Activity progression in acute cardiac patients.

Progressive advancement of activity in cardiac patients is well documented in the literature. However, the concern in today's practice centers on balancing prudent progression of activity with a cost-effective delivery of care. This article presents a review of the literature, comparing the state of knowledge with current clinical pathway suggestions for activity therapy in various cardiac populations. An overview of the historical background and the physiological adaptations to bedrest, orthostasis, and exercise are described. Research documenting energy costs and cardiovascular responses to activities of daily living, such as bathing, toileting, and ambulating is also critiqued. Generalizability of research findings is examined, particularly regarding the heterogeneity of cardiac populations (i.e., effects of age, gender, multiple medications, comorbidity), and implications for practice are addressed.

Weight loss methods used by African American and Euro-American women.

In this naturalistic study employing intensive interviews and anthropometric measures, an educationally and economically diverse community-based sample of 40 African American and 40 Euro-American women described their lifetime experiences with weight management. Twenty types of weight loss methods were identified and grouped into one of three categories: lifestyle work, head work, and professional services. The most frequently used weight loss methods were from the lifestyle work category, with the leading methods identified as exercise on own and reduce high calorie and/or increase low calorie foods. African Americans and Euro-Americans overwhelmingly used similar weight loss methods, with the only significant difference occurring in the more frequent use of commercial diet products among the African American group. Methods from the head work category were used significantly more often by women with higher social status, while heavier women more frequently sought professional services to lose weight than thinner women. The Euro-American women engaged in weight loss methods for significantly longer periods of time and were found to weigh significantly less than the African American women. These findings suggest that the shorter duration of weight loss attempts may be a major factor contributing to the larger body size in African American women.

Developing a standard for endotracheal tube cuff care.

Potential complications from the use of cuffed endotracheal tubes are well documented and have generated a large body of research focusing on cuff design and interventions to decrease tracheal damage caused by the cuffs. The authors conducted a state-wide survey to determine the extent to which these procedures were incorporated into practice and to develop a current standard of care for patients with cuffed endotracheal tubes.

The physiologic basis for continuous mixed venous oxygen saturation monitoring.

Critically ill patients often have conditions that reduce oxygen delivery and increase oxygen demand. Routine nursing care, such as suctioning, positioning, and bathing, also increases the patient's oxygen demand. If the patient's oxygen demand exceeds the supply, dysrhythmias, hypotension, altered level of consciousness, and other adverse responses can occur. We describe use of continuous monitoring of mixed venous oxygen saturation (SvO2) as a tool to assess the patient's supply/demand balance during nursing care. The physiology of oxygen transport is reviewed, and oxygen delivery, reserve, and consumption are defined. Conditions that decrease oxygen delivery and increase oxygen demand are discussed, and the effects on SvO2 are illustrated. With continuous SvO2 monitoring, critical care nurses can see the effect of their nursing care on the patient's oxygenation and can adjust their care according to the patient's tolerance.

Effects of endotracheal suctioning on mixed venous oxygen saturation and heart rate in critically ill adults.

The purpose of this multisite study was to determine the effects of endotracheal suctioning on mixed venous oxygen saturation (SvO2) and heart rate in 189 critically ill adults. One-pass, intermittent suction was applied for 10 or fewer seconds, with three prehyperoxygenation and three posthyperoxygenation breaths of 100% oxygen. Subjects at three hospitals (n = 127) underwent suctioning using hyperoxygenation with anesthesia bags and traditional suction catheters (open suction method). Subjects at one hospital (n = 62) underwent suctioning with hyperoxygenation by ventilator and in-line suction catheters (closed suction method). For subjects from all hospital sites combined, the SvO2 decreased from 67% to 64% (p = 0.001), a 4% change from baseline, and returned to baseline within 2 minutes. However, in subjects receiving the open method of suction, SvO2 dropped from 66% to 62% immediately after suctioning and returned to baseline within 4 minutes. In contrast, when the closed suction method was used, SvO2 rose from 67.7% to 67.86% immediately after suctioning, drifting upward to 71% for the next 2 minutes before dropping toward the baseline after 4 minutes. Mean heart rate increased from a baseline of 99 beats/min to 104 beats/min immediately after suctioning (p = 0.001), a 5% change from baseline, and gradually returned to baseline over the next 4 minutes. No significant differences were seen in heart rate between subjects having the open versus closed suction method. In conclusion, the closed suction method showed a higher SvO2 after endotracheal suctioning compared with the open suction method (p = 0.0001). Some form of hyperoxygenation before and after endotracheal suctioning is recommended.

Effects of a 1-minute back rub on mixed venous oxygen saturation and heart rate in critically ill patients.

In this study we evaluated mixed venous oxygen saturation (SvO2) and heart rate responses after a 1-minute back rub in 173 critically ill patients. The back rub was the third and last intervention in a study conducted in intensive care units at four hospitals. For this multiple-intervention study all patients were placed in a supine position to obtain baseline SvO2 and heart rate, then underwent suctioning via endotracheal tube, and were turned to a lateral position. After 15 minutes in a side-lying position, the subjects received a 1-minute back rub. Data were collected immediately after the back rub and at 1-minute intervals for 4 minutes. After the back rub, SvO2 decreased immediately from the mean baseline of 67% to 63% and gradually increased, returning to baseline by minute 4. The mean baseline heart rate of 99 beats/min increased to 103 beats/min immediately after the back rub and gradually decreased after massage, but remained higher than baseline by minute 4. Although the findings were statistically significant (p = 0.0001), these minimal physiologic changes do not represent clinical significance. Based on the findings, the back rub, a traditional nursing measure that can provide comforting touch, represented a minor stimulus affecting heart rate and oxygen demands in most critically ill patients. However, because of the variability found in heart rate and SvO2, individual responses need to be assessed.

Effects of a lateral turn on mixed venous oxygen saturation and heart rate in critically ill adults.

The purpose of this study was to determine the effects of a lateral turn on mixed venous oxygen saturation (SvO2) and heart rate in 183 critically ill adults. Mean SvO2 decreased from a baseline of 67% to 61% saturation (p less than 0.0001) immediately after turning and gradually returned to 66% saturation (p less than 0.002) within 4 minutes. Mean heart rate increased slightly from a baseline of 99 beats/min to 102 beats/min (p less than 0.0001) immediately after turning and decreased slightly to 101 beats/min (p less than 0.0004) within 4 minutes. These statistically significant changes in SvO2 and heart rate were not clinically significant for most patients. However, physiologic responses to turning were highly variable. SvO2 reductions of 25% or more from baseline, heart rate increases and decreases of 10 beats/min or more, and signs of activity intolerance occurred in some patients. Nurses should expect critically ill patients to have a decrease in SvO2 of approximately 9% of baseline and small changes in heart rate after turning. These changes should be transient, with SvO2 and heart rate gradually returning toward baseline levels during the next 4 minutes. If turning triggers large or prolonged changes in SvO2 or heart rate, prompt repositioning and evaluation are needed to prevent adverse effects.