Introduction

At the core of nursing is the therapeutic nurse-client relationship. The nurse1 establishes and
maintains this key relationship by using nursing knowledge and skills, as well as applying caring
attitudes and behaviours. Therapeutic nursing services contribute to the client’s2 health and well-
being. The relationship is based on trust, respect, empathy and professional intimacy, and
requires appropriate use of the power inherent in the care provider’s role.
 This document replaces the 1999 Therapeutic NurseClient Relationship practice standard,
and provides greater clarity and direction on: giving gifts to and receiving gifts from
clients;
 accepting power of attorney on behalf of clients;
 setting appropriate boundaries for the relationship;
 identifying and dealing effectively with unacceptable and/or abusive behaviour in
nurseclient relationships;
 and exercising professional judgment when establishing, maintaining and terminating a
therapeutic relationship.

Respiratory Conditions
The respiratory system carries oxygen to the lungs. The lungs send oxygen all over the
body through the blood. The lungs also clean toxins out of the blood and breathe them
out. When the respiratory system does not work correctly, the entire body is affected.
Common respiratory conditions include:

Asthma
Bronchitis
Cancer
Chronic obstructive pulmonary disease (COPD)
Congestive Heart Failure
Croup
Cystic Fibrosis
Pneumonia
Tuberculosis (Zimlich, 2022)
Care of Patients with Respiratory Conditions
Patients with respiratory conditions not only have problems with breathing, but this
affects everything else that they do. They become tired more easily and have less energy
to do everyday things such as bathing, dressing, and even eating. They also have anxiety
when they cannot get enough oxygen.

Patient Positioning
Check with the patient’s nurse to make sure that there are no special instructions about
positioning the patient or any position that the patient cannot be placed in. Normally, the
best positions for patients with respiratory conditions are the semi-fowler’s or fowler’s
position because these positions make it easier for them to breathe. Semi-fowler’s
position is the patient is lying on their back with the head of the bed raised to between a
30-degree and 45-degree angle. The patient's legs can be bent or straight. Fowler’s
position is the head of the bed is raised to between a 45-degree and 60-degree angle. The
patient’s legs can be placed straight out or slightly bent. It is a higher position than semi-
fowlers. Fowler’s position makes chest expansion easier for the patient and improves
breathing (STERIS, 2023).

For patients who cannot get out of bed, reposition them as often as possible, every 2
hours if allowed, to make breathing easier for them and stop secretions from pooling in
their airways. Respiratory therapists teach patients breathing exercises, such as coughing
and deep breathing movements. CNAs working with the patient should know what
exercises the patient has been taught and encourage the patient to do them. If the patient
is having problems doing breathing exercises or does not want to do them, the CAN
should report this to the respiratory therapist or the nurse.

Watch for Changes

Watch the amount and type of sputum that the patient is bringing up. Changes in the
amount, thickness, or color of the sputum can be a sign of an infection or other change in
the patient’s condition and should be recorded and reported to the nurse. Notice the
patient’s breathing pattern. Notify the respiratory therapist or nurse if there are changes in
breathing, and if the patient is having difficulty breathing. A patient who is having
difficulty with breathing should not be left alone, send someone to get help, turn on the
call light, or open the patient’s door and call out that help is needed immediately.

Mouth Care
Keep the patient’s mouth moist and do regular mouth care. Never adjust the oxygen
setting or stop the oxygen flow. If you have a concern about the patient’s oxygen setting,
talk to the patient’s nurse or respiratory therapist. If the patient complains that they are
not getting in enough oxygen, call the nurse to check on the settings and stay with the
patient.

Exercise
Regular exercise is important for a patient with respiratory conditions to strengthen their
lungs and heart. In the hospital, the physical therapist will put together an exercise
program for the patient and work with them on activities such as getting out of bed and
walking short distances.

The CAN needs to talk to the nurse or therapists working with the patient to decide on the
best time to plan activities such as bathing and dressing the patient so that they are ready
to do other activities but are not worn out. Patients who are too tired to do their exercise
program lose interest in it and are more inclined to give up. Occupational therapists teach
patients energy-saving skills that make it possible for them to do self-care and stay as
independent as possible. These skills should be on the care plan. The CAN should know
the skills that the patient has been taught and help them to continue using them as needed
throughout the day. The CAN needs to report back to the nurse or therapists how the
patient is getting on with what they have learned and if the CAN sees any problems that
they are having.

Eating
The patient’s diet and eating habits can also be affected by their respiratory condition, and
the type of food they eat can affect their breathing. For example, reducing the amount of
carbohydrates in the diet can help make breathing easier. Carbohydrates are sugar, starchy
vegetables like potatoes, bread, rice, and pasta. When the body turns carbohydrates into
energy, it gives off more carbon dioxide for the amount of oxygen used. The patient then
must exhale extra carbon dioxide. Sometimes, it can be hard for patients with respiratory
conditions to eat enough calories each day. A special diet may be planned to help them
stay at a healthy weight.

The patient should rest before eating. Assist the patient to sit upright for meals and make
sure that they are in a comfortable position. Advise the patient to eat slowly and take
small bites of food. Stop between bites and do some deep breathing exercises. It is best to
eat 4-6 small meals a day. This makes it easier for the diaphragm to move and helps
prevent problems with breathing. If taking drinks with meals makes the patient too full to
finish eating, it can be better to drink fluids after meals.

Other things that can be done to make eating easier and more enjoyable for patients with
respiratory conditions is to know the foods that they like and how they like them served.
Can they prepare their meals at home, and what problems, if any, are they having with
shopping for food and meal preparation? Helpful meal preparation advice includes
cooking vegetables until they are soft. Use liquids such as broth, juice, or water to cook
food until it is tender. Meats may be easier to chew if they are cut up into small pieces or
minced. Dipping breads in liquid can make them easier to eat (American Lung
Association, 2023).

Stop Infection
Before going into a patient’s room, a CAN should know if any special precautions need
to be taken. Precautions are steps that healthcare workers take to stop the spread of
infections. This information can be obtained from reports, care plans, and signs that are
placed on the door of the patient’s room. Good handwashing before and after caring for
the patient is standard. Personal Protective Equipment includes gowns, gloves, masks,
and eye protection.
Droplet Precautions are steps taken to protect you against drops of moisture that come
from an ill patient when they cough, or sneeze. Respiratory droplets can also be produced
when certain procedures are being done with the patient, such as suctioning. Normally,
the droplets can travel about 3 feet, and CNAs caring for these patients will need to wear
a gown, gloves, face mask, and eye protection.

Airborne Precautions are used with a patient with certain infections that can be spread
through the air. As well as the protective equipment listed above, CNAs caring for these
patients will also need to wear an approved N95 respirator mask.

Following isolation precautions protects the CAN, the patient, other patients, and the
members of the healthcare team(Douedi, 2022).

Tracheostomy
A tracheostomy is a surgical procedure that makes a small opening in the trachea to allow
the patient to breathe. A tube is put into the tracheostomy opening, and this tube must
always be kept in place and clear of secretions. These patients have blockage of their
upper airway, and the only way they can get air into their lungs is through the
tracheostomy tube. Never cover the opening of a tracheostomy with a blanket or anything
else (Raimonde, 2023). Depending on the qualifications and training of the CAN, their
work with a patient who has a tracheostomy may differ.

When bathing a patient with a tracheostomy, the CAN should be careful not to get water
into the tracheostomy tube. Care should also be taken not to dislodge the tracheostomy
tube. It is held in place with special tracheostomy ties that are attached to each side of the
tracheostomy tube and tied around the patient’s neck. All caregivers should check to see
if the ties are wet or covered with mucus and let the nurse know.

Also, when caring for a patient with a tracheostomy, it is important to check that the
tracheostomy ties are neither too tight nor too loose around the patient’s neck. For an
adult patient, it should be possible to put a finger under the tracheostomy tie. For a child,
 it should only be possible to put a fingertip under the tie. If the tracheostomy tie is found
to be too tight or to lose, this needs to be reported immediately to the nurse. Ties that are
too tight can cause pressure on the patient’s skin, with redness and skin breakdown. A tie
that is too loose puts the tracheostomy tube at risk of falling out (Emory, 2022).
Heat therapy helps improves blood flow to the area where the heat is applied. It’s best for
muscle pain or stiffness. Cold therapy helps reduce inflammation. It’s most helpful when
used for acute injuries and pain.

We treat everything from arthritis to pulled muscles to inflammation with ice packs or
heating pads. Treating pain with hot and cold can be extremely effective for a number of
different conditions and injuries, and easily affordable.

The tricky part Is knowing what situations calls for hot, and which calls for cold.
Sometimes a single treatment will even include both.

As a general rule of thumb, use ice for acute injuries or pain, along with inflammation
and swelling. Use heat for muscle pain or stiffness.
Treating Pain with Heat and Cold

 Heat therapy
 Applying heat therapy
 Cold therapy
 Applying cold therapy
 Risks
 Takeaway
Heat therapy helps improves blood flow to the area where the heat is applied. It’s best for muscle
pain or stiffness. Cold therapy helps reduce inflammation. It’s most helpful when used for acute
injuries and pain.
We treat everything from arthritis to pulled muscles to inflammation with ice packs or heating
pads. Treating pain with hot and cold can be extremely effective for a number of different
conditions and injuries, and easily affordable.
The tricky part is knowing what situations calls for hot, and which calls for cold. Sometimes a
single treatment will even include both.
As a general rule of thumb, use ice for acute injuries or pain, along with inflammation and
swelling. Use heat for muscle pain or stiffness.
Heat therapy
How it works
Heat therapy works by improving circulation and blood flow to a particular area due to increased
temperature. Increasing the temperature of the afflicted area even slightly can soothe discomfort
and increase muscle flexibility. Heat therapy can relax and soothe muscles and heal damaged
tissue.
Types
There are two different types of heat therapy: dry heat and moist heat. Both types of heat therapy
should aim for “warm” as the ideal temperature instead of “hot.”
 Dry heat (or “conducted heat therapy”) includes sources like heating pads, dry heating
packs, and even saunas. This heat is easy to apply.
 Moist heat (or “convection heat”) includes sources like steamed towels, moist heating
packs, or hot baths. Moist heat may be slightly more effective as well as require less
application time for the same resultsTrusted Source.
Professional heat therapy treatments can also be applied. Heat from an ultrasound, for example,
can be used to help pain in tendonitis.
When applying heat therapy, you can choose to use local, regional, or whole body treatment.
Local therapy is best for small areas of pain, like one stiff muscle. You could use small heated
gel packs or a hot water bottle if you only want to treat an injury locally. Regional treatment is
best for more widespread pain or stiffness, and could be achieved with a steamed towel, large
heating pad, or heat wraps. Full body treatment would include options like saunas or a hot bath.
When not to use
There are certain cases where heat therapy should not be used. If the area in question is either
bruised or swollen (or both), it may be better to use cold therapy. Heat therapy also shouldn’t be
applied to an area with an open wound.
People with certain pre-existing conditions should not use heat therapy due to higher risk of
burns or complications due to heat application. These conditions include:
  diabetes
 dermatitis
 vascular diseases
 deep vein thrombosis
 multiple sclerosis (MS)
If you have either heart disease or hypertension, ask your doctor before using heat therapy. If you
are pregnant, check with your doctor before using saunas or hot tubs.
Applying heat therapy
Heat therapy is often most beneficial when used for a good amount of time, unlike cold therapy,
which needs to be limited.
Minor stiffness or tension can often be relieved with only 15 to 20 minutes of heat therapy.
Moderate to severe pain can benefit from longer sessions of heat therapy like warm bath, lasting
between 30 minutes and two hours.
Cold therapy
How it works
Cold therapy is also known as cryotherapy. It works by reducing blood flow to a particular area,
which can significantly reduce inflammation and swelling that causes pain, especially around a
joint or a tendon. It can temporarily reduce nerve activity, which can also relieve pain.

Types
There are a number of different ways to apply cold therapy to an affected area. Treatment
options include:

Ice packs or frozen gel packs

Coolant sprays
Ice massage
Ice baths
Other types of cold therapy that are sometimes used include:

Cryostretching, which uses cold to reduce muscle spasms during stretching

Cryokinetics, which combines cold treatment and active exercise and can useful for ligament
sprains
Whole-body cold therapy chambers
When not to use
People with sensory disorders that prevent them from feeling certain sensations should not use
cold therapy at home because they may not be able to feel if damage is being done. This includes
diabetes, which can result in nerve damage and lessened sensitivity.

You should not use cold therapy on stiff muscles or joints.

Cold therapy should not be used if you have poor circulation.

Applying cold therapy

For home treatment, apply an ice pack wrapped in a towel or ice bath to the affected area. You
should never apply a frozen item directly to the skin, as it can cause damage to the skin and
tissues. Apply cold treatment as soon as possible after an injury.

Use cold therapy for short periods of time, several times a day. Ten to 15 minutes is fine, and no
more than 20 minutes of cold therapy should be used at a time to prevent nerve, tissue, and skin
damage. You can elevate the affected area for best results.
Potential risks
Risks of heat therapy
Heat therapy should utilize “warm” temperatures instead of “hot” ones. If you use heat
that’s too hot, you can burn the skin. If you have an infection and use heat therapy, there
is a chance that the heat therapy could increase the risk of the infection spreading. Heat
applied directly to a local area, like with heating packs, should not be used for more than
20 minutes at a time.

If you experience increased swelling, stop the treatment immediately.

 If heat therapy hasn’t helped lessen any pain or discomfort after a week, or the pain
increases within a few days, make an appointment to see your doctor.

Risks of cold therapy

If you’re not careful, cold therapy applied for too long or too directly can result in skin,
tissue, or nerve damage.

If you have cardiovascular or heart disease, consult your doctor before using cold
therapy.

If cold therapy hasn’t helped an injury or swelling within 48 hours, call your doctor
What are electrolytes?
Electrolytes are minerals that have an electric charge when they are dissolved in water or body
fluids, including blood. The electric charge can be positive or negative. You have electrolytes in
your blood, urine (pee), tissues, and other body fluids.
Electrolytes are important because they help:
 Balance the amount of water in your body
 Balance your body's acid/base (pH) level
 Move nutrients into your cells
 Move wastes out of your cells
 Support your muscle and nerve function
 Keep your heart rate and rhythm steady
 Keep your blood pressure stable
 Keep your bones and teeth healthy
What are the different types of electrolytes in your body?
The main electrolytes in your body include:
 Bicarbonate, which helps maintain the body's acid and base balance (pH). It also plays an
important role in moving carbon dioxide through the bloodstream.
 Calcium, which helps make and keep bones and teeth strong.
 Chloride, which also helps control the amount of fluid in the body. In addition, it helps
maintain healthy blood volume and blood pressure.
  Magnesium, which helps your muscles, nerves, and heart work properly. It also helps
control blood pressure and blood glucose (blood sugar).
 Phosphate, which works together with calcium to build strong bones and teeth.
 Potassium, which helps your cells, heart, and muscles work properly.
 Sodium, which helps control the amount of fluid in the body. It also helps your nerves
and muscles work properly.
You get these electrolytes from the foods you eat and the fluids you drink.
What is an electrolyte imbalance?
An electrolyte imbalance means that the level of one or more electrolytes in your body is too low
or too high. It can happen when the amount of water in your body changes. The amount of water
that you take in should equal the amount you lose. If something upsets this balance, you may
have too little water (dehydration) or too much water (overhydration). Some of the more
common reasons why you might have an imbalance of the water in your body include:
 Certain medicines
 Severe vomiting and/or diarrhea
 Heavy sweating
 Heart, liver or kidney problems
 Not drinking enough fluids, especially when doing intense exercise or when the weather
is very hot
 Drinking too much water

How are electrolyte imbalances diagnosed?

A test called an electrolyte panel can check the levels of your body’s main electrolytes. A
related test, the anion gap blood test, checks whether your electrolytes are out of balance
or if your blood is too acidic or not acidic enough.

What are the treatments for electrolyte imbalances?

The treatment for an electrolyte imbalance depends on which electrolytes are out of
balance, if there is too little or too many, and what is causing the imbalance. In minor
cases, you may just need to make some changes to your diet. In other cases, you may
need other treatments. For example:
If you don’t have enough of an electrolyte, you may get electrolyte replacement therapy.
This involves giving you more of that electrolyte. It could be a medicine or supplement
that you swallow or drink, or it may be given intravenously (by IV).
If you have too much of an electrolyte, your provider may give you medicines or fluids
(by mouth or by IV) to help remove that electrolyte from your body. In severe cases, you
may need dialysis to filter out the electrolyte.