Skill 15-1

Performing Cardiopulmonary Resuscitation

The American Heart Association (AHA, 2020b) identifies interventions to provide emergency cardiovascular care, using the metaphor “Chain of Survival.” Elements of this emergency care include cardiopulmonary resuscitation (CPR), the combination of chest compressions (to circulate blood), mouth-to-mouth breathing (to supply oxygen to the lungs), and defibrillation (to interrupt or stop an abnormal heart rhythm using controlled electrical shocks). The elements and order of actions in the Chain of Survival differ based on the situation, whether the patient has the cardiac arrest outside the hospital or inside the hospital and whether the patient is an adult, child, or infant (AHA, 2020b). The brain is very sensitive to hypoxia, and damage to the brain begins to occur within minutes without oxygen; after 5 minutes, permanent anoxic brain injury can occur (Headway, 2021; Lacerte et al., 2020). The faster emergency cardiovascular care (CPR) is initiated, the greater the chance of survival (AHA, 2020b).

After making sure the environment is safe for rescuers and the patient and checking the patient for responsiveness, health care providers in the hospital activate the emergency response system, get an automated external defibrillator (AED) or defibrillator and emergency equipment, and begin CPR. In the health care setting, it is imperative that personnel be aware of the patient's stated instructions regarding any wish not to be resuscitated. This should be clearly expressed and documented in the patient's health record.

The AHA provides guidelines related to emergency interventions outside of health care facilities. Learning conventional CPR is still recommended, and trained lay rescuers should provide rescue breaths in addition to chest compressions (AHA, 2020a). However, the AHA guidelines recommend that when a teen or adult suddenly collapses, untrained lay bystanders should call 911 (activate the emergency response system) and push hard and fast in the center of the patient's chest (AHA, 2020a). These two steps, called Hands-Only CPR, can be as effective as conventional CPR (AHA, 2021). Providing Hands-Only CPR to a teen or adult who has collapsed from a sudden cardiac arrest can more than double or triple that person's chance of survival (AHA, 2021).

Delegation Considerations

The initiation and provision of cardiopulmonary resuscitation is appropriate for all health care providers.

Equipment

PPE, such as a face shield or one-way valve mask and gloves, if available
Bag-valve-mask device and oxygen, if available
Automated external defibrillator (Skill 15-2 details use) or
Manual external defibrillator (Skill 15-3 details use)

Assessment

Assess the patient's vital parameters and determine the patient's level of responsiveness. Check for partial or complete airway obstruction. Assess for the absence or ineffectiveness of respirations. Assess for the absence of signs of circulation and pulses.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired cardiac output
Impaired gas exchange
Altered breathing pattern

Outcome Identification and Planning

The expected outcome to achieve when performing CPR is that CPR is performed effectively without adverse effect to the patient. Additional outcomes include that the patient regains a pulse and respirations; the patient's heart and lungs maintain adequate function to sustain life; advanced cardiac life support (ACLS) is initiated, if indicated; and the patient does not experience serious injury.

Implementation

Action	Rationale
1. Verify scene safety. Check for responsiveness in the patient. Call for help, pull the call bell, and call the facility emergency response number. Call for emergency equipment and the AED or defibrillator, if available.	Verification of scene safety makes sure the environment is safe for rescuers and the patient. Assessing responsiveness prevents starting CPR on a conscious patient. Activating the emergency response system initiates a rapid response, and accessing equipment supports appropriate interventions.
2. Put on gloves, if available. Position the patient supine on their back on a firm, flat surface, with their arms alongside their body. If the patient is in bed, place a backboard or other rigid surface under them (often the footboard of the patient's bed). Position yourself at the patient's side.	Gloves prevent contact with blood and body fluids. The supine position is required for resuscitative efforts and evaluation to be effective. A firm surface allows compression of the chest and heart to create adequate blood flow (AHA, 2020b). A backboard provides a firm surface on which to apply compressions.
3. Provide defibrillation (if indicated) at the earliest possible moment, as soon as an AED becomes available. Refer to Skills 15-2 and 15-3.	Early defibrillation (along with high-quality CPR and all components of the Chain of Survival) is necessary to improve chances of survival from pulseless ventricular tachycardia and ventricular fibrillation (AHA, 2020b). The AED quickly delivers a shock (defibrillation) to the heart muscle to interrupt shockable rhythms and resets the heart's electrical system so a normal (organized) heart rhythm can return (AHA, 2020b).
4. Simultaneously look for no breathing or only gasping and check for a pulse, palpating the carotid pulse, for no more than 10 seconds. If the patient has no breathing or is only gasping and no pulse is felt, begin CPR using the compression/ventilation ratio of 30 compressions to two breaths, starting with chest compressions (CAB sequence) (Step 5). Alternatively, if there is no normal breathing but the patient has a pulse, see Step 14. Alternatively, if the patient is breathing normally and has a pulse, monitor until advanced care providers take over.	Pulse assessment evaluates cardiac function. Gasping is not normal breathing and is a sign of cardiac arrest (AHA, 2020b). Delays in chest compressions should be minimized, so the health care provider should take no more than 10 seconds to check for a pulse. If it is not felt within that time period, chest compressions should be started (AHA, 2020b). Rescue breathing should be provided to maintain effective oxygenation and ventilation (AHA, 2020b).
5. Chest compressions (C): Position the heel of one of your hands in the center of the patient's chest between the nipples, directly over the lower half of the sternum. Place the heel of your other hand directly on top of your first hand. Extend or interlace your fingers to keep them above the chest. Straighten your arms and position your shoulders directly over your hands (Figure 1). Alternatively, put one hand on the patient's sternum to push on the chest and grasp the wrist of that hand with your other hand to support the first hand as you push down on the chest (Figure 2) (AHA, 2020b).	Proper hand positioning ensures that the force of compressions is on the sternum, ensuring that the chest compressions are as effective as possible.
6. Push hard and fast. Chest compressions should depress the sternum to a depth of at least 2 inches (adult). Push straight down on the patient's sternum. Perform 30 chest compressions at a rate of 100-120/min, counting “1, 2, etc.” up to 30, keeping your elbows locked, arms straight, and shoulders directly over your hands (refer to Figure 1). Allow full chest recoil (reexpansion) after each compression. Do not lean on chest wall between compressions. Chest compression and chest recoil/relaxation times should be approximately equal (AHA, 2020b).	Direct cardiac compression and manipulation of intrathoracic pressure supply blood flow during CPR. Compressing the chest at least 2 inches ensures that compressions are not too shallow and provides adequate blood flow. Full chest recoil allows adequate venous return to the heart. Avoid leaning on the chest wall between compressions to ensure complete chest recoil (AHA, 2020b).
7. Ventilate using a barrier device (face mask or bag-valve-mask device, if available, or face shield) (refer to Skill 14-16 in Chapter 14). Give two breaths (as described below) after each set of 30 compressions. Cycles of 30 compressions and 2 ventilations are recommended (AHA, 2020b).	Breathing and compressions simulate lung and heart function, providing oxygen and circulation.
8. Airway (A): Use the head tilt-chin lift maneuver to open the patient's airway (Figure 3). Place one hand on the patient's forehead and apply firm, backward pressure with your palm to tilt the head back. Place the fingers of your other hand under the bony part of the lower jaw near the chin and lift the jaw upward to bring the chin forward.	The head tilt-chin lift maneuver lifts the tongue, relieving airway obstruction by the tongue in an unresponsive person (AHA, 2020b).
9. If trauma to the head or neck is present or suspected, use the jaw-thrust maneuver to open the airway (Figure 4). Position yourself at the patient's head. Place one hand on each side of the patient's head. Rest your elbows on the flat surface under the patient, grasp the angle of the patient's lower jaw, and lift with both hands, displacing the jaw forward. If the jaw thrust does not open the airway, use the head tilt-chin lift maneuver (AHA, 2020b).	The jaw-thrust maneuver may reduce neck and spine movement.
10. Seal the patient's mouth and nose with the face shield, one-way valve mask (Figure 5A), or handheld resuscitation bag (Ambu bag), if available (Figure 5B). (Refer to Skill 14-16 in Chapter 14 for use of a handheld resuscitation bag.) If not available, seal the patient's mouth with your mouth. If two rescuers are present, one rescuer should open the airway and seal the mask against the face, while the other rescuer squeezes the bag (AHA, 2020b).	Sealing the patient's mouth and nose prevents air from escaping. Devices such as masks reduce the risk for transmission of infections. Bag-mask ventilation during CPR is more effective when two rescuers provide it together, with one rescuer opening the airway and sealing the mask against the face, while the other squeezes the bag (AHA, 2020b).
11. Breathing (B): Instill two breaths, each lasting 1 second, making the chest rise.	Breathing into the patient provides oxygen to the patient's lungs. Noting the rise of the chest affirms adequate ventilation.
12. If you are unable to ventilate or the chest does not rise during ventilation, reposition the patient's head and reattempt to ventilate. If still unable to ventilate, resume CPR. Each subsequent time the airway is opened to administer breaths, look for an object. If an object is visible in the mouth, remove it. If no object is visible, continue with CPR.	Inability to ventilate indicates that the airway may be obstructed. Repositioning maneuvers may be sufficient to open the airway and promote spontaneous respirations. It is critical to minimize interruptions in chest compressions to maintain circulatory perfusion.
13. After about 2 minutes (until prompted by AED or about five complete cycles of CPR), assess the patient's rhythm on the defibrillator. Defibrillate as indicated (see Skill 15-2 or Skill 15-3). If a shock is not advised, resume CPR, beginning with chest compressions. Do not recheck to see if there is a pulse. Follow the AED voice prompts.	This evaluates cardiac function. Resuming CPR provides optimal treatment. Even when a shock eliminates the dysrhythmia it may take several minutes for a heart rhythm to establish and even longer to achieve perfusion. Chest compressions can provide coronary and cerebral perfusion during this period.
14. Rescue breathing: If the patient has a pulse but is not breathing normally, continue with rescue breathing, without chest compressions. Administer rescue breathing at a rate of one breath every 6 seconds, for a rate of 10 breaths/min. If the situation involves a possible opioid overdose, administer naloxone if available, as per protocol. Check the pulse about every 2 minutes. If there is no pulse, begin CPR (Step 5).	Rescue breathing maintains adequate oxygenation. For patients with suspected opioid overdose who are unresponsive with no normal breathing but have a pulse, administration of naloxone is indicated to reverse the opioid effects (AHA, 2020b).
15. If spontaneous breathing resumes, place the patient in the recovery position (Figure 6) and monitor until advance care providers take over.	This prevents obstruction of the airway.
16. Otherwise, continue CPR and use of the AED until advanced care providers take over, the patient starts to breathe or move or otherwise react, you are too exhausted to continue, or an advanced health care provider discontinues CPR.	Once started, CPR must continue until one of these conditions is met. In an acute care setting, help should arrive within a few minutes.
17. Remove gloves, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when CPR has been performed effectively without adverse effect to the patient, the patient has regained a pulse and respirations, the patient's heart and lungs have maintained adequate function to sustain life, ACLS has been initiated, and the patient has not experienced serious injury.

Documentation

Guidelines

Document the time the patient was discovered unresponsive and CPR was initiated. Continued intervention, such as by the code team, is typically documented on a code form, which identifies the actions and drugs provided during the code. Provide a summary of these events in the patient's health record.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

When performing chest compression, there is an audible crack: Be aware that this sound most commonly indicates cracking of the ribs. Recheck your hand position. Then continue compressions.
You find a patient lying on the floor: Determine the patient's level of responsiveness. If the patient is unresponsive, quickly clear an area, call for assistance and AED, and begin CPR as indicated.

Special Considerations

General Considerations

Every effort should be taken to minimize interruptions in chest compressions. A shorter duration of interruptions in chest compressions is associated with better outcomes(AHA, 2020b).
Do not move the patient while CPR is in progressunless the patient is in a dangerous environment (such as a burning building), or you believe you cannot perform CPR effectively under the current circumstances; the resuscitation team may choose to continue CPR at the scene or transport the patient to an appropriate environment (AHA, 2020b).
Perform CPR in the same manner if the patient is obese. Techniques may need to be adjusted in the presence of morbid obesity, due to the physical attributes of individual patients (AHA, 2020b).
Do not delay providing chest compressions for a pregnant woman in cardiac arrest. Perform CPR for pregnant patients using the same guidelines.Perform continuous manual lateral uterine displacement (LUD) for visibly pregnant women (approximately 20 weeks'; uterus at or above the umbilicus) if additional rescuers are present (AHA, 2020b). Manually move the uterus to the patient's left to relieve the pressure from the right of the patient by using one hand to push upward and leftward off the maternal vessels, or from the left of the patient, using two hands to cup and lift up and leftward off the maternal vessels; LUD relieves the pressure of the uterus on the large blood vessels in the abdomen, to improve blood flow to the heart (AHA, 2020b).
If it is not possible to seal the patient's mouth completely for reasons such as oral trauma, perform mouth-to-nose breathing. If the patient has a tracheostomy, provide ventilation through the tracheostomy instead of the mouth.
A nonconventional CPR approach has been suggested for patients with an advanced airway in the prone position if turning the patient supine would lead to delays or risk to providers or patients (Bhatnager et al., 2018). Compressions in the prone position are delivered on the thoracic spine (T7/T10), 0 to 2 vertebral segments below the scapulae (reversed precordial compressions) (Bhatnager et al., 2018; Douma et al., 2020; Edelson et al., 2020). Evidence on the provision of CPR in the prone position is ongoing and further research is needed (Moscarelli et al., 2020).
The AHA provides guidelines related to emergency interventions outside of health care facilities. Learning conventional CPR is recommended, and trained lay rescuers should provide rescue breaths in addition to chest compressions (AHA, 2020b). However, when a teen or adult suddenly collapses, untrained lay bystanders should call 911 (to activate the emergency response system), and push hard and fast in the center of the patient's chest (AHA, 2021). These two steps, called Hands-Only CPR, can be as effective as conventional CPR (AHA, 2021). Providing Hands-Only CPR to a teen or adult who has collapsed from a sudden cardiac arrest can more than double or triple that person's chance of survival (AHA, 2021). The AHA (2021) still recommends CPR with compressions and breaths for infants and children, victims of drowning or drug overdose, and for people who have collapsed due to breathing problems.
Be familiar with facility guidelines and/or standards of care related to family presence during resuscitation (FPDR), and advocate for the presence of a family facilitator and support for family needs. The presence of people who are relatives or significant others with whom the patient shares an established relationship during resuscitation or invasive procedures is controversial. Evidence in the literature suggests family members desire FPDR and identifies multiple associated benefits (AACN, 2016; McAlvin & Carew-Lyons, 2014; Pankop et al., 2013; Soleimanpur et al., 2017; Toronto & LaRocco, 2018; Vanhoy et al., 2019). The AACN (2016) and the Emergency Nurses Association (Vanhoy et al., 2019) recommend family members of all patients undergoing resuscitation and invasive procedures should be given the option of presence at the bedside (AACN, 2016; Vanhoy et al., 2019). The development of related policies or standards of practice in all patient care areas to address the needs of family members when they are present during invasive procedures and resuscitative events is recommended (AACN, 2016; Toronto & LaRoco, 2018; Vanhoy et al., 2019).

Infant and Child Considerations

Once a child reaches puberty (breast development and/or underarm hair), use adult CPR guidelines for resuscitation (AHA, 2020b).
As soon as it is determined that the scene is safe and an infant or child is unresponsive, shout for help to activate the emergency response system. Assess for breathing and a pulse (brachial artery in an infant and carotid or femoral artery in a child); this should take no more than 10 seconds. If a pulse is not detected or not detected for certain, begin chest compressions. The only difference in chest compressions is for infants. A lone health care provider can use either the 2-finger or 2-thumb-encircling hands technique (AHA, 2020b). The two-thumb-encircling hands technique is recommended when CPR is provided by two rescuers. If it is not possible to encircle the patient's chest, compress the chest with the two fingers (AHA, 2020b).
Perform the head tilt-chin lift and give two breaths after 30 compressions (15 compressions if two rescuers) (AHA, 2020b).
Children with unwitnessed collapse: Give 2 minutes of CPR, then leave the patient to activate the emergency response system and get the AED. Return and resume CPR; use the AED as soon as it is available (AHA, 2020b).
Most AED models are designed for both pediatric and adult resuscitation attempts; use the pediatric AED pads for children younger than age 8 years (AHA, 2020b).
Many AEDs are equipped with a pediatric attenuator to decrease (attenuate) the delivered energy to make them suitable for infants and children younger than age 8 years; a pediatric attenuator is often attached to the pediatric AED pads (AHA, 2020b).
Check the AED for a key or switch that will deliver a child shock dose; turn the key or switch before activating the AED (AHA, 2020b).

Older Adult Considerations

Nurses can help promote informed, shared decision making about CPR to older adults and their families. Educate, support, and advocate for patients as they face this critical choice (Einav et al., 2021). Provide evidence-based information, supportive listening, and a willingness to respect their choices (Sharma et al., 2016).

EVIDENCE FOR PRACTICE

Cardiopulmonary Resuscitation and Emergency Cardiac Care

The AHA provides guidelines for cardiopulmonary resuscitation and emergency cardiac care and has incorporated these guidelines into the Basic Life Support and Advanced Life Support education for health care providers who respond to cardiovascular and respiratory emergencies.

American Heart Association (AHA). (2020a, October 20). 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Parts 1-7. Circulation, 142(16 Suppl 2). https://www.ahajournals.org/toc/circ/142/16_suppl_2/
American Heart Association (AHA). (2020b). 2020 CPR & ECC guidelines. BLS provider manual. AHA product number: 20-1102.
American Heart Association (AHA). (2020c). 2020 ACLS for experienced providers. Manual and resource text. AHA product number: 15-3134.

EVIDENCE FOR PRACTICE

Cardiopulmonary Resuscitation and Family Presence

The option for family presence during resuscitation (FPDR) or invasive procedures is recommended by multiple professional organizations (AACN, 2016; Toronto & LaRoco, 2018; Vanhoy et al., 2019) but remains controversial among nurses (Powers & Reeve, 2020). What interventions might improve nurses' support for and implementation of FPDR?

Related Research

Powers, K., & Reeve, C. L. (2020). Family presence during resuscitation: Medical-surgical nurses' perceptions, self-confidence, and use of invitations. American Journal of Nursing, 120(11), 28-38. https://doi.org/10.1097/01.naj.0000721244.16344.ee

The purpose of this study was to examine the personal, professional, and workplace factors associated with medical-surgical nurses' perceptions, self-confidence, and use of invitations regarding family presence during resuscitation (FPDR). Potential barriers to FPDR were also explored to inform the design of interventions that might improve FPDR implementation in the medical-surgical practice setting. A cross-sectional survey design was used to investigate which factors are predictors of medical-surgical nurses' FPDR perceptions, self-confidence, and use of invitations regarding FPDR; nurses' perceptions of barriers to FPDR; and nurses' educational preferences related to FPDR. A convenience sample of medical-surgical nurses (n = 51) was obtained through a study advertisement in a professional journal for medical-surgical nurses and through an email sent to members of the organization. Participants completed the study survey tools via an online survey site platform. Participants reported overall neutral perceptions of FPDR; 63% had never invited family members to experience resuscitation. The most significant predictor of more favorable perceptions, higher self-confidence, and greater use of invitations was having prior experience with FPDR. Analysis of perceived barriers indicated that these can be addressed through providing nurses with supportive FPDR policies and education. Only 14% of participants reported that their facility or unit had a written FPDR policy and only 16% had ever received any FPDR education. The authors concluded that FPDR is not commonly practiced on medical-surgical units. The authors recommended that medical-surgical nurses should be provided with experience, policies, and education related to FPDR to improve FPDR implementation rates in this setting. The authors suggest opportunities to implement FPDR in medical-surgical settings are abundant and should be utilized to support the patient-family unit and promote positive outcomes.

Relevance for Nursing Practice

Nurses are important patient advocates. Evidence supports the development, implementation, and evaluation of family presence protocols to ensure that patient- and family-centered care is provided. Nurses should be active participants in the development of educational interventions to address options for FPDR. Nurse educators should consider implementing educational interventions to improve nurses' support for FPDR and prepare them to implement FPDR in clinical practice.

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Skill 15-1

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE