In the Hospital Case Scenario

What is normal arterial carbon dioxide tension (PaCO2)? (Potter and Perry 965)

35-45mmHG

What is normal arterial oxygen tension (PaO2)? (Potter and Perry 965)

80-100mmHG

What is normal oxygen saturation range? (Potter and Perry 965)

95-100%

What is hyperventilation? (Potter and Perry 965)

State of ventilation in excess of that required to eliminate the normal venous carbon dioxide produced by cellular metabolism

What can cause hyperventilation? (Potter and Perry 965)

Anxiety, infections, drugs, acid-base imbalance, hypoxia, fever, chemically induced

What is hypoventilation? (Potter and Perry 965)

Occurs when alveolar ventilation is inadequate to meet the body's demand or to eliminate sufficient carbon dioxide

What can cause hypoventilation? (Potter and Perry 965)

Severe atelectasis, COPD,

What is hypoxia? (Potter and Perry 965)

Inadequate tissue oxygenation at the cellular level

What can cause hypoxia? (Potter and Perry 965)

Deficiency in oxygen delivery or oxygen utilization at the cellular level, decreased hemoglobin level, diminished conc of inspired oxygen (high alt.), inability of tissues to extract oxygen from blood (cyanide poisoning), decreased diffusion of oxygen from alveoli to blood, poor tissue perfusion (shock), impaired ventilation (rib frac, chest trauma)

How is the cardiac and respiratory system different in an older patient? (Potter and Perry 966)

-Development of atherosclerotic plaques in arterial system

-Osteoporosis leads to changes in size and shape of thorax

-Trachea and bronchi become enlarged

-Alveoli enlarge, decreasing SA available for gas exchange

-Functional cillia reduced, decreases effectiveness of coughing mechanisms

-Increased risk of respiratory infections

-Ventilation and transfer of respiratory gases decline due to lungs being unable to expand fully

What are signs and considerations in changes to respiratory and cardiac system of older adults? (Potter and Perry 966)

-When cardiac problems become acute, they necessitate immediate hospitalization

-Existing/developing atherosclerosis or hypertension results in increased consequences in older adults

-Mental status changes (forgetfulness/irritability) are first signs of respiratory problems

-Older people may not complain about dyspnea until it affects ADLs

-Changes in cough mechanisms result in retention of pulmonary secretions, airway plugging, and atelectasis

-Age related changes to chest structure and muscle strength can affect ability to cough, increasing risk of respiratory infections

-Sedentary older adults who are immunocompromised are at greater risk of respiratory complications, should be encouraged to take influenza and pneumococcal vaccines

What are lifestyle risk factors that decrease cardiopulmonary function? (Potter and Perry 966)

-Poor nutrition

-Inadequate Exercise

-Smoking

-Excessive substance use

-Stress

How can poor nutrition decrease cardiopulmonary function? (Potter and Perry 966)?

-Obesity decreases lung expansion

-Increase body weight increases oxygen demands to meet metabolic needs

-Malnourished patient may experience muscle wasting, resulting in decreased muscle strength and respiratory excursion

-Reduced cough efficiency results in retention of pulmonary secretions, increases risk of infection

-High fat diets increase cholesterol and atherogensis in coronary arteries

-Obesity and malnourishment increases risk of anemia

-High carbs diets increase carbon dioxide load for patients with co2 retention

How can exercise increase cardiopulmonary function? (Potter and Perry 966)

-Increases body metabolic activity and oxygen demand, which over time, increases the rate and depth of respiration

-30-60 minute exercise per day results in lower pulse and bp, lower cholesterol level, increased blood flow, and greater oxygen extraction by working muscles (good things!)

What are exercise recommendations for increasing cardiopulmonary function? (Potter and Perry 966)

-30-60 minutes exericse per day

-150 minutes moderate to vigorous activity per week

-(achievable by 10 minutes of aerobic activity at a time)

What are diet recommendations for increasing cardiopulmonary function? (Potter and Perry 967)

-High # of fresh fruits, vegetables, dietary fibre, nonaminal protein, low-fat dairy products, and reduced sat fat in cholesterol

-High potassium may prevent hypertension

-Reduce intake of conc sugars (ultra-processed foods + beverages) helpful for pts with coronary heart disease

-Total intake of free sugars should not exceed 10% of total daily calorie intake

How does excessive substance use decrease cardiopulmonary function? (Potter and Perry 967)

-Results in poor nutritional intake and decrease in hemoglobin production due to decreased iron intake

-Depresses respiratory center, reducing rate and depth of respiration and amount of inhaled oxygen, direct injury to lung tissues

What should be done during the nurse's health history of a patient's cardiopulmonary function? (Potter and Perry 968)

-Pain

-Fatigue

-Smoking

-Dyspnea

-Coughing

-Wheezing

-Environmental or Geographic Exposure

-Past Respiratory Infections

-Allergies

-Health Risks/Family Health History

-Medications

How is cardiac chest pain subjectively felt in women? (Potter and Perry 968)

May be a sensation of choking, breathlessness, or pain that radiates through to back

What occurs during the physical examination of the cardiopulmonary system? (Potter and Perry 970)

Inspection

-Skin + mucous membrane colour

-General appearance

-LOC

-Adequate systemic circulation

-Breathing patterns

-Chest wall movement

-Nail Clubbing

Palpitation

-Amount+Type of thoracic excursion

-Tenderness

-Tactile fremitus

-Thrills/Heaves

-Cardiac point of maximal impulse

-Abnormal masses or lumps

-Peripheral pulses

-Edema

Percussion

-Abnormal fluid or air in lungs

-Diaphragmatic excursion

Auscultation

-Heart and lung sounds

What is generally done during the assessment phase of caring for a pt's cardiopulmonary function? (Potter and Perry 968)

-Identify recurring and present signs and symptoms associated with the patient's impaired oxygenation

-Ask patient about use of medication

-Determine patient's normal and current activity status

-Determine patient's tolerance to activity

What is generally done during the planning phase of caring for a pt's cardiopulmonary function? (Potter and Perry 976)

-Select nursing interventions that promote optimal oxygenation in the primary care, acute care, or restorative and continuing care setting

-Consult with other health care providers as needed

-Involve pt and family in designing plan of care

Which health care professionals do nurses work with when delivery primary care of cardiopulmonary function? (Potter and Perry 976)

-Physiotherapists

-Nutritionists

-Community based nurses

What are objectives, teaching strategies, and evaluation methods for a pt with cardiovascular disease? (Potter and Perry 978)

Objectives

-Patient will describe risk factors assoc with cardiovasc disease

-Patient will demonstrate health promotion behaviors

Strategies

-Explain patient about modifying risk factors

-Inform patient about other risk factors for cardiovasc disease

-Discuss patient importance of regular bp and blood cholesterol monitoring

-Educate pt on low-fat, low-salt, and calorie appropriate diets

-Educate patient about benefits of exercising 30-60 min per day to reduce weight and lower bp

Evaluation

-Patient will describe modifiable and nonmodifiable risk factors for cardiovasc disease

-Patient will verbalize strategies for balanced nutrition

-Obtain pt weight and bp

-Monitor patient serum cholesterol levels

What are various health teachings that nurses should provide to patients to increase cardiopulmonary function? (Potter and Perry 978)

-Vaccinations

->Annual influenza vaccines recommended everyone +6 months

->Esp pts with chronic illnesses

-> Anyone in close contact with high risk groups

->Pneumococcal vaccine recommended for pts w/ increased risk of developing penumonia

-Healthy Lifestyle Behaviors

->Diet

->Stress

->Exercise (20-30 minute/3-4 times a week)

-->Walking

-->Pulse taking

-->Pacing

->Elimination of use of cigs

->Reduce exposure to pollutants

->Hydration

-Pts with or at risk of cardiopulmonary conditions

->avoid exertion/alcohol in cold weather

->avoid crowded places

->exercise early or late in day when temp is low

->avoid antidiuretics

-Environmental Pollutants

->avoid 2nd hand smoke

->pollutants in work place

What are nursing interventions in acute care of cardiopulmonary dysfunction? (Potter and Perry 980)?

-Dyspnea Management

-Airway Maintenance (Humidification, Nebulization, Chest physiotherapy)

-Suctioning

-Artificial Airway

-Maintenance and Promotion of Lung Expansion

-Maintenance and Promotion of Oxygenation

-Restoration of Cardiopulmonary Functioning

How should dyspnea management be delivered as a nursing intervention to cardiopulmonary dysfunction? (Potter and Perry 980)?

Underlying process of dyspnea must be treated before using a combination of pharmacological measures, oxygen therapy, physical therapy, and psychosocial techniques

How should airway maintenance be delivered as a nursing intervention to cardiopulmonary dysfunction? (Potter and Perry 980)

-Adequate hydration

-Use of proper coughing techniques to remove secretions and keep airway open

-Humidification of oxygen delivered to patient

-Nebulization (adding moisture or medications to inspired air by mixing particles of varying sizes with the air) clears pulmonary secretions

-Chest physiotherapy, group of therapies used in combination to mobilize pulmonary secretions, should be followed by productive coughing and suctioning

How should suctioning be delivered as a nursing intervention to cardiopulmonary dysfunction? (Potter and Perry 981)

Necessary when a patient is unable to clear respiratory tract secretions with coughing

-Oropharyngeal and Nasopharyngeal suctioning-

-> Used when pt can cough effectively but unable to clear secretions by swallowing or expectorating

-Orotracheal and Nasotracheal Suctioning-

-> Used when patient with pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway

-Tracheal suctioning-

-> Used via artificial airway like endotracheal tube or tracheostomy tube

-Open suctioning-

-> Involves sterile catheter that is opened at the time of suctioning

-Closed Suctioning-

-Multi use suction catheter encased in plastic sheath, used on patients who require mechanical ventilation to support respiration

How should artificial airways be delivered as a nursing intervention to cardiopulmonary dysfunction? (Potter and Perry 990)

Used for patients with decreased LOC and an airway obstruction or to aid in the removal of tracheobronchial secretions

-Oral Airway-

Prevents obstruction of trachea by displacement of tongue into oropharynx

-Endotracheal and Tracheal airway-

Used for patients with decreased loc or airway obstruction, and aids in removal of tracheal bronchial secretions

How should maintenance and promotion of lung expansion techniques be delivered as a nursing intervention to cardiopulmonary dysfunction? (Potter and Perry 991)

Noninvasive techniques

-Ambulation-

->Increases general strength and lung expansion

-Positioning-

->Adequate ventilation and oxygenation are maintained through frequent position changes during daily activities

->Reduces risk of stasis of pulmonary secretions and decreased chest wall expansion

-> Most effective = 35-45 degree semi-Fowler's pos

-Incentive Spirometery-

-> Method of encouraging voluntary deep breathing by providing visual feedback to patients about inspiratory volume

Invasive techniques

-Chest tubes-

-> Used to remove air and fluids from the pleural space, prevent air or fluid from re-entering pleural space, and re-establishing normal intrapleural and intrapulmonic pressures

How should maintenance and promotion of oxygenation techniques be delivered as a nursing intervention to cardiopulmonary dysfunction? (Potter and Perry 1001)

-Oxygen Therapy-

-> Used to relieve or prevent tissue hypoxia, should be treated as a medication

-> Adequate safety precautions should be undertaken since oxygen is highly combustible

-> Oxygen is supplied to patients via oxygen tanks or wall-piped system

-> Oxygen is delivered through low-flow (provide oxygen in concentrations that vary depending on pt resp pattern) or high-flow (deliver oxygen higher than normal pt resp pattern)

-Home Oxygen Therapy-

-> Beneficial for patients with chronic cardiopulmonary diseases as it improves patient exercise tolerance, fatigue levels, and management of dyspnea

How should restoration of cardiopulmonary function techniques be delivered as a nursing intervention to cardiopulmonary dysfunction? (Potter and Perry 1006)

If patient is hypoxic is long and severe enough, cardiac arrest will occur, which results in O2 not being delivered to tissues and CO2 not transported. This necessitates cardiopulmonary resuscitation (CPR)

What is the goal of restorative and continuing care of cardiopulmonary dysfunction? (Potter and Perry 1006)

Involves actively helping patient to achieve and maintain optimal levels of health through controlled physical exercise, nutrition counselling, relaxation, and stress management techniques, prescribed medications and oxygen, and adherence to this plan.

What are health teachings for restorative and continuing care of cardiopulmonary dysfunction? (Potter and Perry 1009)

-Hydration-

->keeps mucous ciliary clearance via coughing easier

->recommended intake of 1500-2000mL of fluids per day

-Coughing Techniques-

->Effective for maintaining patent airway, enables removal of secretions from airways

-> Recommended every hour while awake and every 2-3 hours while asleep

->Cascade cough technique: Pt takes slow deep breath while contracting expiratory muscles, then opens mouth and performs series of coughs throughout exhalation

->Huff cough technique: Pt opens glottis by saying word huff

->Quad cough technique: Pt pushes inward and upward on abdominal muscles toward the diaphragm while pt breathes out with maximal expiratory effort, producing a cough

-Breathing Exercises-

-> Improves ventilation and oxygenation

->Pursed lip breathing technique: deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse

-> Diaphragmatic breathing technique: Pt relaxes intercostal and accessory respiratory muscles while taking deep inspirations

What is pneumonia? (Mondor 589)

Acute inflammation of lung parenchyma (tissues responsible for gas exchange) caused by a microbial agent

What causes pneumonia? (Mondor 589)

Likely to result when defense mechanisms of respiratory system (filtration, humidification, epiglottis closure, coughing, mucociliary, IGG A, alveolar macrophages) become overwhelmed by infection

- Decreased LOC inhibits cough and epiglottis

- Tracheal intubation inhibits cough, mucocilliary mechanism, humidification, and filtration

-Air pollution, smoking, infections and aging inhibit mucociliary mechanism

-Malnutrition inhibits IGG and alveolar macrophages

What are the three methods in which infectious agents can reach the lungs? (Mondor 590)

1. Aspiration from nose or mouth

2. Inhalation of microbes present in the air

3. Hematogenous spread from elsewhere in the body

What are different types of pneumonia? (Mondor 590)

Community-Acquired Pneumonia -> lower respiratory tract infeciton of the lung parenchyma with onset in community or first 2 days of hospitalization

Hospital Acquired Pneumonia -> pneumonia occurring 2 days after hospitalization

Fungal Pneumonia -> fungal cause of pneumonia

Aspiration Pneumonia -> Abnormal entry of secretions or substances into lower airway, usually from the mouth or stomach

Opportunistic Pneumonia -> altered immune response, become highly susceptible for resp infections

What are symptoms/clinical manifestations of pneumonia? (Mondor 591, 592)

Fever, chills, tachypnea, tachycardia, dyspnea, nonproductive cough, hypoxemia, chest pain, confusion in older pts

What is the pathophysiology of pneumonia - four stages of disease process (Mondor 591)?

Step 1. Congestion -> outpouring of fluid into alveoli after infectious agents reach alveoli via droplets or saliva. Agents spread and multiply in fluid, which interferes with lung function

Step 2. Red hepatization -> dilation of capillaries occurs, alveoli are filled with agents, neutrophils, rbcs and fibrin. This results in the lung appearing red and granular

Step 3. Grey hepatization -> blood flow decreases and leukocytes and fibrin consolidate in the affected part of the lung

Step 4. Resolution -> resolution and healing occur if no complications are present

What treatment methods are used to support patients with pneumonia? (Mondor 593, 594)

-Antibiotic therapy

-Oxygen therapy -> hypoxemia

-Analgesics -> chest pain

-Antipyretics -> fever

-Plenty of rest and limit activity

-Nutritional Therapy -> 3L of fluid per day and 15000 calories per day

Which populations should be given the pneumococcal vaccine? (Mondor 593)

1. ppl who have chronic illnesses

2. ppl who are recovering from a severe illness

3. Older adults (>65 yrs)

4. Residence in a long-term care facility

5. Immunosuppressed individuals (recom every 5 yrs)

What are the outcomes of poor communication in interprofessional healthcare teams? (Gluyas, 51)

- Poor cooperation and coordination of care

-Errors at handover lead to inaccurate diagnoses, incorrect treatment, and medication errors

-Leads to different perceptions of situations and what is required to manage them

-Delayed response to deteriorating patients

-Compromised patient safety in surgical interventions

What are the 4 skills that contribute to successful teamwork? (Gluyas 51)

Leadership -> awareness, understanding, purpose, planning, responsibilities

Mutual Support -> Feedback, assistance, trust

Situation monitoring -> review team performance, adjust +adapt

Communication-> sharing information, clear communication, acknowledge and check for interpretation

What are 4 cognitive processes that are employed during cognitive overload? (Gluyas 53)

-Attentional tunnelling (only paying attention to one aspect of a challenge)

-Confirmation bias (only consider confirming evidence)

-Memory failures (lapses or slips in carrying out actions)

-Inaccurate mental models (erroneous model of what decisions and actions are required)

What is the effect of the hierarchical gradient in the healthcare profession in terms of communication? (Gluyas 52)

Those further down hierarchy may be hesitant to challenge those further up the hierarchy, resulting in reluctance to speak up, even if the hcp perceives a high risk

What factors contribute to hesitancy for hcps to speak up about risks during their work? (Gluyas 53)

Hierarchal gradient

Rudeness or intimidation from other stuff

Poor leadership and relationships in healthcare team

Fear of response from others

Concerns about appearing incompetent in ambiguous or complex situations

What are strategies to improve team communication in health care? (Gluyas 54)

-Education and training programmes

-Checklists + readback protocols

-Instigating structured communication tools (SBAR)

-Introducing briefing and debriefing procedures

Who are crucial members of a patient care team? (TeamSTEPPS, Mod 1)

Patients

What are methods to engage patients and families as part of the patient care team? (TeamSTEPPS, Mod 1)

-Conducting handovers with the patient present

-Including patients in beside rounds

-Providing patients with tools for communicating with their care team such as the use of a whiteboard

-Actively involve patients on planning committees

-Encourage and allow time for questions

-Get input from the patient and family about the care plan

-Give them access to relevant information, presented so they can understand

-Be creative in how you relay information as learning styles will vary from patient to patient

-Ask patients for feedback, encourage them to speak up if they are uncomfortable, afraid, if they see something unsafe, or dont understand something

What are the multiple teams within a multi-team system in the hospital? (TeamSTEPPS, Mod 1)

Core team - small group of care providers who work independently to manage a set of assigned patients from point of assessment to discharge or disposition, involved with direct care with patient

Contingency team - time-limited team formed for emergent or specific events and composed of members from various teams

Coordinating Team - Team comprising those work area members who are responsible for managing the operational environment that support the core team

Ancillary and Support Services Team - provides direct, task-specific, time-limited care to patients

Administration team - includes executive leadership of a unit or facility and have accountability for the overall function and management of the organization

Why should hcp engage with the patient during their care? (TeamSTEPPS, Mod 1)

1. Its the right thing to do

2. Its the safe thing to do

3. It enables innovative solutions

4. Its an expectation standard

What are the 4 basic standards for effective communication? (TeamSTEPPS, Mod 2)

Complete - Communicate relevant and important information

Clear - Convey information that can be plainly understood, using common terminology, avoid using acronyms

Brief - Communicate information in a concise manner

Timely - Avoid delays in communication, be dependable and offer or request information in an appropriate timeframe

What is the SBAR technique of communication? (TeamSTEPPS, Mod 2)

Situation - What is going on with the patient

Background - What is the clinical background or context

Assessment - What do you think the problem is

Recommendation - What should you do to correct it

What is a call-out in hcp communication? (TeamSTEPPS, Mod 2)

A strategy used to communicate important or critical info

-Informs all team mebers simultaneously during emergent situation

-Helps team members anticipate next steps

-Directs responsibility to a specific individual responsible for carrying out the task

What is a check-back in hcp communication? (TeamSTEPPS, Mod 2)

The use of closed-loop communication to ensure that information is conveyed by the sender is understood by the receiver as intended

1. Sender initiates the message

2. Receiver accepts the message and provides feedback

3. Sender double-checks to ensure that the message was received

What is a handover in hcp communication? (TeamSTEPPS, Mod 2)

Transfer of information during transitions in care across the continuum, including an opportunity to ask questions, clarify and confirm

Consists of

1. Transfer of responsibility and accountability

2. Clarity of information

3. Acknowledgement by receiver

4. Opportunity to review

I- Introduction

P- Patient

A- Assessment

S- Situation

S- Safety

B- Background

A- Actions

T- Timing

O- Ownership

N- Next

What is vaccine hesitancy? (Canada)

A refusal of vaccination or a delay in an immunization schedule due to concerns about immunization

What are the most important determinants of vaccine hesitancy? (Canada)

-Lack of understanding about the vaccine being given and about immunizations in general

-Conflicting info from various sources

-Mistrust of source of information

-Perceived risk of serious adverse events and concerns regarding injections

-Lack of appreciation of severity and incidence of vaccine preventable diseases

-Sociocultural beliefs

What principles can be used by vaccine providers to communicate immunization facts effectively to vaccine recipients or parents? (Canada)

-Adopt a vaccine recipient-centered approach (ability to decide, transparency and honesty, dialogue)

-Respect differences of opinion about immunization (listen to origins of vaccine hesitancy, non-judgemental and non-confrontational)

-Represent the risks and benefits of vaccines fairly and openly (communicate risks of disease, safety of vaccines)

-Clearly communicate current knowledge using an evidenced-based approach (present evidence in an understandable way, use of positive terms, varied information formats, less stress)

Why should individuals get vaccines? (Canada)

1. Vaccines work - immunization is the most effective way to protect against vaccine preventable diseases

2. Vaccines stimulate and strengthen the immune system, they train it to defend rapidly against vaccine preventable infections before illness can occur

3. Vaccines are safe

4. The risk of vaccine preventable diseases are many times greater than the risk of a serious adverse reaction to a vaccine

5. Vaccines are not linked to chronic diseases

6. Multiple injections are an effective way of ensuring up to date immunization

7. Vaccine preventable diseases can occur at any time because these pathogens have not been eliminated

8. Unvaccinated individuals have a much greater chance of getting a vaccine-preventable disease than people who have been vaccinated, even in countries with high levels of immunization