Cardiorespiratory Issues

Support—Psychosocial, Cultural, and Spiritual Considerations According to the American Nurses Association (2015), nurses must consider the "culture, value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language" of patients when planning their care (p. 17). The patient with the new cardiorespiratory illness will have a plethora of needs, most of which they had never considered prior to the occurrence of their illness. Nurses are uniquely qualified to educate patients on available resources.

Psychosocial Support When learning to live with a cardiorespiratory diagnosis, patients will need an abundance of psychosocial support. It is vital that nurses show empathy when providing care, as the patient's sense of self-worth has likely been altered. Many factors will determine the support patients have available at home, including culture, family dynamic, age, gender, spirituality, and religion.

Psychosocial support can come in the form of formal counseling or talk therapy, one-on-one or in a group. Many patients do not have insurance to cover medications or psychotherapy. If that is the case, patients and caregivers can join support groups through local chapters of the American Heart Association or COPD Foundation or through their religious/spiritual affiliations. Patients may even join a free online group for their condition, which can help people who live in remote areas or with mobility issues to connect with peers. Sharing feelings with others who are going through similar experiences can help to improve patient mood and self-esteem.

Cultural Considerations Because of the constant migration of patients from around the world to the United States, cultural competence must be considered in a global context (Douglas et al., 2014). Cultural competence is the belief that people of all cultures deserve to be treated with dignity. The culturally competent nurse honors diversity by participating in positive cultural interactions and advocating for the removal of barriers to care for all people. Douglas et al. (2014) recommended the following guidelines for culturally competent practice:

1. Nurses must have knowledge of the values, practices, and family systems of culturally diverse patients, populations, and communities.

2. Nurses must be purposefully trained in care that is congruent with culture, during their initial nursing preparation and throughout their nursing career.

3. Nurses must regularly reflect on their cultural values and beliefs to ensure that they know the impact their heritage has on their practice.

4. Verbal and nonverbal communication should be used to identify culturally unique health care needs.

5. Nursing practice should use culturally sensitive skills to implement culturally congruent care.

6. Health care organizations should provide the resources to evaluate the language and cultural needs of their clients.

7. Nurses shall advocate for inclusion of their patients' cultural beliefs and practices, recognizing that health care policies and delivery systems can negatively affect patient populations.

Health disparities are a sad fact of many chronic illnesses. Women, African Americans, and the poor are disproportionately affected by many chronic cardiorespiratory illnesses (Criner & Han, 2018). While improving access to care is known to remove some health inequities, many patients in the United States do not have health insurance. This is particularly distressing as chronic illnesses are very expensive to manage and treat.

Spiritual Considerations

• Nurses provide spiritual care to patients through intentional use of presence and compassion (Bone, Swinton, Hoad, Toledo, & Cook, 2018). Prayer with patients and family, especially during a life-threatening illness, may be part of the holistic care that nurses offer. While helping others spiritually, nurses are often better able to personally cope with very sick or dying patients. Chaplains are an integral part of spiritual care, and nurses often employ them to help fulfill this vital patient need.

Contributing Factors to Consider There are risk factors for CVD that can be changed through patient behavioral modification and those that cannot. According to Whelton et al. (2017), modifiable risk factors for CVD include:

• tobacco smoking (first or second-hand), • appropriate self-management of diabetes mellitus, • high cholesterol (hyperlipidemia), • overweight or obesity, • lack of physical activity, and • eating an unhealthy (high carbohydrate, high fat) diet.

Fixed risk factors are those that are relatively unchangeable, such as patient age, gender, having obstructive sleep apnea, family history, and psychosocial stress (Whelton et al., 2018). Patient education is empowering. It helps to avoid cardiorespiratory conditions altogether, but once a cardiorespiratory condition has been diagnosed, the patient goals change to educating the patient to appropriate self-management of the condition, thereby avoiding exacerbation and hospital readmission.

Patient Education: Hypertension

• Hypertension increases the risk of CVD and many other chronic conditions, so nurses must stay abreast of the most recent guidelines for management. Patient education should include the stages of hypertension and whether the patient’s blood pressure is elevated (see Table 1.6). Once they are aware of where they fall in the guidelines, patients should be educated to modify hypertension risk factors. According to Whelton et al. (2018), this includes:

• reduction or elimination of dietary sodium; • exercising 3 to 5 days per week for at least 30 minutes; • reduction of daily alcohol consumption to two or fewer drinks for men, and no more than

one drink for women; • avoiding cigarette smoke; and • weight loss.

Table 1.6

2017 Hypertension Guidelines

Type of Hypertension Systolic BP Diastolic BP

Normal Blood Pressure < 120mm Hg and < 80mm Hg

Elevated Blood Pressure 120-129mm Hg and < 80mm Hg

Stage 1 Hypertension 130-139mm Hg or 80-89mm Hg

Stage 2 Hypertension > or = to 140mm Hg or > or = to 90mm Hg

Hypertensive Crisis > 180mm Hg and/or >120mm Hg

Note. Adapted from "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary," by Whelton et al., in the Journal of the American College of Cardiology, 2018, 71, 2199-2269.

Patient Education: Hyperlipidemia

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Hyperlipidemia is the medical term for elevated serum cholesterol levels. Hyperlipidemia can be managed with medications (such as HMG-CoA reductase inhibitors, better known as "statins") or with lifestyle management. Statins can be prescribed alone or in combination with other lipid- lowering medications. According to Ngo-Metzger and Gottfredson (2017), adults with high cholesterol should be treated with a statin, even if they have no history of CVD, if they are between 40 and 75 years of age or have abnormal lipids, diabetes, hypertension, or use tobacco. In addition to using statins, lifestyle changes should be made, including:

• losing weight; • eating a low fat, low sodium diet; • increasing dietary fiber intake; • increasing exercise; and • avoiding alcohol consumption.

Patients often refuse to take statins because of their side effects. When educating patients about statins, nurses should explain that the side effect of joint ache is serious, but very rare. Patients who have this side effect will usually experience it in all their joints.

Patient Education: Diabetes

• Diabetes mellitus is a complex comorbidity that increases the risk of CVD. According to the American Diabetes Association (2018), patient self-management education should include:

• education on diabetic nutrition, meal planning, and examples of each; • that patient medications should be taken as prescribed; • the need for weight loss if patient is overweight; • the importance of physical activity; • the importance of screening for and management of hypertension and hyperlipidemia; • the importance of smoking cessation; and • the necessity of regular provider appointments, at least twice annually.

Prevention and Health Promotion

• Patients must be educated to avoid risks and engage in health promotion activities. Health promotion activities include:

• following recommended nutritional and exercise guidelines,

• losing weight, • avoiding tobacco smoke, • getting recommended immunizations, and • taking all prescribed medications.

Nutrition: General Dietary Recommendations The dietary recommendations for all Americans, according to the U.S. Department of Health and Human Services (HHS) and U.S. Department of Agriculture (USDA) (2015) specify the need to eat:

• a variety of vegetables in a variety of colors, from all subgroups; • whole fruits and grains; • dairy products that are reduced fat or nonfat, including fortified soy; and • lean proteins, including seafood, lean meats, poultry, and nuts.

Trans fats, saturated fats, sodium, and added sugars should be eaten in only very small quantities. Less than 10% of calories each day should be from either saturated fats or added sugar, and less than 2,300mg of sodium should be consumed daily (U.S. Department of Health and Human Services [HHS] & U.S. Department of Agriculture [USDA], 2015). Alcohol, if consumed by adults, can be one drink per day for women and two drinks per day for men. The recommendation is that most of the foods that people consume be "nutrient dense," meaning that the protein source is not diluted by fats, sodium, and sugars (HHS & USDA, 2015, p. xiv). No matter what, serving sizes should be observed. Food labels indicate the size of each serving. Patients must be educated to multiply the number of servings they will eat by that item. For example, many products claim that they are "low sodium" on the label, but when determining the actual amount of sodium that will be consumed, it may turn out to be higher than the recommended daily amount.

Nutrition: Cardiorespiratory Requirements

• Patients with cardiorespiratory conditions have some unique nutritional requirements. For example, the AHA (2018c) recommends that the cardiac patient consume no more than 1,500mg of sodium per day. Patients taking warfarin must avoid foods high in Vitamin K, as it reverses the anticoagulant effect of the medication, and increases the patient's international normalized ration (INR) level. Nursing education should advise patients on warfarin to avoid green, leafy vegetables such as kale, collard greens, spinach, broccoli, chard, and asparagus. Patients on warfarin should also avoid drinking green tea (as it also lessens the effect of warfarin) or consuming alcohol or cranberry juice (which increases the effect) (Mayo Foundation for Medical Education and Research, 2018). Patients with COPD have increased nutritional requirements because of the additional work of breathing (COPD Foundation, 2016). If dietary requirements are not met, musculature of the chest wall could deteriorate. If COPD patients are underweight, patients can be educated to add

the following sources of additional calories: butter, margarine, mayonnaise, peanut butter, nuts, and high-fat ice cream (COPD Foundation, 2016). Meeting nutritional requirements is one way nurses can help to reduce hospital readmissions for the COPD patient.

Preventing Cardiorespiratory Illness Through Exercise/Mobility When attempting to prevent cardiorespiratory illness, people must be active. The AHA (2015) offers the following recommendations for overall cardiac health:

• moderate-intensity aerobic activity should be performed a minimum of 30 minutes each day, at a minimum of 5 days per week, or

• vigorous aerobic activity should be performed for at least 75 minutes per day for a minimum of 3 days per week, and

• moderate- to high-intensity muscle strengthening should be performed at least 2 days per week.

The above list mentions two types of exercise, endurance/aerobic exercise and strength training (AHA, 2015c). Examples of moderate-intensity endurance exercise include water aerobics, gardening, or ballroom dancing. Examples of vigorous aerobic exercise include jogging or running, singles tennis, or jumping rope (AHA, 2015c). Another fitness category is flexibility exercise, which includes stretching, yoga, and Pilates. Flexibility exercise can help maintain or improve mobility. If not stretched, muscle fibers shorten, hampering muscle contraction (President and Fellows of Harvard College, 2016). Stretching helps to increase the range of motion of all joints, reduce risk of injury, and improve balance. Stretching tips include:

• Start with warm muscles. • Relax while stretching. • Breathe normally throughout the stretch—usually exhaling while pulling. • Hold each stretch for 10 to 30 seconds and repeat each stretch three to five times. • Stretching should never hurt, but a pulling feeling is normal. • Avoid locking joints (like knees) when stretching (AHA, 2015a).

Patients should be encouraged to do a variety of exercises to prevent boredom, and to not give up even if their routine is interrupted. Staying active is important to prevent cardiorespiratory illness or exacerbation.

Exercise Recommendations for Cardiorespiratory Patients

• For the cardiac patient, exercise recommendations are changed by individual conditions. For example, the patient on an anticoagulant for afib needs to exercise in a safe environment, such as a pool, to avoid the risk of bleeding due to a fall. It is important that cardiac patients not exacerbate a cardiac condition, so they may have specific parameters placed on their exercise. Exercise can increase circulation, lower blood pressure, relieve stress, reduce depression, and

reduce the likelihood of stroke (AHA, 2015c). The cardiac patient must get cardiology clearance before starting any program. Patients with COPD and asthma should be encouraged to exercise, as it increases cardiac function, muscle mass and bone density, and overall mobility (Corbridge & Nyenhuis, 2017). In the COPD patient particularly, exercise increases the ability to perform ADLs, such as combing hair or reaching above the head (Corbridge & Nyenhuis, 2017). Respiratory patients should get clearance from their pulmonologist before starting any exercise program.

Exercise is a known trigger for bronchoconstriction, which is caused by the hyperventilation of cool, dry air (Corbridge & Nyenhuis, 2017); however, the asthma patient can be educated to avoid an exacerbation by premedication with an albuterol inhaler 15 to 20 minutes prior to exercise and performing 15 minutes of warm-up and cool-down exercises (Corbridge & Nyenhuis, 2017). The patient should be educated to focus on aerobic exercise, and patients should avoid exercising outside when pollution levels, such as ozone and particulates, are high. Finally, asthma patients should make sure to always have their rescue inhaler with them in case they become dyspneic during exercise.

The mental health benefits of exercise are well known. Cardiorespiratory patients often have psychological challenges, as they feel sidelined by their illnesses; however, improved mental health through exercise can benefit these patients as they are able to improve their overall fitness and mobility, and restore function.

Smoking Cessation Cigarette smoke has long been recognized as an allergen and pathogen; however, the current use of inhaled nicotine, also known as e-cigarettes or vape, have started a new round of research, and a debate about whether e-cigarettes are safer. In the absence of reproducible research, many medical providers have suggested that e-cigarettes are safer than traditional cigarettes because liquid nicotine does not have many of the other dangerous ingredients; however, a few things are currently known:

• E-cigarettes come in fruit and candy flavors, so they are more enticing to young people. • There is no guarantee that the vapor coming from an e-cigarette is only nicotine, as many

police departments report illicit drugs being inhaled from the vape devices. • Many states have outlawed flavored nicotine for use in the e-cigarettes.

Therefore, while the conversation about smoking cessation has traditionally been about quitting cigarette smoking, it is now about the cessation of any tobacco use. The risks of cigarette smoking are undeniable. COPD and CVD are largely diseases of the tobacco smoker, and addiction to cigarettes is worldwide (Criner & Han, 2018).

Immunizations To promote health, nurses should encourage patients to get all recommended immunizations. If patients under the age of 18 have missed a dose of a recommended vaccination, the Centers for Disease Control and Prevention (CDC) has a schedule for patients to use to catch up on their immunizations. If patients are age 19 or older, the adult schedule should be followed (CDC, 2018). When offering a patient an immunization, a nurse must obtain a completed questionnaire and offer the most recent vaccine information statement.

Seasonal Influenza Vaccines and Pneumococcal Vaccines

The CDC (2017b) recommends that from early autumn until late spring all people in the United States who are candidates get the seasonal influenza (flu) vaccination. Seasonal flu can lead to severe morbidity and even death. Patients cannot get the flu from vaccination, as it uses a dead virus; however, there is a possibility that patients may experience a mild reaction as the body prepares for a reaction to a viral attack.

Bacterial pneumonia can also be prevented through vaccination. There are two pneumonia immunizations: The pneumococcal conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPSV23) (CDC, 2017a). As their names would imply, the PCV13 protects patients against 13 strains of bacteria and the PPSV23 against 23. Promoting health in patients would require education that all patients aged 65 and older, or younger patients with increased risk, which includes cigarette smokers, people living in a group home or facility, or patients with chronic illness, should get the pneumococcal vaccines (CDC, 2017a).

People that should avoid the pneumococcal vaccines are those who have had an allergic reaction to eggs (which is part of the manufacturing process) or have suffered anaphylaxis from a previous pneumonia vaccination (like Prevnar or PCV7) or diphtheria toxoid (CDC, 2017a). While immunizations are safe overall, expected side effects include edema or soreness at the injection site. Patients should be educated that it is safe to get both the influenza and either pneumococcal vaccine simultaneously. Immunizations can be received from primary care offices, as a patient in the hospital, or through a pharmacy. If a patient has no insurance, many community health centers or hospitals offer free or low-cost options.

Handwashing Handwashing is the primary prevention method for all illnesses, including viral and bacterial infections. Nurses should recommend handwashing to patients and model good handwashing techniques, which include:

1. Wet hands with clean water. 2. Lather hands with soap, making sure to focus on all parts of the hand, including under the

nails, the backs of the hand, and between each finger. 3. Scrub hands for a minimum of 20 seconds. 4. Use clean water to rinse hands. 5. Use a clean towel or air dryer to dry (CDC, 2016).

Patients should wash hands after touching an animal, food, waste, garbage, or a wound, as well as after coughing, sneezing, or blowing the nose (CDC, 2016). Nurses should perform hand hygiene using soap and water or with a hand sanitizing liquid or foam before and after patient care.

Medications Patients with cardiorespiratory conditions can have many expensive medications. This will be a challenge for a low-income, poor, or homeless patient. Patients cannot take medication they cannot afford. This is particularly problematic for cardiorespiratory patients because new technology, research, legislative changes, and few cost restrictions make for very expensive medications. For example, the patient with COPD or asthma may have three different inhaled, prescription medications, all of which are likely to be name-brand medications and very expensive. Legislation that outlawed generic albuterol inhalers in the United States because of

the environmental impact allowed pharmaceutical companies to get a new patent on inhaled albuterol. While the environmental impact was improved, the cost grew exponentially.

Nurses should encourage patients to be forthcoming with their ability to afford medications, as there are many resources available to reduce or eliminate their cost. The Partnership for Prescription Assistance (PPA) is a free service that acts as a clearinghouse for patients who cannot afford medications. Once the patient fills out an online form, PPA will direct them to local resources (Partnership for Prescription Assistance [PPA], n.d.). Through partnerships with many nationwide organizations, PPA places the cost of medications in reach for many. Each community has a variety of resources for affordable medications, including community centers and hospitals, low-cost medication lists at many big box stores, and pharmacy coupons to be used when the copays of many medications are too high.

• Medications must be used as prescribed to prevent exacerbation or rehospitalization; therefore, nurses must explain to patients that it is better to ask for samples or alternative medications than to use them less frequently than prescribed. In addition, patients must get concise written instructions for each inhaled medication, as many cardiorespiratory patients are confused about which inhaler is long acting and which is to be used during a dyspneic episode. If a patient complains that an inhaler is not working, that is a sign he or she needs further education. Tobacco Cessation Medications

Education regarding tobacco cessation medication should include a list of medications for use in cessation. Chantix (varenicline) is a smoking cessation aid that allows for a low starter dose that a patient takes while continuing to smoke after establishing a "quit date." On the "quit date," the patient stops smoking cigarettes and takes the higher dose of medication. Patient education must include the fact that there are two dosages in the starter pack, and that following its completion, a continuing pack will be taken with only the higher dose of medication. Side effects of the medication are multiple, and patients should be encouraged to read the package insert and return to their prescription provider with any questions.

Nicotine patches and gum remain options to help patients stop smoking cigarettes, with many Medicaid plans paying for the medications in full (even though they are found over-the-counter at most pharmacies). If patients use a nicotine patch, patients must be educated to remove old patches every 24 hours and to place a new patch in a different location. Nicotine gum or lozenge directions on the package should be followed carefully. Patients must also be educated that they should never use nicotine patches, gum, or lozenges while using tobacco products.

Medication Side Effects

Patient education about any medication must include information about side effects, but cardiorespiratory medications have some that are unique. For example, albuterol rescue inhalers cause patients to get light-headed for a few moments after inhalation, so they should be advised

to know how it would affect them before using them while driving. ICS inhalers are steroids, so they have the same effect as oral steroids, in that they will thin patient skin and compromise patient immunity.

Medications that lower blood pressure will often have the side effects of dizziness, while some in the diuretic class will increase urination. Other antihypertensives, such as angiotensin converting (ACE) inhibitors, cause mild angioedema, which causes the "ACE cough" that patients may experience. Beta-blockers, used in many patients to control blood pressure, will also slow the heart rate. Because of this side effect, many prescribers use this class of medications to control an elevated heart rate as well. Regardless of the medication, nurses should educate patients on expected side effects. While many of the side effects are well known, the patient should still be encouraged to notify their prescriber immediately when they occur, as many drugs have suitable alternatives.

Resources for Nonacute Care The cardiorespiratory patient will have a variety of needs after being discharged from an acute care facility. This includes cardiac rehabilitation, pulmonary rehabilitation, or just the need for different types of durable medical equipment. Table 1.7 lists many of the resources that must be considered to help the patient transition back to self-care. Table 1.7

Resources Needed for Nonacute Care

Durable Medical Equipment

• Walkers, canes, or wheelchairs for balance or mobility • Oxygen concentrators or supplies • Portable oxygen tanks

Medication • Prescription medication assistance to avoid running out of medications

Transportation • Specialist appointments • Primary care appointments • Pharmacy

Living Conditions • Ramps, wheelchair accessible hallways/shower, if patient is in wheelchair • Ability to move to a ground-floor apartment if respiratory status is

compromised • Family, group home, or skilled nursing facility, if patient is unable to live

independently

Cardiac Rehab • Bridge to independence for patients with multiple cardiac conditions: post- MI, postcardiac catheterization

• Patients learn to self-manage conditions with the help of a team

Pulmonary Rehab • Bridge to independence for patients with COPD or pulmonary fibrosis • Patients rehabilitate their lungs and learn to exercise and manage condition

in a controlled environment

Return to Employment Issues

• Time off needed for rehabilitation • Change of duties and modification of workload • Breathing difficulty may interfere with job performance