, palpation may accompany, as clothing is moved or removed and the patient is touched. Further signs of perfusion can be assessed, like the temperature and moisture of the skin (e.g., warm and dry versus cool and clammy). To complete palpation, capillary refill and peripheral pulses should be assessed. After completing a cardiovascular assessment, it is important for the nurse to use critical thinking to determine whether any findings require follow-up (Table 18.5).
| Assessment | Expected Findings | Unexpected Findings (Document and Notify Provider if a New Finding*) |
|---|---|---|
| Inspection | Apical impulse may or may not be visible |
|
| Palpation | Apical pulse felt over midclavicular fifth intercostal space |
|
| Auscultation | S1 and S2 heart sounds in regular rhythm |
|
|
*CRITICAL CONDITIONS
to report immediately |
|
Auscultation is routinely performed over five specific areas of the heart to listen for corresponding valvular sounds. These auscultation sites are often referred to by the mnemonic “APE To Man,” referring to aortic, pulmonic, Erb point, tricuspid, and mitral areas (Figure 18.25).
Auscultation usually begins at the aortic area (upper right sternal edge). Use the diaphragm of the stethoscope to carefully identify the S1 and S2 sounds. They will make a “lub-dub” sound. Note that when listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S2). Move the stethoscope sequentially to the pulmonic area, Erb point, and tricuspid area. Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a sixty-second period. For an adult, the HR should be between 60 and 100 with a regular rhythm to be considered within normal range.
A review of blood flow and the heart’s sounds is provided in this video. Listen for normal and abnormal sounds and what they mean.
The first heart sound (S1) identifies the onset of systole, and the second heart sound (S2) identifies the end of systole and the onset of diastole; when the semilunar valves close, the AV valves open, and the ventricles fill with blood. When auscultating, it is important to identify the S1 (“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds.
Encourage Breathing Techniques
There are several techniques a nurse can teach a patient to use to enhance their breathing and coughing. These techniques include diaphragmatic breathing, pursed-lip breathing, incentive spirometry , and coughing and deep breathing.
Diaphragmatic Breathing
Diaphragmatic breathing is a technique that is helpful for patients who are tachypneic, whether from a physiological source or anxiety. The technique helps focus attention on breathing and consciously learn to control it. The nurse teaches the patient to intentionally realize whether the chest or the abdomen is the source of breaths. It is often recommended to advise the patient to place a hand on the chest and one on the abdomen and self-assess the source. This begins the slowing and relaxing process. Once the patient realizes the source of breath is the chest, teaching is aimed at the patient redirecting attention toward breathing from the abdomen (diaphragm). With concentration on the technique, the tachypnea should begin to resolve, and with it, an improvement as the physical response to pH changes from hyperventilation normalizes and/or a sense of relaxation and anxiety reduction takes place. Sometimes the anxiety involved with severe dyspnea , or from a mental health situation, may respond well to anxiolytic drug therapy in addition to diaphragmatic breathing.
Pursed-Lip Breathing
Pursed-lip breathing is a technique that allows people to control their oxygenation and ventilation . The technique requires a person to inspire through the nose and exhale through the mouth at a slow, controlled flow. This type of exhalation gives the person a puckered or pursed appearance. By prolonging the expiratory phase of respiration , a small amount of positive end-expiratory pressure is created in the airways that helps to keep them open so that more air can be exhaled, thus reducing air trapping that occurs in some conditions such as COPD. Pursed-lip breathing often relieves the feeling of shortness of breath, decreases the work of breathing, and improves gas exchange . People also regain a sense of control over their breathing while simultaneously increasing their relaxation.
Incentive Spirometry
An incentive spirometer is a medical device often prescribed after surgery to prevent and treat atelectasis (Figure 18.6). Atelectasis occurs when alveoli become deflated or filled with fluid, and this can lead to pneumonia. While sitting upright, the patient should breathe in slowly and deeply through the tubing with the goal of raising the piston to a specified level. The patient should attempt to hold their breath for five seconds, or as long as tolerated, and then rest for a few seconds. This technique should be repeated by the patient ten times every hour while awake. The nurse may delegate this intervention to unlicensed assistive personnel, but the frequency at which it is completed and the volume achieved should be documented and monitored by the nurse.
Coughing and Deep Breathing
Teaching the coughing and deep breathing technique is similar to incentive spirometry , but no device is required. The patient is encouraged to take deep, slow breaths and then exhale slowly. After each set of breaths, the patient should cough. This technique is repeated three to five times every hour.
Nurse:
Aarti, RN
Clinical setting:
ICU
Years in practice:
2
Facility location:
San Jose, California
My patient assignment for the night was a male (Mr. Leonard, or Mr. L) who had undergone coronary artery bypass grafting (CABG) earlier in the day. His surgery had gone well, with no major events during or in the first few hours of recovery in the ICU. As we did shift report, and bedside check, hemodynamics were stable, and Mr. L’s major issue was pain. I brought a syringe of morphine with me when I did his initial assessment and gave him his first divided dose. By the time I was done with a head-to-toe at 7:30 p.m., he was gently snoring.
The standard for ICU patients was for them to be turned at least every two hours; post-op CABG patients hourly, to keep pulmonary secretions mobile, and the chest tubes draining. The IS orders were for “ten times while awake,” but Mr. L had refused the previous hour with the day shift nurse, and now he was asleep. I let him rest at 7:30 p.m., and since he was still sleeping at 8 p.m., didn’t wake him. His VS continued to be fine, and while I turned him at 9 p.m., I didn’t insist he do his ten reps of the IS. When I checked his VS at 10 p.m., all was stable except his temperature of 100.6°F (38°C); I medicated his 8-of-10 pain and went to the nurses’ station to review the flowchart and chart—his temperature had been 97.8°F (36.6°C) at 7:30 p.m. One of my colleagues asked how Mr. L was doing, and I told her about the low-grade fever. Her first question was, “How has he been doing on his IS?” Surprised, I admitted that I hadn’t had him do it, as I was focused on his pain control and rest. But her question clicked that subject open in my mind, and I began consistent pulmonary toilet—while he was not happy to be kept awake, he did the breathing exercises as I requested. An hour later, I medicated his pain, and a few minutes later insisted on the IS again.
At midnight, I checked his temperature again, fully expecting it to have climbed further, but it was 98.9°F (37.2°C). At that moment, early in my practice, I became fully convinced of the power of aggressive pulmonary toilet and the ability of deep breathing to reduce and prevent atelectasis . Mr. L and I continued with his hourly IS throughout the early morning hours, and his temp was 98.3°F (36.8°C) at 4 a.m. As I drove home and reflected on the events of the shift, I thought about how easy it is for a patient to develop atelectasis, and the importance of early prevention through deep breathing and coughing. The other realization for me was how easy it probably would have been for me to prevent it entirely by starting the IS with my first shift assessment. However, by having had this experience (and happily with Mr. L’s quick recovery from all aspects of his surgery, without development of post-op pneumonia!), my patient education on the rationale for use of the IS from that night forward became much more compelling.
Frequent Repositioning
Repositioning a patient with impaired cardiopulmonary status maintains body alignment, prevents pressure injuries from low perfusion and hypoxia , and prevents foot drop and contractures. When repositioning a patient in bed, supportive devices such as pillows, rolls, and blankets can aid in providing comfort and safety. It is important to reposition patients appropriately to prevent neurological injury that can occur if a patient is inadvertently placed on their arm. Frequent repositioning also allows for respiratory secretions to mobilize rather than pool in one location (usually dependent, based on gravity). Being turned may cause deeper breaths and may inspire coughing. Position changes also enhance comfort, which reduces pain, allowing for ease of breathing and again more likelihood of full and effective breaths.
Medication Administration
There are medications recognized as specific to the respiratory system and those associated with the cardiovascular system; some have effects on both components of the cardiopulmonary system . Medication administration for respiratory and cardiac drugs involves nurses being familiar with a variety of administration routes. Respiratory drugs may be given as nasal sprays and drops, inhalers, tablets, or capsules to be administered orally or through injections by intramuscular (IM), subcutaneous (SC), or intravenous (IV) access. Cardiac medications add the potential for topical (e.g., nitroglycerin ordered by patch or cream) application and do not include the wide variety through sprays, drops, or powders. When immediate actions are desired, drugs for cardiopulmonary emergencies are typically administered by IV or intraosseous (IO) routes, though respiratory emergencies may still require inhaled doses of certain drugs.
Respiratory Medications
There are various drug classes to treat respiratory pathophysiological problems—all with a goal relative to improving function, whether through improved oxygenation or ventilation (Table 18.6).
| Type | Drug | Mechanism of Action |
|---|---|---|
|
Sympathetic nervous system:
Beta 2 adrenergic agonists |
Albuterol (Proventil HFA) | Capitalizes on the bronchodilation response of SNS stimulation |
|
Parasympathetic nervous system:
anticholinergics |
Tiotropium (Spiriva—long acting), ipratropium (Atrovent—short acting) | Blocks the bronchoconstriction response of muscarinic PSNS stimulation |
| Methylxanthine derivatives | Theophylline (Theo-24) | Smooth muscle relaxation allowing bronchodilation |
| Corticosteroids | Triamcinolone Nasocort Allergy—nasal; Aristospan—systemic) | Prevention of reaction or worsening reaction to inflammation, whether local or systemic depends on drug, dose, and route |
| Leukotriene receptor antagonists | Montelukast (Singulair) | Blockade of leukotriene receptors and related decreased inflammatory responses |
| Cromolyn | NasalCrom | Blocks mast cells and related inflammatory actions |
| Antihistamines | Diphenhydramine (Benadryl), loratadine (Claritin) | Blocks action of histamine; first generation has broader effects, including sedation |
| Decongestants | Pseudoephedrine (Sudafed) | Adrenergic stimulation releases norepinephrine, causing vasoconstriction |
| Expectorants | Guaifenesin (Mucinex) | Causes vagal response that increases fluid in the respiratory tract; thins mucous |
| Antitussives | Dextromethorphan (Robitussin) | Depression of cough center (medulla) and cough receptors in respiratory tract |
| Anti-infectives | Numerous classes of anti-infectives—selection based on type of infection (C&S results) | Cause injury or death to infectious microbial cells |
Cardiac Medications
As varied as the potential diagnoses that affect the cardiovascular system are the drugs to treat the disorders. Medications are used to modify actions of the ANS in order to lower or raise BP; they treat dyslipidemias and often-linked CAD; antianginal drugs relieve chest pain; there are drugs to treat HF, medications to help the kidneys remove excess fluid; there are those that may treat or prevent dysrhythmias, and there are drugs to prevent and/or treat clotting problems (Table 18.7).
| Type | Drug | Mechanism of Action |
|---|---|---|
| ACE inhibitors | Lisinopril, enalapril | Vasodilation from inhibition of angiotensin-converting enzyme, and therefore prevention of angiotensin I conversion to angiotensin II (vasoconstrictor); decreases cardiac remodeling and overt HF (some patients) |
| Angiotensin receptor blockers (ARBs) | Valsartan (Diovan) | Blocks angiotensin II effects of aldosterone release and vasoconstriction at the angiotensin receptors |
| Antianginals | Nitroglycerin | Arterial and venous vasodilation increases perfusion and decreases O 2 demand |
| Anti-arrhythmic | Adenosine (Adenocard) | Temporarily slows or arrests AV conduction and return to NSR |
| Antianginals | Nitroglycerin | Arterial and venous vasodilation increases perfusion and decreases O 2 demand |
| Beta blockers | Atenolol, sotalol | Inhibits stimulation of beta receptors; prolongs cardiac cycle refractory period |
| Calcium channel blockers | Diltiazem (Cardizem) | Smooth muscle relaxation allows for vasodilation; decreases cardiac workload inhibition of calcium during depolarization |
| Cardiac glycosides | Digoxin (Lanoxin) | Improves cardiac contractility by three mechanisms: positive inotrope (increases contractility, SV, and CO), negative dromotrope (decreased cardiac conduction), and negative chronotrope (lowers HR) |
| Catecholamines | Norepinephrine | SNS stimulation causes vasoconstriction for enhanced organ perfusion |
| Diuretics (loop) | Furosemide | Inhibits reabsorption of sodium in the loop of Henle and distal tubule; increases urine and electrolyte output |
| Diuretics (potassium sparing) | Spironolactone (Aldactone) | Aldosterone antagonist—inhibits sodium reabsorption without loss of potassium |
| Diuretics (thiazide) | Hydrochlorothiazide (Microzide) | Inhibits reabsorption of sodium in the distal tubule—increases urine output |
| HMG CoA reductase inhibitors (a.k.a. “statins”) | Rosuvastatin (Crestor) | Inhibits production of cholesterol by inhibiting HMG CoA reductase; LDL is decreased |
| Neprilysin inhibitor and ARB combination | Sacubitril/valsartan (Entresto) | Inhibits neprilysin (enzyme), allowing for increased natriuretic peptides, which causes vasodilation and sodium (and water) excretion; valsartan (see ARBs) |
| Potassium channel blockers | Amiodarone (Pacerone) | Prolongs repolarization through blockade of potassium channels |
| Sodium channel blockers | Lidocaine | Decreases influx of sodium to cardiac cells—depolarization is prolonged |
Oxygen Therapy
O 2 is considered a drug and requires a prescription or healthcare provider’s order for nurses to administer it. When administering oxygen to a patient, it is important to ensure that oxygen flow rates are appropriately set according to the type of administration device (Table 18.8). When administering oxygen therapy, it is important for the nurse to assess the patient before, during, and after the procedure and document the findings.
See the competency checklist for Administering Oxygen. You can find the checklists on the Student resources tab of your book page on openstax.org.
| Device | Flow Rates and Oxygen Percentage | Image |
|---|---|---|
| Nasal cannula |
Flow rate: 1 to 6 L/min
FiO 2 : 24 to 44 percent |
|
| High-flow nasal cannula |
Flow rate: up to 60 L/min
FiO 2 : up to 100 percent |
|
| Simple mask |
Flow rate: 6 to 10 L/min
FiO 2 : 28 to 50 percent |
|
| Non-rebreather mask |
Flow rate: 10 to 15 L/min
FiO 2 : 60 to 80 percent Safety Note: The reservoir bag should always be partially inflated. |
|
| CPAP, bilevel positive airway pressure (BiPAP), Venturi mask, mechanical ventilator | Use the settings provided by the respiratory therapist and/or provider order. |
CPAP:
Endotracheal tube (ETT): Mechanical ventilator: |
| Bag valve mask |
Flow rate: 15 L/min FiO
2
: 100 percent
Squeeze the bag once every five to six seconds for an adult or once every three seconds for an infant or child. |
Refer back to Unfolding Case Study #3: Part 7 to review the patient data.
| Provider’s Orders |
1940:
Supplemental oxygen to maintain oxygen saturation greater than 92 percent
Insert peripheral IV Furosemide 20 mg IV × one dose Monitor and document accurate intake and output |
Patient Education
It is important to modify patient education methods depending on the individual’s knowledge, skills, and abilities. For example, some older adults readily engage in using electronic technology, but others have low digital literacy or experience difficulty when accessing electronic health resources. Nurses should adapt patient education to the needs of the individual and provide verbal, written, or electronic resources, as needed, while considering any sensory, cognitive, or functional impairments. The ultimate goal of health promotion and patient education is to improve their understanding, motivation, and engagement in self-management and promote their quality of life.
Behavioral Modifications
Knowing there are many behaviors that can negatively impact the cardiopulmonary system , it can be important for nurses to provide patient education about behavioral modifications. As part of the nursing history and physical, behaviors like smoking, exercise, nutrition, alcohol, and other intake of drugs, should all be discussed with the patient.
Helping the patient realize how certain applicable behaviors affected overall health, and cardiopulmonary health in particular, is important and can provide the necessary first step in recognition of the action-reaction relationship. Nurses are often the first providers of such information, as so much time is spent directly with patients, and relationships are established whereby patients feel comfortable asking questions. Once identified and recognized, the nurse can begin to introduce applicable information to help modify any negative behaviors.
There is a lot of information available regarding smoking cessation and many resources to help patients quit. Dietary recommendations can be provided, including cardiac diets, and recommendations for calorie intake in the presence of COPD. Patients may need guidance and contacts for support groups in order to consider quitting alcohol or illicit drug use. If expert information is needed, such as specific dietary limitations, the nurse can discuss with the prescribing healthcare provider about a consult with a specialist, in this case, a nutritionist or dietitian.
Pollutants
As patients are seen in outpatient settings or are preparing for discharge from acute inpatient care, exploration by the nurse should include environmental exposures the patient is prone to. Whether this is secondhand smoke, exposure to motor vehicle exhaust, coal dust, or smoke from fires of any variety, patients may not understand the importance of exposure prevention. Patients should know about warnings for poor air quality and actions to take to avoid exposure. Education about appropriate respiratory protection devices, when to don and doff them, and how to wear them correctly can be discussed. And for information beyond the scope of nursing practice, the nurse can teach patients how to find reliable resources.
Coping Techniques to Reduce Anxiety
Coping strategies are behaviors used to manage anxiety. Effective strategies control anxiety and lead to problem-solving, but ineffective strategies can lead to abuse of food, tobacco, alcohol, or drugs. Nurses teach and reinforce effective coping strategies.
The nurse should determine what techniques the patient has used historically, and together the nurse and patient can discuss which have been successful and which have not. This can lead to behavior modifications and introduce new and healthy recommendations for coping in stressful situations. Often techniques like slow, deep breaths can be helpful. Some patients respond well to distraction and imagining a pleasant place or recalling a fond memory. The nurse can also suggest to the patient and prescriber the possibility of pharmacological intervention for anxiety to be added or adjusted to the patient’s care plan.
Comfort Measures
Establishing and maintaining comfort can be vital to patients while they are battling illness, painful symptoms, and fear. Nurses should be aware that some physical problems cause pain or discomfort, and many diagnostic tests and interventions inflict pain upon patients, who may already be uncomfortable.
The nurse should remain mindful of not only the treatments and pharmacological interventions that will enhance those direct cardiopulmonary physical needs but also the addition of pain medications, anxiolytics, and hypnotics if and when needed. Sometimes the most basic of interventions can better meet a patient’s most basic needs: a warm bath, preferred music, or a visit from a pet may help reduce stress, enhance comfort, and assist with rest and healing.
Interdisciplinary Collaboration
Many patients with serious, life-limiting illnesses have common symptoms that the nurse can assess, prevent, and manage to optimize their quality of life. Good symptom management improves quality of life and functioning in all states of chronic illness. Nurses play a critical role in recognizing these symptoms and communicating them to the interdisciplinary team for optimal management.
Collaborating with physical, occupational, speech therapists, and nutrition specialists in the design and implementation of care planning truly enhances patient care and improves patient outcomes (Figure 18.26). The importance of establishing and fostering good relationships with all members of the interdisciplinary team is crucial to safe patient care. Important departments that ensure cardiovascular and pulmonary health are nutrition, cardiac rehabilitation, and chest physiotherapy.
Nutrition
Healthy nutrition helps to prevent obesity and chronic diseases, such as cardiovascular disease. By proactively encouraging healthy eating habits, nurses provide the tools for patients to maintain their health, knowing it is easier to stay healthy than to become healthy after disease sets in. When patients are recovering from illness or surgery, nurses use strategies to promote good nutrition even when a patient has a poor appetite or nausea. If a patient develops chronic disease, the nurse provides education about prescribed diets that can help manage the disease, such as a low-fat, low-salt, low-cholesterol diet for patients with cardiovascular disease.
Patients often need guidance from dietitians to understand, plan for, and follow their specific nutritional needs. Also, whether the patient is actively involved in dietary choices or limitations while hospitalized, the dietitian is involved in the preparation of menu items that meet the needs of all specific diets.
Similar to being aware of a patient’s needs in regard to prescribed medications, it is important for nurses to understand patients’ dietary requirements and restrictions. Awareness of a cardiac diet, for example, which has limitations relative to sodium and fats, helps nurses provide the correct diets as well as guide patients and families to understand choices and follow recommendations. Patients with significant respiratory illness, like late-stage emphysema, often have increased calorie needs and require supplements with meals to provide enough energy for the extra physiological needs. For those who have comorbidities like DM or renal disease, dietary restrictions and recommendations are added to their care plans, while in the hospital and on discharge. Nurses tend to be the providers of discharge education, so the ability to describe various diets and caloric needs is important.
Cardiac Rehabilitation
Patients who have substantial cardiac dysfunction, whether having had an MI, or from progressive deterioration like HF, or who are postoperative after surgery for valvular disorder or CABG, are usually prescribed cardiac rehabilitation. Depending on the length of hospitalization, the patient may be quite deconditioned, with anticipated needs for a variety of interdisciplinary therapies in order to gain some strength back and be well enough to return home. Others may not have had significant damage requiring complicated rehabilitation and various therapies. Such rehabilitation may or may not involve time as an inpatient at a dedicated rehabilitation unit or facility.
Many are able to begin their cardiac rehabilitation while inpatient and be taught exercises and activities to be done after discharge. Like physical therapy (which may also be ordered), many rehabilitation actions can be carried out at home by the patient and perhaps with assistance from a family member or friend. Often, there are outpatient visits for some time after discharge, to a cardiac rehabilitation agency, in order to check in, be evaluated, and adjust activities as indicated by patient status and tolerance.
Chest Physiotherapy
There are devices and techniques that can assist patients with maintaining pulmonary function and recuperating from illness or exacerbation of an illness. Previously introduced was the IS, which many patients receive shortly after admission, whether for a long stay in the hospital or merely an overnight stay. These devices are disposable so patients are encouraged to take the IS upon transfer or discharge and continue using it several times daily.
Other methods of chest or respiratory physiotherapy include valves like a flutter valve which use vibration or oscillation to assist with positive expiratory pressure and enhance airway clearance. There are also specialized vests that inflate and deflate and offer vibration and percussion. Percussion can also be done manually by using cupped hands and repeated dull strikes to the chest and back, or with manufactured devices that provide similar thumping to the chest and back.
The goal of these interventions is to loosen and mobilize secretions from smaller to central airways to enable their removal by coughing or postural drainage (positioning the patient to use gravity to allow secretions to drain) (Figure 18.27).
Emergency Interventions
When things go wrong with the cardiopulmonary system , the results can quickly be devastating or fatal. Of course, not all abnormalities are lethal, but an ability to recognize normal and therefore be able to identify abnormal (whether being able to define exactly what is wrong or not) is critical for nurses. It is also important to be vigilant about assessments and know what changes in a patient’s status are worthy of immediate follow-up. A few of the things that require urgent or emergent interventions follow in the next and final section of this chapter.
Chest Tube Insertion
Depending on the reason for the insertion of a chest tube, it may be urgent or emergent; it is not typically a routine intervention. Emergent chest tube insertion is perhaps most commonly done for a pneumothorax; hemothorax (or the mixture of hemopneumothorax) and chylothorax are also possibilities that necessitate a chest tube. The lungs have a limited amount of space within the thoracic cage, so situations that alter the area for lungs to inflate and deflate, and those that change the normal pressure, are problematic.
The location for chest tube placement is based on radiography, as pneumothoraces are visible on chest x-rays (Figure 18.28). The nursing role includes reassuring and frequently assessing the patient, providing medication for pain and anxiety, and assisting the physician (or advanced practitioner) with the procedure, including the setup of the chest tube system. The insertion is done under sterile technique, either at the bedside or in an operating room. The flexible tubing from the chest tube system needs to be attached to the chest tube itself, so the nurse holds the clean tubing and the provider who inserted the tube inserts the tube end into the system’s tubing.
A related emergency that requires the insertion of a chest tube for ongoing management is a tension pneumothorax. This develops suddenly and impacts the lung or lungs, heart, and blood vessels. Without immediate intervention, it can be quickly life threatening. Since time is limited before the provider takes the time for chest tube insertion, a large gauge needle is inserted in the second intercostal space and midclavicular line to allow air to escape and the lung to reinflate.
The video Chest Tubes—Nursing Management and Assessment Made Easy presents more information about chest tubes.
Cardiopulmonary Resuscitation
According to the AHA (2023), high-quality CPR is the principal contributor to post–cardiac arrest survival. Nursing students, as well as nurses at all levels—from licensed practical nurses through advanced practice nurses, are normally certified as BLS providers and recertify every two years. Depending on the cause of the arrest, and the subsequent status of the patient, interventions include rescue breathing, chest compressions, and use of an automated external defibrillator (AED) or manual defibrillator. Not all actions are indicated for all patients. For example, a patient who has suffered a respiratory arrest but has a pulse does not need chest compressions, and asystole is not a shockable rhythm. If the patient is pulseless, CPR is indicated, in order to perfuse the body, particularly the brain.
The animation CPR in Action shows the perfusion capabilities of high-quality CPR. It also illustrates what happens when CPR is not done adequately.
Defibrillation
Based on the term itself, defibrillation is the delivery of an electric shock to stop fibrillation (ineffective quivering movement of the heart muscle). Fibrillation, though, can occur in the atria or the ventricles, and atrial fibrillation (A-fib) is not typified as a “deadly rhythm.” If an electrical intervention is sought for the treatment of A-fib, it involves fewer joules of electricity and is termed cardioversion . Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are nonperfusing rhythms, and defibrillation is indicated emergently. Usually, this is delivered as part of BLS or ACLS efforts and accompanies CPR.
In acute care settings, a cart for arrest situations, also called a code, or COR-0, is present on most or all patient care units. The cart contains a hard backboard to place under the patient to enhance the quality of chest compressions, airway devices and bag- valve masks of various sizes, emergency drugs, and a manual defibrillator/monitor. In many other settings, automated external defibrillators (AEDs) are available and can be used by laypersons, as the device offers step-by-step instructions. Those who are BLS certified have practiced with AEDs. Defibrillation delivers 150 to 300 joules (depending on the type of device), in an effort to essentially reset (depolarize) the heart and resume a more normal rhythm. Refer to the AHA’s guidelines and algorithms (linked in the previous heading) for defibrillator (shock) indications and timing.
A demonstration of defibrillation with an AED is presented in this video. Watch the rhythm examples, as they are from an actual patient. Also, the AHA guidelines and algorithms may be reviewed.
Intubation
When a patient is receiving general anesthesia prior to a procedure or surgery or is experiencing respiratory failure or respiratory arrest, an ETT is inserted by an advanced practitioner, such as a respiratory therapist, paramedic, or anesthesiologist, to maintain a secure airway. The ET tube is sealed within the trachea with an inflatable cuff, and oxygen is supplied via a bag valve mask or via mechanical ventilation .
Placement is verified with a CO 2 detection device to ensure it is in the airway and not the esophagus . Auscultation should be done to verify equal, bilateral breath sounds. A chest x-ray will be ordered and performed for definitive placement confirmation and also to verify the ETT is in the optimal position. The ETT is attached to an Ambu bag, and the patient’s ventilation is provided by squeezing the bag every six seconds to deliver breaths until a mechanical ventilator is available. At that point, the bag is disconnected from the ETT, and the mechanical ventilator circuit is attached. Nurses collaborate with RTs and healthcare providers regarding the overall care of the patient on a mechanical ventilator.
This video shows intubation, bagging, placement detection, and attachment of the ETT to a ventilator in an emergency. Watch the technique and landmarks used with the laryngoscope, how the ETT is passed through the vocal cords, and the postintubation actions.
Mechanical Ventilation
A mechanical ventilator is a machine attached to an ETT to assist or replace spontaneous breathing. Mechanical ventilation is termed invasive because it requires the placement of a device inside the trachea through the mouth, such as an ETT. Mechanical ventilators are managed by RTs via protocol or provider order. The FiO 2 can be set from 21 to 100 percent.
Intubation and mechanical ventilation are uncomfortable and distressing to the patient, so patients are customarily sedated with an anxiolytic (e.g., lorazepam or midazolam) or anesthetic-type (e.g., propofol) medication. These drugs help the patient achieve synchrony with the ventilator, allowing the ventilator to provide all, or most of, the ventilation support. Some ventilator settings are so contrary to normal physiological breathing that patients will require continuous IV neuromuscular blockade or chemical paralysis. This drug therapy allows for complete control of breathing by the ventilator, and it is vital to provide sedation for patients on paralytics. Intubated and ventilated patients are at increased risk for ventilator-associated pneumonia (VAP), and there are nursing care actions like maintaining patients with the head of the bed at 30 degrees minimum, frequent oral care, and proton-pump inhibitor therapy in order to prevent the occurrence of VAP.