2. A REVIEW OF E VIDENCE B ASED P RACTICE E RIN B URDI, A SHLEY J ACOBSON, M ELANIE L YON, R ACHEL N IVISON, & P AULA S AWYER F ERRIS S TATE U NIVERSITY A REVIEW OF E VIDENCE B ASED P RACTICE E RIN B URDI, A SHLEY J ACOBSON, M ELANIE L YON, R ACHEL N IVISON, & P AULA S AWYER F ERRIS S TATE U NIVERSITY

3.  It is our responsibility as nurses to advocate for our patients.  This includes, but is not limited to, developing a individualized patient plan of care with evidence based interventions to help them attain their highest level of function.  Nurses also have a responsibility to periodically review current interventions and practice to ensure that they are the most up to date and evidence based for patients in their care.  It is our responsibility as nurses to advocate for our patients.  This includes, but is not limited to, developing a individualized patient plan of care with evidence based interventions to help them attain their highest level of function.  Nurses also have a responsibility to periodically review current interventions and practice to ensure that they are the most up to date and evidence based for patients in their care.

4.  Provide a review of evidence based research applied to the use and effectiveness of Incentive Spirometry (IS) for patients having under gone Coronary Artery Bypass Grafting (CABG) surgery.

5.  Respiratory complications are common in patients who have had a CABG  “Up to 65% of patients may have atelectasis, and 3% may develop pneumonia ” (Pasquina et al,2003,p.1).  Respiratory complications are common in patients who have had a CABG  “Up to 65% of patients may have atelectasis, and 3% may develop pneumonia ” (Pasquina et al,2003,p.1).  Research has found the addition of IS to a regimen of early mobilization and C&DB did not improve postoperative lung function more rapidly” (Jenkins,et.al,1989,pp 637-638).  Research has found the addition of IS to a regimen of early mobilization and C&DB did not improve postoperative lung function more rapidly” (Jenkins,et.al,1989,pp 637-638).

6.  The evidence based research reviewed regarding the advantage of IS with CABG patients seems ambiguous.

7.  Strider et al. (1994) researched the IS and its effectiveness on pulmonary shunts.  Limitations: Sample size was small. Population included only intubated patients.  Strider et al. (1994) researched the IS and its effectiveness on pulmonary shunts.  Limitations: Sample size was small. Population included only intubated patients.  Jenkins et al. (1989) studied the effects of IS included with huffing and deep breathing  Advantage: Attempted to control internal validity by monitoring physiotherapists.  Limitation: Population included only men.  Jenkins et al. (1989) studied the effects of IS included with huffing and deep breathing  Advantage: Attempted to control internal validity by monitoring physiotherapists.  Limitation: Population included only men.

8.  Harton et al.(2007) researched the percentage of preoperative IS volume achieved using IS after cardiac surgery.  Advantage: Standardized teaching helped improve internal validity.  Limitation: Inconclusive of how long it would take patients to achieve 100% preoperative volume.  Harton et al.(2007) researched the percentage of preoperative IS volume achieved using IS after cardiac surgery.  Advantage: Standardized teaching helped improve internal validity.  Limitation: Inconclusive of how long it would take patients to achieve 100% preoperative volume.  Gale & Sanders (1980) compared the use of IS with intermittent positive pressure breathing.  Limitations: Inconsistencies in the method of treatment: respiratory therapists were not monitored. Treatments only performed 4x per day: previous research states IS should be used 10x per hour.  Gale & Sanders (1980) compared the use of IS with intermittent positive pressure breathing.  Limitations: Inconsistencies in the method of treatment: respiratory therapists were not monitored. Treatments only performed 4x per day: previous research states IS should be used 10x per hour.

9.  Even in the shadow of research ambiguity, IS remains an integral part of post operative nursing care and a frequently used technique for prophylaxis of respiratory complications nationwide.  95% of hospitals in the United States that perform cardiothoracic or abdominal surgeries still utilize IS as a part of post operative care (Overend et al.,2001, p.972).  This includes the West Michigan Cardiothoracic Surgeons (WMCTS) at Spectrum Health in Grand Rapids, Michigan.  Even in the shadow of research ambiguity, IS remains an integral part of post operative nursing care and a frequently used technique for prophylaxis of respiratory complications nationwide.  95% of hospitals in the United States that perform cardiothoracic or abdominal surgeries still utilize IS as a part of post operative care (Overend et al.,2001, p.972).  This includes the West Michigan Cardiothoracic Surgeons (WMCTS) at Spectrum Health in Grand Rapids, Michigan.

10.  The WMCTS on the Cardiovascular Unit at Spectrum Health order IS in conjunction with C&DB and early ambulation as a standard plan of care for their post CABG patients.  Nurses on this unit are trained to assist patients with these techniques as early as twelve hours post procedure.  Patients are instructed to use the IS and C&DB hourly while in bed and are mobilized up to their chair for meals and assisted to ambulate in the unit hallways four times a day.  The WMCTS on the Cardiovascular Unit at Spectrum Health order IS in conjunction with C&DB and early ambulation as a standard plan of care for their post CABG patients.  Nurses on this unit are trained to assist patients with these techniques as early as twelve hours post procedure.  Patients are instructed to use the IS and C&DB hourly while in bed and are mobilized up to their chair for meals and assisted to ambulate in the unit hallways four times a day.

11.  Patient compliance with treatment is a determining factor to the success of treatment and pain control plays a major role in patient compliance.  CABG patients experience incisional pain, acute pain related to invasive lines and chest tubes, and musculoskeletal pain from intra-operative positioning.  While pain is a subjective experience and relative to the individual, most post CABG patients arrive to the unit with a lot of pain  Patient compliance with treatment is a determining factor to the success of treatment and pain control plays a major role in patient compliance.  CABG patients experience incisional pain, acute pain related to invasive lines and chest tubes, and musculoskeletal pain from intra-operative positioning.  While pain is a subjective experience and relative to the individual, most post CABG patients arrive to the unit with a lot of pain

12.  Cardiovascular nurses on this unit are trained to expect and manage these types of pain with prescribed analgesics, splinting techniques, and patient positioning in order to facilitate WMCTS’ prescribed activities.

13.  While the evidence that we as group have reviewed indicates no specific benefit to IS and C&DB exercises, as a cardiovascular nurse of ten years on this unit, I have personally witnessed the difference in the recovery of post CABG patients compliant with the prescribed course of treatment.  Patients compliant with this course of treatment seem to recover quicker and have fewer complications.  Therefore in compliance with WMCTS’ recommendations, cardiovascular nurses on this unit continue to incorporate these methods in their patient’s plan of care.  While the evidence that we as group have reviewed indicates no specific benefit to IS and C&DB exercises, as a cardiovascular nurse of ten years on this unit, I have personally witnessed the difference in the recovery of post CABG patients compliant with the prescribed course of treatment.  Patients compliant with this course of treatment seem to recover quicker and have fewer complications.  Therefore in compliance with WMCTS’ recommendations, cardiovascular nurses on this unit continue to incorporate these methods in their patient’s plan of care.

14.  The evidence is inconclusive  Cardiothoracic Surgeons still incorporate IS as standard practice  Nurses can take two different paths  Choose to continue to teach the use of IS  Choose not to teach the use of IS  The evidence is inconclusive  Cardiothoracic Surgeons still incorporate IS as standard practice  Nurses can take two different paths  Choose to continue to teach the use of IS  Choose not to teach the use of IS

15.  Based on Nursing judgment & experience, we believe that the use of IS practice still offers benefits to patients.  Patient education plays a vital role to IS’ effectiveness. Nurses should: Ensure all patients receive same teaching Teach correct use Encourage frequent use  Nurses should always remain dedicated to our role as patient advocates.  Based on Nursing judgment & experience, we believe that the use of IS practice still offers benefits to patients.  Patient education plays a vital role to IS’ effectiveness. Nurses should: Ensure all patients receive same teaching Teach correct use Encourage frequent use  Nurses should always remain dedicated to our role as patient advocates.

16.  Harton, S., Grap, M., Savage, L., & Elswick, R. (2007). Frequency and predictors of return to incentive spirometry volume baseline after cardiac surgery. Progress in Cardiovascular Nursing, 22(1), 7-12. Retrieved from CINAHL database.  Jenkins, S. C., Soutar, S. A., Loukota, J. M., Johnson, L. C., & Moxham, J. (1989). Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax, 44(8), 634-639. Retrieved from PubMed (2799743).  Nieswiadomy, R. M. (2008). Foundations of Nursing Research (fifth ed., pp. 201-202). Upper Saddle River, NJ: Pearson Prentice Hall.  Overend, T., Anderson, C., Lucy, S., Bhatia, C., Jonsson, B., & Timmermans, C. (2001). The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. CHEST, 120(3), 971-978. Retrieved from CINAHL database.  Pasquina, P., Tramèr, M., & Walder, B. (2003). Prophylactic respiratory physiotherapy after cardiac surgery: systematic review. BMJ: British Medical Journal, 327(7428), 1379-1381. Retrieved from CINAHL database.  Strider, D., Egloff, M., Burns, S. M., & Truwit, J. D. (1994). Stacked inspiratory sprirometry reduces pulmonary shunt in patients after coronary artery bypass. CHEST, 106, 391-395. doi: 10.1378/chest.106.2.391  Harton, S., Grap, M., Savage, L., & Elswick, R. (2007). Frequency and predictors of return to incentive spirometry volume baseline after cardiac surgery. Progress in Cardiovascular Nursing, 22(1), 7-12. Retrieved from CINAHL database.  Jenkins, S. C., Soutar, S. A., Loukota, J. M., Johnson, L. C., & Moxham, J. (1989). Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax, 44(8), 634-639. Retrieved from PubMed (2799743).  Nieswiadomy, R. M. (2008). Foundations of Nursing Research (fifth ed., pp. 201-202). Upper Saddle River, NJ: Pearson Prentice Hall.  Overend, T., Anderson, C., Lucy, S., Bhatia, C., Jonsson, B., & Timmermans, C. (2001). The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. CHEST, 120(3), 971-978. Retrieved from CINAHL database.  Pasquina, P., Tramèr, M., & Walder, B. (2003). Prophylactic respiratory physiotherapy after cardiac surgery: systematic review. BMJ: British Medical Journal, 327(7428), 1379-1381. Retrieved from CINAHL database.  Strider, D., Egloff, M., Burns, S. M., & Truwit, J. D. (1994). Stacked inspiratory sprirometry reduces pulmonary shunt in patients after coronary artery bypass. CHEST, 106, 391-395. doi: 10.1378/chest.106.2.391