Cardio_Chapter_017

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Chapter 17: Interventions for Acute Cardiopulmonary Conditions:

Chapter 17: Interventions for Acute Cardiopulmonary Conditions

Introduction:

Introduction Factors That Contribute to Functional Loss Acute inflammation, severity of illness, marginal baseline function, exposure to corticosteroids, neuromuscular blockers, prolonged immobilization, length of stay Acute cardiopulmonary conditions – disease in which O 2 transport system fails to meet immediate demand Acute cardiopulmonary dysfunction is associated with ischemic CVD, COPD, postoperative pulmonary complications, HTN, DM, obesity

Introduction:

Introduction Table 17-1. Clinical Systemic Effects of Immobilization

Airway Clearance Techniques:

Airway Clearance Techniques Manual or mechanical procedures that facilitate mobilization of secretions from airways Optimal airway clearance choice based on pathophysiology and symptoms, stability of medical status, patient’s adherence Patient examination before, during, and after treatment provides information to judge patient tolerance and treatment effectiveness Goals: optimize airway patency, increase ventilation and perfusion matching, promote alveolar expansion, increase gas exchange

Airway Clearance Techniques:

Airway Clearance Techniques Table 17-3. Summary of Devices Used for Airway Clearance

Airway Clearance Techniques:

Airway Clearance Techniques Postural Drainage Assumption of one or more body positions that allow gravity to assist with draining secretions from each lung segment Positions can be modified to address precaution or relative contraindication Positioning requires adjustable bed, pillows, blanket rolls Priority given to treating most affected lung segment first Encourage deep breathing and coughing

Airway Clearance Techniques:

Airway Clearance Techniques Fig. 17-1. Patient positions for postural drainage.

Airway Clearance Techniques:

Airway Clearance Techniques Box 17-1. Precautions and Relative Contraindications for Postural Drainage

Airway Clearance Techniques:

Airway Clearance Techniques Percussion Chest percussion aimed at loosening retained secretions (manually or mechanically) Vibration Performed manually or mechanically and utilized in postural drainage positions to clear secretions Cough Techniques and Assists Effective cough consists of four stages Positioning and teach proper cough Surgical patients: instruct in splinting

Airway Clearance Techniques:

Airway Clearance Techniques Box 17-2. Precautions and Relative Contraindications for Percussion and Vibration

Airway Clearance Techniques:

Airway Clearance Techniques

Airway Clearance Techniques:

Airway Clearance Techniques Active Cycle of Breathing Consists of a series of maneuvers performed by patient to emphasize independence in secretion clearance and thoracic expansion Aids for Coughing Devices and techniques that involve manual or mechanical application of forces to body or intermittent pressure changes to airway to assist inspiratory/expiratory muscle function Mechanical cough delivers deep insufflations followed immediately by deep exsufflations ; may add abdominal thrust

Airway Clearance Techniques:

Airway Clearance Techniques Airway Suctioning Suctioning is performed routinely for intubated patients to facilitate the removal of secretions and stimulate the cough reflex Patients with artificial airways can be instructed in huffing and cough assist techniques Suction catheter can reach only to level of mainstem bronchi Suctioning should be the last resort Lavage can be used to stimulate reflexive cough

Airway Clearance Techniques:

Airway Clearance Techniques Fig. 17-5. Suctioning procedure. A, Administration of supplemental oxygen via manual resuscitator bag. B, Insertion of sterile catheter into tracheal tube.

Breathing Strategies, Positioning, and Facilitation:

Breathing Strategies, Positioning, and Facilitation Therapeutic Positioning Techniques and Ventilatory Movement Strategies Assist with progression from dependence to independence in mobility and breathing Indicated for patients who have weakness of the diaphragm Inspiratory and expiratory effort breathing with upper extremity movement Progress breathing techniques to functional activities

Breathing Strategies, Positioning, and Facilitation:

Breathing Strategies, Positioning, and Facilitation Therapeutic Positioning Techniques and Ventilatory Movement Strategies (cont’d) Position of body greatly influences ventilation and respiration Use of prone positioning is beneficial Positioning for Dyspnea Relief Arms supported allows the accessory breathing muscles to act on the rib cage allowing more expansion for inspiration

Breathing Strategies, Positioning, and Facilitation:

Breathing Strategies, Positioning, and Facilitation Fig. 17-7. Positioning for relief of dyspnea.

Breathing Strategies, Positioning, and Facilitation:

Breathing Strategies, Positioning, and Facilitation Table 17-4. Indications and Outcomes for Breathing Strategies

Breathing Exercises:

Breathing Exercises Pursed-Lip Breathing Decreases patient’s symptoms of dyspnea Slows RR Paced Breathing Volitional coordination of breathing during activity Inspiratory Hold Technique Involves prolonged holding of breath at maximum inspiration Stacked Breathing Series of deep breaths that build on top of previous breath without expiration

Breathing Exercises:

Breathing Exercises Diaphragmatic Controlled Breathing Used to manage dyspnea, reduce atelectasis, increase oxygenation Facilitating outward motion of abdominal wall while reducing upper rib cage motion during inspiration Sniffing can be added to engage the diaphragm Scoop technique Lateral Costal Breathing Addresses rib cage mobility and intercostal muscles

Breathing Exercises:

Breathing Exercises Upper Chest Inhibiting Technique Inhibiting the upper chest can help a patient recruit the diaphragm during inhalation Used after implementation of other techniques Thoracic Mobilization Techniques Simple thoracic mobilization techniques to increase the ability of the thorax to expand during breathing Counterrotation Increases tidal volume and decreases respiratory rate by reducing neuromuscular tone and increasing thoracic mobility Butterfly Upright version of counterrotation technique

Breathing Exercises:

Breathing Exercises Inspiratory Muscle Training (IMT) Indicated for patients with signs and symptoms of decreased strength or endurance of diaphragm and intercostal muscles D ecreased chest expansion, decreased breath sounds, SOB, uncoordinated breathing, bradypnea , decreased tidal volume Goal: increase ventilatory capacity and decrease dyspnea IMT program consists of two parts – strengthening and endurance Resistive training – handheld training devices Incentive spirometer Combined with deep breathing 10 times per waking hour

Breathing Exercises:

Breathing Exercises Fig. 17-9. Patient using an incentive spirometer.

Special Considerations for Mechanically Ventilated Patients:

Special Considerations for Mechanically Ventilated Patients Goal of ventilated patients is to return to spontaneous breathing Weaning – process of discontinuing mechanical ventilation Combination of mechanical ventilation and medications leads to complications

Special Considerations for Mechanically Ventilated Patients:

Special Considerations for Mechanically Ventilated Patients Intervention Considerations Optimize airway clearance and pulmonary function Balance patient’s energy expenditure Determining effective means of communication with patient Airway clearance Breathing strategies Optimizing communication with other healthcare professionals Special attention to preoperative teaching for prevention of pulmonary complications

Exercise:

Exercise Exercise in form of both endurance and strength training should be used in acute care setting to prevent and treat negative neuromuscular sequelae of critical illness Goal of endurance – maximize independence and efficiency when patient performs ADLs Did the patient really tolerate treatment well?

Exercise:

Exercise Table 17-5. Normal Adult Ranges for Cardiopulmonary Values at Rest

Exercise:

Exercise Components of Exercise: Frequency, Intensity, Time, Type PT needs to be aware of current medications Monitor HR, BP, RR, SaO 2 Frequency – multiple short intervals of exercise followed by rest is tolerated better in acute care Intensity – Borg RPE, Dyspnea scale, complaints of angina Time – amount of time patient can tolerate activity

Exercise:

Exercise Components of Exercise: Frequency, Intensity, Time, Type Type – method of exercise or technique that is to be used for training Functional activities are commonly used in acute care (bed mobility, transfers, standing, ambulation, stairs, stationary bike, pedal exerciser, recumbent bike, upper body ergometer, treadmill)

Exercise:

Exercise Box 17-4. Abnormal Responses to Exercise

Exercise:

Exercise Functional Mobility Training May be initiated as soon as patient has stable vital signs Bed mobility Transfers and ambulation Use of assistive devices Recruit personnel assistance for equipment management Progress patient to least restrictive device

Exercise:

Exercise Box 17-5. Contraindications or Precautions for Advancing Functional Mobility

Injury Prevention and Equipment Provision:

Injury Prevention and Equipment Provision Safety is paramount Must monitor patients closely to determine how the patient is responding to patient interventions Start with low-level exercise and progress slowly, monitoring patient’s response

Patient Education:

Patient Education Patient and caregiver education is essential Decreases length of stay, decreases patient anxiety, increases quality of life, increases adherence with medical advice, increases patient’s participation as an active member of the healthcare team Must assess areas of need and learning style

Patient Education:

Patient Education Three factors contribute to noncompliance barriers patients perceive, lack of positive feedback, perceived helplessness PT should evaluate the effectiveness of the education program Teaching is never complete until learning is assessed

Discharge Planning:

Discharge Planning Crucial part of PT’s role in acute care setting At evaluation, determination of patient’s rehabilitation potential bears on discharge disposition PT works with discharge planner in acute care May include securing durable medical equipment

Discharge Planning:

Discharge Planning Fig. 17-13. Decision tree for discharge planning.

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