Cardiorespiratory Complexities By Andrea R. Johnson

Cardiorespiratory Complexities By Andrea R. Johnson

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Introduction

Within the human chest cavity lie the heart and lungs; the complex systems that contain them are the cardiovascular and respiratory (pulmonary) systems. The cardiovascular system is comprised of the heart and the blood vessels, while the pulmonary system contains the lungs and thoracic cavity. Both systems can be affected by patient lifestyle, which can include exercise, diet, and avoidable risks, and by the comorbid conditions that cause or exacerbate cardiac, vascular, and pulmonary conditions. In this chapter, pathophysiology will be reviewed, nursing management of prevalent cardiovascular and respiratory problems will be discussed, and educational resources will be provided so nurses can help patients return to their optimal level of functioning.

Pathophysiology

Normal Function: Cardiovascular System

The heart is a hollow, four-chambered organ, which is normally about the size of a fist. It is located within the thoracic cavity, between the right and left lung. The cardiac septum separates the heart vertically, creating a right and left atrium and a right and left ventricle. There are four valves of the heart that keep the blood moving in a single direction. The sounds of the opening and closing of the valves create the “lub-dup” sound of the heart (Figure 1.1).

Cardiovascular Anatomy

Arteries take the oxygenated blood from the heart to the organs, branching into arterioles and capillaries. This is called perfusion. Arterial flow, which is felt through various pulse points, is strong, as the heart is an efficient pump.

Once the oxygen (O2) has left the blood through the capillaries, it becomes deoxygenated. Deoxygenated blood is then returned to the heart through the veins. The venous blood flow is much slower because venous blood pressure is much lower; therefore, a series of one-way valves prohibit blood from traveling backward and pooling.

Figure 1.1

Cardiac Circulation

Normal Function: Respiratory System

The respiratory system functions as a means of gas exchange between the air outside the body and the blood. The respiratory system is comprised of the upper respiratory tract (nares, paranasal sinuses, pharynx, and larynx) and lower respiratory tract (trachea, bronchi, bronchioles, and alveoli of the lungs) (see Figure 1.2). The gases that are exchanged are O2 and carbon dioxide, which help to regulate the pH of the blood and the body’s acid-base balance (Corroon & Hynes, 2014).

Figure 1.2

The Respiratory System

Arterial blood gases (ABGs) are a quick way of determining lung function, as well as how well the body is being oxygenated (see Table 1.1). ABGs are taken from a punctured artery, often by a respiratory therapist, at the patient’s bedside. The nurse should request an order from the medical provider whenever the patient has a change in respiratory condition.

Table 1.1

Normal Arterial Blood Gas Levels

Note. Adapted from M. Sole, D. G. Klein, & M. J. Moseley, Introduction to Critical Care Nursing (7th ed.). St. Louis, MO: Elsevier, 2017.

Ventilation occurs when a person breathes in and out, also known as inspiration and expiration respectively, moving air throughout the lungs (Corroon & Hynes, 2014). Perfusion is the blood flow through the capillary bed of the lungs or other tissues. In the patient with healthy lungs, there is a 1:1 ratio of ventilation to perfusion.

Diffusion is when O2 and carbon dioxide move back and forth across the alveolar-capillary membrane. This is also called air exchange and is how the lungs oxygenate the blood supply. PaO2 is the partial pressure of O2 in arterial blood, which shows the amount of O2 in the blood plasma. SpO2 (pulse oximetry) is the percentage of hemoglobin molecules, a part of the red blood cell, in which the O2 receptors are full. Each hemoglobin molecule has four O2 receptors.

Breath sounds are those auscultated through a stethoscope. Depending on the type of sound and location, the nurse can determine if additional assessment is necessary (see Table 1.2). Other indicators of poor oxygenation are cyanosis, inability to speak, and poor capillary refill.

Table 1.2

Normal/Abnormal Breath Sounds

Note. Adapted from M. Sole, D. G. Klein, & M. J. Moseley, Introduction to Critical Care Nursing (7th ed.). St. Louis, MO: Elsevier, 2017.

Abnormal Findings: Cardiovascular System

Findings that would indicate that a patient is having a cardiac event can be either subjective or objective. An example of a subjective finding is a patient complaint of chest pain of 8 on a 10-scale, with radiation to the jaw and left arm. An example of an objective finding would be a blood pressure reading of 156/82. While there are many abnormal cardiovascular conditions, exemplars to be discussed are coronary artery disease, chest pain either from angina or myocardial infarction (MI), and cardiac arrhythmias.

Abnormal Findings: Respiratory System

The tissue of the lungs is sensitive to environmental pollutants; therefore, exposure to pollutants, such as dust, mold, tobacco smoke, or cockroaches, can create both reversible and irreversible respiratory illnesses. When there is a ventilation/perfusion (V/Q) mismatch, breathing either exceeds or is exceeded by perfusion, causing abnormal lung function (see Table 1.3). Chronic obstructive pulmonary disease (COPD), asthma, influenza, and pneumonia, which can cause atelectasis, are all respiratory disorders which, when severe, can cause a V/Q mismatch and respiratory failure.

Table 1.3

Causes of Ventilation/Perfusion (V/Q) Mismatch

Note. Adapted from “Nursing Care and Conditions Related to the Respiratory System,” by A. M. Corroon & G. Hynes, in A. Brady, C. McCabe, & M. McCann (Eds.), Fundamentals of Medical-Surgical Nursing: A Systems Approach (pp. 243-283). Hoboken, NJ: John Wiley & Sons, 2014.

Prevalent Cardiological Problems

Coronary Artery Disease (CAD)

Coronary artery disease (CAD) is another name for atherosclerosis, which can affect the arteries of the entire cardiovascular system (American Heart Association [AHA], 2018a). Atherosclerosis occurs when plaque develops within the cardiovascular system because of damage from comorbid conditions, such as hypertension, hyperlipidemia, or diabetes. The plaque causes the arterial walls to harden and thicken, which narrows the lumen of the vessel (see Figure 1.3). CAD can be chronic, building up slowly over time until the arteries are partially or totally occluded, or can be acute, causing a thrombus from ruptured plague. A computed tomography (CT) scan with injected dye is often obtained to determine the degree to which coronary arteries are blocked and whether there is a likelihood of rupture. Rupture can occur at any place within the cardiovascular system, such as in the carotid arteries or within the aorta.

Figure 1.3

Arterial Plaque

Research Minute — Why “Door-to-ECG” in less than 10 minutes in the Emergency Department?

Yiadom et al. (2017) studied how long it took to identify that a patient was having an ST-elevated myocardial infarction (STEMI) by electrocardiogram (ECG) in seven different emergency departments (EDs) across the United States. The time ranged from 14 to 80 minutes prior to ECG assessment. “Door-to-ECG” time of less than 10 minutes allows for optimal STEMI patient outcomes with earlier detection. Remember the idiom “time is heart muscle,” because the longer it takes to implement cardiac interventions, the more heart damage occurs.

Chest Pain – Angina

When there is greater than a 70% blockage of the coronary arteries, angina can occur (Olson & Bowden, 2014). Angina refers to chest pain that is not indicative of a MI. Stable angina is the most common symptom of CAD, which results from myocardial ischemia. Ischemia occurs when the myocardial tissue is starved for O2, and necrosis has started to occur. Stable angina is often treated in an outpatient clinic as a chronic condition, when interventions such as angioplasty are impossible or ineffective.

The hallmark of stable angina is pain that occurs intermittently at the same time of onset, duration, and with the same intensity (Olson & Bowden, 2014). This can develop either from increased O2 demand or consumption, or decreased O2 supply. Stable angina usually occurs during exertion, which increases myocardial O2 demand, and is relieved by rest. Nurses evaluate chest pain using the PQRST acronym (see Figure 1.4).

Unstable angina is chest pain that is not predictable—it follows no regular pattern (National Heart, Lung, Blood Institute, n.d.). Unstable angina often leads to MI, as coronary vessels are blocked by blood clots or dislodged arterial plaque. When this occurs, the patient is usually treated with angioplasty and placement of a cardiac stent to reopen the artery and limit the cardiac damage. This process is also called revascularization.

Chest Pain – Myocardial Infarction

There are two types of MIs: ST-elevated myocardial infarctions (STEMI) and non-ST-elevated myocardial infarctions (NSTEMI). STEMIs are diagnosed by a cardiologist or other medical provider by viewing the ECG tracing and seeing that the ST-segment of the cardiac waveform does not return to baseline (see Figure 1.5). STEMIs occur when a coronary artery is fully occluded, starving the cardiac muscle of O2 and resulting in sudden cardiac cellular necrosis (Olson & Bowden, 2014). The damage caused by STEMIs affects the entire heart at a great depth (American College of Cardiology [ACC], 2016).

STEMIs require immediate revascularization, as the more time that passes the greater likelihood that the patient will suffer neurological complications or die. While the priority is getting the patient to the catheterization laboratory (cath lab) within 90 minutes, not every hospital has one at its disposal (ACC, 2016); therefore, some STEMIs are treated with thrombolytics instead of or prior to revascularization and stent placement.

NSTEMIs are the result of a severely narrowed coronary artery lumen, which is not fully occluded (ACC, 2016). In addition to not showing ST-elevation on an ECG tracing, NSTEMIs do not cause damage through the entire cardiac muscle. In addition, there are different types of clotting proteins and platelets at work, which is why NSTEMIs cannot be treated with thrombolytics. Patients who have confirmed NSTEMIs are treated with blood thinners, such as heparin, to avoid further occlusion of a coronary artery.

If the patient suffers sudden cardiac arrest at any time during a cardiac event, the patient may be a candidate for therapeutic hypothermia (ACC, 2016). Therapeutic hypothermia, also called targeted temperature management, is used to lower a patient’s core body temperature with the goal of reducing neurological complications after sudden cardiac arrest (AHA, 2018b). There are a variety of temperatures and lengths of time that a patient can be kept at that temperature, based on multiple patient factors.

Patient Education: Signs and Symptoms of MI

There are multiple signs and symptoms of MI, and patients must be educated to get emergency help immediately if they occur. According to the AHA (2016), common signs of MI include:

Midsternal chest discomfort (which may feel like pain, pressure, squeezing, or fullness) that lasts for longer than a few minutes, but may go away and come back;

Pain or discomfort in the jaw, shoulder, back, neck, or arms;

Unexplained shortness of breath (with or without other chest signs); or

Diaphoresis, nausea, or lightheadedness.

Myocardial Infarction in Women

While women may have the same signs of an MI as men, there are multiple differences. The chest pressure that is felt by men is often described as feeling like an elephant is sitting on the chest, but women often do not describe their chest discomfort as pressure (AHA, 2015b). In addition, women may experience fainting or pain in the lower chest and abdomen, with accompanying nausea and vomiting. Signs are often less severe than expected, sometimes being confused with gastric distress or an upper respiratory infection; therefore, it is imperative that nurses prepare women for what to expect because, while the signs may be less severe, the outcome may be just as deadly (AHA, 2015b).

Myocardial Infarction in Diabetic Patients

People with diabetes often have no idea they are having an MI because the neurovascular complications of diabetes often eliminate or dull the common signs of pain or pressure. According to the ADA (2018), diabetic autonomic neuropathy is an “independent risk factor for cardiovascular death and silent myocardial ischemia” (p. S44) and can also increase the likelihood that patients will be injured if they exercise to avoid cardiac disease. Therefore, it is imperative that all diabetic patients be educated on the need for cardiological investigation at least annually as well as before starting an exercise program to determine if CVD is present.

Figure 1.4

PQRST of Chest Pain Assessment

Note. Adapted from “Nursing Care and Conditions Related to the Circulatory System,” by K. Olson, & T. Bowden, in A. Brady, C. McCabe, & M. McCann (Eds.), Fundamentals of Medical-Surgical Nursing: A Systems Approach (pp. 284-320). Hoboken, NJ: John Wiley & Sons, 2014.

Table 1.4 discusses some of the laboratory values that a nurse can anticipate being ordered on a cardiac patient. It gives a brief description of the lab test, when it is ordered, and what is considered an abnormal result.

Table 1.4

Abnormal Cardiac Laboratory Values

Note. Adapted from “Nursing Care and Conditions Related to the Circulatory System,” by K. Olson, & T. Bowden, in A. Brady, C. McCabe, & M. McCann (Eds.), Fundamentals of Medical-Surgical Nursing: A Systems Approach (pp. 284-320). Hoboken, NJ: John Wiley & Sons, 2014; and “ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report From the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America,” by C. W. Yancy et al., in the Journal of the American College of Cardiology, 70(6) 776-803 (2017).

Cardiac Arrhythmias

An arrhythmia is an abnormal cardiac rhythm. While any abnormal heart rate is a concern, an arrhythmia should be confirmed with a 12-lead ECG (see Figure 1.6). This is because there is emergency nursing management of some arrhythmias. One such tachyarrhythmia, atrial fibrillation, has such requirements.

Atrial fibrillation (afib) cannot be counted using an apical or radial pulse, as it is irregularly irregular. This means that the atria and the ventricles are moving at different rates, which can only be seen with an ECG (see Figure 1.6). If an ECG is not obtained, the nurse may miss a rapid ventricular rate. The speed of the ventricles is important because it may not allow for adequate ventricular fill time, and there will not be enough oxygenated blood to send to the systemic circuit when the heart contracts; therefore, the rate must be controlled, usually through administration of intravenous medication.

During afib, the two atria beat chaotically, rapidly, and out of sequence with the ventricles, which can cause blood clots to form. If one of those clots goes to the pulmonary or neurovascular system, the patient can develop a pulmonary embolism (PE) or have a cerebrovascular accident, also known as a brain attack. To avoid this, patients will be placed on an anticoagulant medication, such as warfarin.

If the cardiologist feels that the patient may have already developed blood clots in the heart, a Transesophageal Echocardiogram (TEE) will be performed (see Figure 1.5). A TEE is performed by inserting a probe in the esophagus or stomach to create and record an ultrasound image (Stanford Medicine, 2018). TEEs are used to diagnose and manage multiple cardiac conditions including heart failure, supraventricular arrhythmias (including afib and atrial flutter), and physiological abnormalities such as valve disease (Stanford Medicine, n.d.).

Figure 1.5

Transesophageal Echocardiogram (TEE)

Note. Adapted from “Our Approach for TEE,” by Stanford Medicine on the Stanford Health Care website at https://stanfordhealthcare.org/medical-tests/t/transesophageal-echocardiogram/conditions.html

Figure 1.6

12-Lead Electrocardiogram (ECG)

Table 1.5

Vital Signs in the Adult Patient

Note. Adapted from “Nursing Care and Conditions Related to the Circulatory System,” by K. Olson, & T. Bowden, in A. Brady, C. McCabe, & M. McCann (Eds.), Fundamentals of Medical-Surgical Nursing: A Systems Approach (pp. 284-320). Hoboken, NJ: John Wiley & Sons, 2014;

Nurses must be aware of multiple cardiac conditions, and this list of exemplars is not exhaustive. Nurses must also be aware that many cardiological conditions place patients at greater risk for additional chronic conditions, as each organ system is interdependent upon multiple others. In the next section, respiratory problems will be discussed, with chronic obstructive pulmonary disease, asthma, and pneumonia as exemplars.

Prevalent Lower Respiratory System Problems

Chronic Obstructive Pulmonary Disease (COPD)

COPD is another name for chronic, progressive, nonreversible, respiratory disease (Bostock-Cox, 2017). COPD includes emphysema and chronic bronchitis, as well as nonreversible asthma. Spirometry, with which COPD is diagnosed and managed, is a test where a patient blows into a machine called a spirometer. To have COPD, the ratio of FEV1/FVC must be 80% or less. FEV1/FVC is the forced expiratory volume (FEV1) of the first second of exhalation divided by the forced vital capacity (FVC), the amount that a patient blows during the entire test.

The 2017 Global Initiative for Obstructive Lung Disease (GOLD) recommendations suggest that nonpharmacological therapies, such as pulmonary rehabilitation (pulmonary rehab), relaxation, diet, and exercise, should be employed before medications (Bostock-Cox, 2017). Medications for COPD include:

long-acting inhaled medications, such as beta agonists (LABAs) or muscarinic agonists (LAMAs), used alone or together;

inhaled corticosteroids (ICS), such as fluticasone or budesonide; and

short-acting inhaled medications (SABA), such as albuterol.

Comorbidities

Patients with COPD often have multiple comorbidities, such as cardiovascular disease (CVD), diabetes, anxiety, and depression (Bostock-Cox, 2017). In addition to administering medications, nurses should educate patients on pursed-lip breathing (see Figure 1.7). Pursed lip breathing allows patients to feel more in control of their COPD through controlled breathing. It increases alveolar airways, helps to remove carbon dioxide, and reduces anxiety.

Asthma

Asthma is a chronic, reversible airway disorder characterized by inflammation and bronchospasm. It can be diagnosed at any age, often affecting infants and adults alike. Allergens, exercise, or viral illness can trigger asthma, but the hallmark of the asthma exacerbation or asthma attack is the symptom of wheezing (see Table 1.2).

Medications used to treat and manage asthma exacerbation include SABAs, LABAs, and ICSs. If a patient is using a rescue inhaler (nebulized albuterol) more than two to three times per week, a preventive medication must be started. As mentioned above, asthma can be triggered by allergens, so management may also include nondrowsy antihistamines or even anti-inflammatory medications such as montelukast.

Asthma action plans (AAPs) are documents that tell patients what to do to prevent asthma attacks, what medications to take and when, and what to do in the event of an emergency (Wagner & Steefel, 2017). School personnel use AAPs to manage childhood asthma while the patient is in school; providers use them to adjust medications in family practice. AAPs must be created and adjusted for optimal quality of life for the patient with asthma.

Pneumonia

Pneumonia can be either viral, fungal, or bacterial, developed outside the hospital, called community-acquired pneumonia, or as a hospital-acquired illness (Corroon & Hynes, 2014). Regardless of the microorganism, the hallmarks of pneumonia are a sharp, piercing pleuritic chest pain, fever, anorexia, productive cough, and tachypnea (see Table 1.2). Auscultation of lung fields may indicate crackles, dullness, or absent breath sounds over peripheral lung fields. Viral pneumonia is one that occurs from infection with a virus. Examples include the influenza virus or rhinovirus, and because of fever, patients often complain of chills. Pneumonia is primarily diagnosed through chest x-ray, but sometimes a chest CT is ordered. Treatment of pneumonia depends on the organism of infection.

Restoration of Function

Patients may be forever changed after having a cardiac or respiratory event, exacerbation, or being diagnosed with a chronic cardiorespiratory condition. Acute care of a patient with an MI or pneumonia includes quick nursing assessment of patient symptoms, administration of O2, and intravenous medications; however, once the patient is stabilized, it is important that the nurse encourage the patient to participate fully in inpatient physical and occupational therapies, so that his or her physical condition does not further deteriorate. This is the most important first step in supporting the cardiorespiratory patient’s restoration of function.

Inpatient and outpatient nursing education must be consistent to ensure there is no confusion regarding the interventions that will return the patient to an optimal level of functioning. Patients must be educated to comply with all prescribed medications, therapies, specialist appointments, activity levels, and dietary changes. Each patient and family member should be given multiple credible, written and Web-based resources for self-education about the diagnosed condition to avoid future cardiorespiratory exacerbations or worsening of the condition. Nurses must also work to develop a therapeutic relationship by actively encouraging patient questions and evaluating patient understanding at each step in the educational process.

Transition to Independence

Patient independence is often jeopardized by a cardiorespiratory illness. Patients may have to change where they live if there are access problems, such as narrow stairs hallways; they need a great deal of help with their activities of daily living (ADLs); or if their employment is lost. Nurses should help patients stay as independent as possible, while advocating for patient safety.

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:

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

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

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

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

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

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

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

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

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:

Wet hands with clean water.

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.

Scrub hands for a minimum of 20 seconds.

Use clean water to rinse hands.

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

Checks for Understanding

What is the goal of nursing management in the care of patients with a cardiac or respiratory problem?

What modifiable risk factors should nurses educate patients about to prevent a cardiorespiratory condition?

How do nurses advocate for patients when they cannot afford medications?

What are the nutritional requirements of the patient with COPD?

What are ways to bridge cardiorespiratory patients to independence, while helping them manage their condition?

Conclusion

The aforementioned cardiorespiratory conditions are just some of the common disease processes. Each one has components that requires patients to perform self-care behaviors in order to sustain wellness. When nurses provide evidence-based education to patients, it allows them a measure of control over their condition and ultimately their lives.

Key Terms

Angioplasty: Surgical repair or unblocking of a coronary vessel.

Aorta: Main artery of the heart, which sends blood to the systemic circuit.

Arrhythmia: A condition in which the heart beats with an irregular or abnormal rhythm.

Arteries: Vessels that take blood away from the heart.

Asthma: Chronic, reversible airway disorder.

Atelectasis: Lung tissue collapse due to poor airflow.

Atherosclerosis: Plaque buildup that causes occlusions of the coronary arteries.

Atrial Fibrillation (afib): Arrhythmia that is irregularly irregular and can lead to blood clotting.

Cardiac Rehabilitation: A rehabilitation program for patients that have suffered a cardiac event.

Cardiac Stent: A tube made of metal or mesh that holds open an artery.

Cardiovascular Disease (CVD): Disease of the blood vessels and heart.

Carotid Arteries: Arteries on each side of the neck that lead to the brain.

Chronic Bronchitis: A type of COPD that causes a lot of mucous and irritation and inflammation of the bronchial tubes.

Chronic Obstructive Pulmonary Disease (COPD): Chronic, progressive lung disease that is nonreversible. COPD includes emphysema and chronic bronchitis.

Comorbidities: The presence of two or more chronic diseases in addition to a primary diagnosis.

Coronary Artery Disease (CAD): The chronic occlusion of the coronary arteries that may lead to myocardial infarction (MI) if untreated.

Cultural Competence: To be respectful and responsive to the health beliefs and practices as well as cultural and linguistic needs of diverse population groups.

Diffusion: Movement of gases (oxygen and carbon dioxide) back and forth across the alveolar-capillary membrane.

Emphysema: Chronic disease of the alveoli in the lungs.

FEV1/FVC: Forced expiratory volume of the first second of exhalation divided by the forced vital capacity; the amount of air that a patient blows during a spirometry test, which determines pulmonary function.

Fixed Risk Factors: Those that are unable or relatively difficult for patients to change.

Hyperlipidemia: Elevated serum cholesterol levels.

Ischemia: When tissue is starved for oxygen and necrosis has started to occur.

Modifiable Risk Factors: Those factors within a patient’s control that, if changed, will improve a patient’s condition.

Myocardial Infarction (MI): The occlusion of one or more major coronary arteries within the heart, leading to oxygen deprivation to an area of the heart and cardiac muscle death, if untreated; another name for heart attack.

Non-ST-Elevated Myocardial Infarction (NSTEMI): Type of heart attack in which the coronary artery is only partially occluded.

PaO2: Partial pressure of oxygen in arterial blood; oxygen in blood plasma.

Perfusion: Blood flow through the capillary beds of the lungs and other organs.

Plaque: Fatty substance that is in and on the walls of the vessels in atherosclerosis.

Pulmonary Rehabilitation: Rehabilitation for patients who have respiratory issues.

Signs: Objective findings based on clinician judgment or test results.

SpO2 (Pulse Oximetry): The percentage of hemoglobin molecules in which oxygen receptors are full.

Stable Angina: Chest pain that occurs intermittently with the same predictability.

ST-Elevated Myocardial Infarction (STEMI): Type of heart attack in which the coronary artery is 100% occluded, requiring revascularization and cardiac stent placement within 90 minutes of patient arrival.

Sudden Cardiac Arrest: When the heart stops during or after a heart attack.

Symptoms: Subjective terms that state what a patient experiences.

Targeted Temperature Management: Another name for therapeutic hypothermia, reflective of the fact that there is a range of temperatures and times at each temperature that are used, based on patient condition.

Therapeutic Hypothermia: When the core temperature of a patient is lowered to prevent neurological complications.

Unstable Angina: Chest pain that is unpredictable and follows no regular pattern.

Veins: Vessels that take deoxygenated blood back to the heart.

Ventilation: Breathing through inspiration and expiration.

Ventilation/Perfusion (V/Q) Mismatch: When there is not a 1:1 ratio of ventilation to perfusion.

References

American College of Cardiology. (2016). Heart attack treatment guidelines. Retrieved from https://www.cardiosmart.org/Heart-Conditions/Guidelines/Heart-Attack-Guidelines

American Diabetes Association. (2018). Standards of medical care in diabetes. Diabetes Care, 41(1), S1-S156. doi:org/10.2337/dc18-Sint01

American Heart Association. (2015a). Flexibility exercise (stretching). Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/Flexibility-Exercise-Stretching_UCM_464002_Article.jsp#.W06XwtJKjIU

American Heart Association. (2015b). Heart attack symptoms in women. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofaHeartAttack/Heart-Attack-Symptoms-in-Women_UCM_436448_Article.jsp#.W0YybdJKjIU

American Heart Association. (2015c). Moderate to vigorous—What is your level of intensity? Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/Moderate-to-Vigorous—What-is-your-level-of-intensity_UCM_463775_Article.jsp#.W06T59JKjIV

American Heart Association. (2018a). Coronary artery disease- coronary heart disease. Retrieved from http://www.heart.org/HEARTORG/Conditions/More/yHeartandStrokeNews/Coronary-Artery-Disease—Coronary-Heart-Disease_UCM_436416_Article.jsp

American Heart Association. (2018b). CPR & first aid: Emergency cardiovascular care. Retrieved from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-9-acute-coronary-syndromes/?strue=1&id=1

American Heart Association. (2018c). The American Heart Association’s diet and lifestyle recommendations. Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/The-American-Heart-Associations-Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp#.W0-9idJKjIU

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

Bone, N., Swinton, M., Hoad, N., Toledo, F., & Cook, D. (2018). Critical care nurses’ experiences with spiritual care: The spirit study American Journal of Critical Care, 27(3), 212-219. doi:10.4037/ajcc2018300

Bostock-Cox, B. (2017). The 2017 GOLD guideline on COPD: Implications for practice. Practice Nurse, 1, 30.

Centers for Disease Control and Prevention. (2016). Handwashing: Clean hands save lives. Retrieved from https://www.cdc.gov/handwashing/when-how-handwashing.html

Centers for Disease Control and Prevention. (2017a). Adults: Protect yourself with pneumococcal vaccines. Retrieved from https://www.cdc.gov/features/adult-pneumococcal/index.html

Centers for Disease Control and Prevention. (2017b). Key facts about seasonal flu vaccine. Retrieved from https://www.cdc.gov/flu/protect/keyfacts.htm

Centers for Disease Control and Prevention. (2018). Recommended immunization schedule for adults aged 19 years or older, United States, 2018. Retrieved from https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-compliant.html

COPD Foundation. (2016). Slim Skinny’s reference guide. Retrieved from file:///C:/Users/ajhom/Downloads/SSRG_NutritionTips_v1.3_WM.CV01.pdf

Corbridge, S. J., & Nyenhuis, S. M. (2017). Promoting physical activity and exercise in patients with asthma and chronic obstructive pulmonary disease. Journal for Nurse Practitioners, 13(1), 41-46.

Corroon, A. M., & Hynes, G. (2014). Nursing care and conditions related to the respiratory system. In A. Brady, C. McCabe, & M. McCann (Eds.), Fundamentals of medical-surgical nursing: A systems approach (pp. 243-283). Hoboken, NJ: John Wiley & Sons.

Criner, R. N., & Han, M. K. (2018). COPD care in the 21st century: A public health priority. Respiratory Care, 63, 591-600. doi:10.4187/respcare.06276

Douglas, M. K., Rosenkoetter, M., Pacquiao, D. F., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., . . . Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 109-121.

Mayo Foundation for Medical Education and Research. (2018). Warfarin diet: What foods should I avoid? Retrieved from https://www.mayoclinic.org/diseases-conditions/thrombophlebitis/expert-answers/warfarin/faq-20058443

National Heart, Lung, and Blood Institute. (n.d.). Angina. Retrieved from https://www.nhlbi.nih.gov/health-topics/angina

Ngo-Metzger, Q., & Gottfredson, R. (2017). Statin use for the primary prevention of cardiovascular disease in adults. American Family Physician, 96, 805-806.

Olson, K., & Bowden, T. (2014). Nursing care and conditions related to the circulatory system. In A. Brady, C. McCabe, & M. McCann (Eds.), Fundamentals of medical-surgical nursing: A systems approach (pp. 284-320). Hoboken, NJ: John Wiley & Sons.

Partnership for Prescription Assistance. (n.d.) PPA is a free service. Retrieved from https://www.pparx.org/

President and Fellows of Harvard College. (2016). Stretching: The new mobility protection. Harvard Health Letter, 42(4), 4.

Stanford Medicine. (n.d.). Our approach for TEE. Retrieved from https://stanfordhealthcare.org/medical-tests/t/transesophageal-echocardiogram/conditions.html

U.S. Department of Health and Human Services & U.S. Department of Agriculture. (2015). Dietary guidelines for Americans: 2015-2020 (8th ed.) (HHS Publication No. HHS-ODPHP-2015-2020-01-DGA-A). Retrieved from https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf

Wagner, F., & Steefel, L. (2017). Beliefs regarding asthma management relating to asthma action plans (AAPs) of African American caregivers residing in Newark, New Jersey public housing communities. Journal of Pediatric Nursing, 36, 92-97.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himelfarb, C., . . . Wright, J. T. (2018). 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. Journal of the American College of Cardiology, 71, 2199-2269.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., . . . Westlake, C. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report from the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Journal of the American College of Cardiology, 70(6), 776-803. doi:10.1016/j.jacc.2017.04.025

Yiadom, Y. A. B., Baugh, C. W., McWade, C. M., Liu, X., Song, K. J., Patterson, B., W.,…Storrow, A. B. (2017). Performance of emergency department screening criteria for an early ECG to identify ST-segment elevation myocardial infarction. Journal of the American Heart Association, 6(3), 1-12. doi:10.1161/JAHA.116.003528