Question

Use ALT Therapeutic Procedure to complete Performing Chest Physiotherapy.

Use Active learning template Nursing Skill to complete Suctioning a Tracheostomy Tube.

Use Active learning template Basic concept to complete Interventions to promote sleep.

Use Active learning template Basic concept to complete teaching reducing the adverse effect of immobility.

Answer 1

1.Use ALT Therapeutic Procedure to complete Performing Chest Physiotherapy.

NURSING SKILLS: CHEST PHYSIOTHERAPY

DESCRIPTIONS OF SKILLS:

Chest physiotherapy (CPT) is a group of therapies for mobilizing pulmonary secretions. These therapies include chest percussion, vibration and postural drainage. CPT is followed by productive coughing or suctioning of a patient who has a decreased ability to cough. This is especially helpful for patients with large amount of secretions or ineffective cough.

CONSIDERATIONS:

INDICATIONS NURSINGINTERVENTIONS(PRE,INTRA,POST)

Indications:

• It is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized secretions.

• Examples:

· Cystic fibrosis

· Bronchiectasis

· Atelctasis

· Lung abscess

· Pneumonia

Contraindications

• Increased ICP

• Unstable head or neck injury

• Active hemorrhage or hemoptysis

• Recent spinal injury

• Rib fracture

• Flail chest

• Uncontrolled hypertension

• Anticoagulation

• Thoracic surgeries

OUTCOME /EVALUATION

Following chest physiotherapy , the nurse should auscultate the client’s lungs, compare the findings to the baseline data, and document the amount, color, and character of expectorated secretions

CLIENT EDUCATION

Teach about sterile techniques ,complications,deep breathing and coughing exercise

POTENTIAL COMPLICATIONS

Chest PT is generally safe for most patients when techniques are appropriate for the patient’s condition. In some cases, such as when the head is lowered, chest physiotherapy can cause the following complications:

· Bleeding in the lungs and coughing up blood

· Cardiac arrhythmia (abnormal heartbeats)

· Increased pressure inside the head

· Inhaling secretions into the lungs

· Low blood pressure

· Low levels of oxygen in the blood

· Rib or spine pain or injury

· Vomiting

Certain people have a higher risk of complications and should not have chest physiotherapy including those with:

· Blood thinning drug therapy (anticoagulants)

· Burns or other open wounds

· Inability to produce any secretions

· Certain respiratory conditions including asthma, bronchopleural fistula, pneumothorax, pulmonary embolism, and lung abscess

· Recent heart attack or uncontrolled high blood pressure

· Rib or vertebral fractures or osteoporosis

· Serious head or neck injury or increased pressure in the skull (intracranial pressure)

· Severe active bleeding (hemorrhage)

· Severe or uncontrolled pain

· Vomiting

NURSING INTERVENTIONS

Assessment for Chest Physiotherapy

Nursing care and selection of CPT skills are based on specific assessment findings. The following are the assessment criteria:

· Know the normal range of patient’s vital signs. Conditions requiring CPT, such atelectasis, and pneumonia, affects vital signs.            

· Know the patient’s medications. Certain medications, particularly diuretics antihypertensive cause fluid and haemodynamic changes. These decrease patient’s tolerance to positional changes and postural drainage.

· Know the patient’s medical history; certain conditions such as increased ICP, spinal cord injuries and abdominal aneurysm resection, contra indicate the positional change to postural drainage. Thoracic trauma and chest surgeries also contraindicate percussion and vibration.

· Know the patient’s cognitive level of functioning. Participating in controlled cough techniques requires the patient to follow instructions.                        

· Beware of patient’s exercise tolerance. CPT maneuvers are fatiguing. Gradual increase   in activity and through CPT, patient tolerance to the procedure improves.

Clinical findings and investigations

1. Detailed History

2. Physical examination

· Inspection

· Palpation

· Percussion

· Auscultation

3.Investigations

4.X-ray

      5.Blood investigations-bleeding and clotting parameters

Techniques in Chest Physiotherapy

A nurse or respiratory therapist may administer CPT, although the techniques can often be taught to family members of patients.The most common procedures used are postural drainage and chest percussion, in which the patient is rotated to facilitate drainage of secretions from a specific lobe or segment while being clapped with cupped hands to loosen and mobilize retained secretions that can then be expectorated or drained.The procedure is somewhat uncomfortable and tiring for the patient.

1. Percussion

· Chest percussion involves striking the chest wall over the area being drained.

· Percussing lung areas involves the use of cupped palm to loosen pulmonary secretions so that hey can be expectorated with ease.

· Percussing with the hand held in a rigid dome-shaped position, the area over the lung lobes to be drained in struck in rhythmic pattern.

· Usually the patient will be positioned in supine or prone and should not experience any pain.

· Cupping is never done on bare skin or performed over surgical incisions, below the ribs, or over the spine or breasts because of the danger o tissue damage.

· Typically, each area is percussed for 30 to 6oseconds several times a day.

· If the patient has tenacious secretions, the area must be percussed for 3-5 minutes several times per day. Patients may learn how to percuss the anterior chest as well.

2. Vibration

· In vibration, the nurse uses rhythmic contractions and relaxations is or her arm and shoulder muscles while holding thee patient flat on the patient’s chest as the patient exhales.

· The purpose is to help loosen respiratory secretions so that they can be expectorated with ease. Vibration (at a rate of 200 per minute) can be done for several times a day.

· To avoid patient causing discomfort, vibration is never done over the patient’s breasts, spine, sternum, and rib cage.

· Vibration can also be taught to family members or accomplished with mechanical device.

Procedure: Percussion & Vibration

· Instruct the patient use diaphragmatic breathing

· Position the patient in prescribed postural drainage positions. Spine should be straight to promote rib cage expansion

· Percuss or clap with cupped hands or chest wall for 5 minutes over each segment for 5 minutes for cystic fibrosis and 1-2 minutes for other conditions

· Avoid clapping over spine, liver, spleen, breast, scapula, clavicle or sternum

· Instruct the patient to inhale slowly and deeply. Vibrate the chest wall as the patient exhales slowly through the pursed lips.

· Place one hand on top of the other affected over area or place one hand place one and on each side of the rib cage.

· Tense the muscles of the hands and hands while applying moderate pressure downward and vibrate arms and hands

· Relieve pressure on the thorax as the patient inhales.

· Encourage the patient cough, using abdominal muscles, after three or four vibrations.

· Allow the patient rest several times

· Listen with stethoscope for changes in breath sounds

· Repeat the percussion and vibration cycle according to the patient’s tolerance and clinical response: usually 15-30 minutes.

3. Postural Drainage

· Postural drainage is the positioning techniques that drain secretions from specific segments of the lugs and bronchi into the trachea.

· Because some patients do not require postural drainage for all lung segments, the procedure must be based on the clinical findings.

· In postural drainage, the person is tilted or propped at an angle to help drain secretions from the lungs.

· Also, the chest or back may be clapped with a cupped hand to help loosen secretions—the technique called chest percussion.

· Postural drainage cannot be used for people who are:

· unable to tolerate the position required,

· are taking anticoagulation drugs,

· have recently vomited up blood,

· have had a recent rib or vertebral fracture, or

· have severe osteoporosis.

· Postural drainage also cannot be used for people who are unable to produce any secretions (because when this happens, further attempts at postural drainage may lower the level of oxygen in the blood).

Procedure

· The patient's body is positioned so that the trachea is inclined downward and below the affected chest area.

· Postural drainage is essential in treating bronchiectasis and patients must receive physiotherapy to learn to tip themselves into a position in which the lobe to be drained is uppermost at least three times daily for 10-20 minutes.

· The treatment is often used in conjunction with the technique for loosening secretions in the chest cavity called chest percussion.

Articles required

· Pillows

· Tilt table

· Sputum cup

· Paper tissues

Steps

· Use specific positions so the force of gravity can assist in the removal of bronchial secretions from affected lung segments to central airways by means of coughing and suctioning.

· The patient is positioned so that the diseased area is in a near vertical position, and gravity is used to assist the drainage of specific segment.

· The positions assumed are determined by the location, severity, and duration of mucous obstruction

· The exercises are performed two to three times a day, before meals and bedtime. Each position is done for 3-15 minutes

· The procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest occurs. The se symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs.

· Bronchodilators, mucolytics agents, water, or saline may be nebulised and inhaled before postural drainage and chest percussion to reduce bronchospasm, decrease thickness of mucus and sputum, and combat edema of the bronchial walls, there by enhancing secretion removal

· Perform secretion removal procedures before eating

· Make sure patient is comfortable before the procedure starts and as comfortable as possible he or she assumes each position

· Auscultate the chest to determine the areas of needed drainage

· Encourage the patient to deep breathe and cough after spending the allotted time in each position.

· Encourage diaphragmatic breathing through out postural drainage: this helps widen airways so secretions can be drained

2.Use Active learning template Nursing Skill to complete Suctioning a Tracheostomy Tube.

NURSING SKILL: SUCTIONING A TRACHEOSTOMY TUBE

DESCRIPTIONS OF SKILLS:

The upper airway warms, cleans and moistens the air we breathe. The trach tube bypasses these mechanisms, so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from the tracheotomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion build-up.

CONSIDERATIONS :

Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. Suctioning should be considered

· Any time the patient feels or hears mucus rattling in the tube or airway

· In the morning when the patient first wakes up

· When there is an increased respiratory rate (working hard to breathe)

· Before meals

· Before going outdoors

· Before going to sleep

OUTCOME /EVALUATION

Patient ‘s air way should be patent,clean and free of secretions and obstuction

CLIENT EDUCATION

· Cleanliness of tracheostomy tube

· Regular follow up

· Immediate access to hoapital in case of emergency

POTENTIAL COMPLICATIONS

• Hypoxia.
• Airway Trauma.
• Psychological Trauma.
• Pain.
• Bradycardia.
• Infection.
• Ineffective Suctioning.

NURSING INTERVENTIONS

Equipment
Clean suction catheter (Make sure you have the correct size)
Distilled or sterile water
Normal saline
Suction machine in working order
Suction connection tubing
Jar to soak inner cannula (if applicable)
Tracheostomy brushes (to clean tracheostomy tube)
Extra tracheostomy tube

1. Wash your hands.

2. Turn on the suction machine and connect the suction connection tubing to the machine.

3. Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked.

4. Connect the catheter to the suction connection tubing.

5. Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders. Some patients may prefer a sitting position which can also be tried.

6. Wet the catheter with sterile/distilled water for lubrication and to test the suction machine and circuit.

7. Remove the inner cannula from the tracheostomy tube (if applicable). The patient may not have an inner cannula. If that is the case, skip this step and go to number 8.

a. There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient's. Usually rotating the inner cannula in a specific direction will remove it.

b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal.

c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).

8. Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient?s secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring.

9. Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place.

10. Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds.

11. Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions.

12. Insert the inner cannula from extra tracheostomy tube (if applicable).

13. Turn off suction machine and discard catheter (clean according to step 3 if to be reused).

14. Clean inner cannula (if applicable).

3. Use Active learning template Basic concept to complete Interventions to promote sleep.

RELATED CONCEPT:

In promoting sleep, nurses are mainly involved in sleep hygiene, which refers to the set of interventions used to improve and promote sleep. Nurses use nonpharmacologic measures to increase the quantity and quality of clients’ sleep. Sleep hygiene encompasses health education on sleep rituals and habits, restful environment, comfort and relaxation, and occasionally, use of hypnotic medicines

BASIC PRINCIPLES:

• Patient should have adequate sleep.
• Sound sleep is required for healthy body.
• Adequate sleep help in healing,thereby recovery.
• Lack of sleep reduces good prognosis and increase the risk of complications.
• providing measures to promote sleep is required along with treatment for the better health of patient
• patient should be taught following :

· good diet

· importance of exercise,meditation

• Complications of insomnia may include:

· Lower performance on the job or at school

· Slowed reaction time while driving and a higher risk of accidents

· Mental health disorders, such as depression, an anxiety disorder or substance abuse

· Increased risk and severity of long-term diseases or conditions, such as high blood pressure and heart disease

NURSING INTERVENTIONS

• Regardless of the therapy type, primary treatment goals are:

(1) to improve sleep quality and quantity and

(2) to improve insomnia related daytime impairments.

• Other specific outcome indicators for sleep generally include measures of wake time after sleep onset (WASO), sleep onset latency (SOL), number of awakenings, sleep time or sleep efficiency, formation of a positive and clear association between the bed and sleeping, and improvement of sleep related psychological distress.
• Sleep diary data should be collected prior to and during the course of active treatment and in the case of relapse or reevaluation in the long term (every 6 months).
• In addition to clinical reassessment, repeated administration of questionnaires and survey instruments may be useful in assessing outcome and guiding further treatment efforts.
• Ideally, regardless of the therapy type, clinical reassessment should occur every few weeks and/or monthly until the insomnia appears stable or resolved, and then every 6 months, as the relapse rate for insomnia is high.
• When a single treatment or combination of treatments has been ineffective, other behavioral therapies, pharmacological therapies, combined therapies, or reevaluation for occult comorbid disorders should be considered.

Psychological and Behavioral Therapies:

• Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia.
  • These treatments are effective for adults of all ages, including older adults, and chronic hypnotic users.
  • These treatments should be utilized as an initial intervention when appropriate and when conditions permit.

Pharmacological Treatment:

• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible.

4. Use Active learning template Basic concept to complete teaching reducing the adverse effect of immobility.

RELATED CONCEPT

Immobility is a common pathway by which a host of diseases and problems in older individuals produce further disability. Immobility often cannot be prevented, but many of its adverse effects can be. Improvements in mobility are almost always possible, even in the most immobile older patients. Relatively small improvements in mobility can decrease the incidence and severity of complications, improve the patients well-being, and make life easier for caregivers

Causes:

• Many physical, psychological, and environmental factors can cause immobility in older persons . The most common causes are musculoskeletal, neurological, and cardiovascular disorders. Pain is a common pathway by which these disorders result in immobility

Common causes of immobility in older adults:

· Arthritides

· Osteoporosis

· Fractures (especially hip and femur)

· Podiatric problems Other (e.g., Pagets disease)

· Stroke

· Parkinsons

· disease Other (cerebellar dysfunction, neuropathies) Cardiovascular disease Congestive heart failure (severe)

· Coronary artery disease (frequent angina)

· Peripheral vascular disease (frequent claudication)

· Pulmonary disease Chronic obstructive lung disease (severe)

· Sensory factors Impairment of vision Fear (from instability and fear of falling)

· Environmental causes Forced immobility (in hospitals and nursing homes) Inadequate aids for mobility Acute and chronic pain

· Other Deconditioning (after prolonged bed rest from acute illness)

· Malnutrition Severe systemic illness (e.g., widespread malignancy)

· Depression Drug side effects (e.g., antipsychotic-induced rigidity)

Complications of immobility:

• skin breakdown
• pressure ulcers
• contractures
• muscular weakness
• muscular atrophy
• disuse osteoporosis
• renal calculi
• urinary stasis
• urinary retention
• urinary incontinence
• urinary tract infections
• atelectasis
• pneumonia
• decreased respiratory vital capacity
• venous stasis
• venous insufficiency
• orthostatic hypotension
• decreased cardiac reserve
• edema, emboli
• thrombophlebitis
• constipation
• the loss of calcium from the bones

UNDERLYING PRINCIPLES

Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. Immobility can adversely affect all physiological bodily systems.

Planning is done according to the actual and potential health problems that were assessed and then expected client outcomes or goals and interventions are planned to meet these needs. Some of the expected client outcomes relating to immobility and mobility can include specific goals such as:

· The client will perform active range of motion to all joints two times a day

· The client will safely transfer from the bed to the chair with assistance

· The client will be free of venous stasis

· The client will demonstrate proper deep breathing and coughing

· The client will ambulate 30 feet three times a day with a walker and the assistance of another

· The client will increase their level of exercise and physical activity

· The client will demonstrate the proper use of their assistive device

· The client will maintain skin integrity

· The client will maintain adequate respiratory functioning

NURSING INTERVENTIONS

· Identify complications of immobility (e.g., skin breakdown, contractures)

· Assess the client for mobility, gait, strength and motor skills

· Perform skin assessment and implement measures to maintain skin integrity and prevent skin breakdown (e.g., turning, repositioning, pressure-relieving support surfaces)

· Apply knowledge of nursing procedures and psychomotor skills when providing care to clients with immobility

· Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts)

· Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings, sequential compression devices)

· Educate the client regarding proper methods used when repositioning an immobilized client

· Maintain the client's correct body alignment

· Maintain/correct the adjustment of client's traction device (e.g., external fixation device, halo traction, skeletal traction)

· Implement measures to promote circulation (e.g., active or passive range of motion, positioning and mobilization)

· Evaluate the client's response to interventions to prevent complications from immobility