Chapter 24: Performing Chest Physiotherapy

The health care provider orders percussion on a patient to help clear airway secretions. Which action by the nurse is appropriate? a. Performing percussion over the ribs, while avoiding the clavicles and sternum b. Administering pain medication before performing the percussion because the vibrations will be painful c. Performing percussion during exhalation only with the flat part of the palm d. Creating a rocking motion by slightly leaning on the patient's chest

ANS: A Percussion is performed by clapping the chest wall with cupped hands over the ribs only. The clavicles, breast tissue, sternum, spine, waist, and abdomen should not be used. If done correctly, percussion painlessly sets up vibrations in the chest to dislodge retained secretions. Vibration is done during exhalation only with the flat part of the palm. Shaking requires the caregiver to slightly lean on a patient's chest and create a rocking motion.

A patient who is very frail and thin with osteoporosis has just undergone abdominal surgery. The nurse anticipates that which technique will be used to control respiratory secretions in this patient? a. Forceful coughing b. Percussion c. Vibration d. Shaking

ANS: A Thin, frail patients with osteoporosis are most susceptible to injury and are taught other secretion control measures (e.g., forceful coughing and humidification). Percussion, vibration, and shaking are contraindicated with rib fracture; fracture of other rib cage structures such as clavicle or sternum; pain; severe dyspnea; and severe osteoporosis.

The nurse receives orders for postural drainage using Trendelenburg's position. On which patients should the nurse question the order? (Select all that apply.) a. Patient with a history of gastroesophageal reflux disease (GERD) b. Postsurgical patient with a distended abdomen c. Patient with blood pressure of 180/100 d. Patient with bronchiectasis on chest x-ray

ANS: A, B, C Trendelenburg's position is contraindicated for uncontrolled hypertension, distended abdomen, esophageal surgery, recent gross hemoptysis, and uncontrolled airway at risk for aspiration. When patients have a risk for or history of GERD, the head-down position should not be used. Bronchiectasis is an indication for postural drainage.

The nurse is teaching the family of a patient with cystic fibrosis how to use a high-frequency chest wall oscillation (HFCWO) vest. The nurse informs the family that this device will do which of the following? (Select all that apply.) a. Allow patient to perform other tasks while receiving therapy. b. Improve patient adherence to chest physiotherapy. c. Assist in the removal of secretions from the lungs. d. Decrease the viscosity of mucus so coughing it up will be easier.

ANS: A, B, C, D The use of high-frequency chest wall oscillation (HFCWO) such as the Vest airway clearance system often improves patient attitude toward chest physiotherapy because the patient is able to perform other tasks while receiving therapy. The HFCWO therapy assists with the removal of secretions from the lungs and decreases the viscosity of mucus, making it easier to cough productively.

The nurse is reviewing medical records on several patients. Which findings reported in the chart indicate the need for postural drainage? (Select all that apply.) a. Atelectasis reported on chest x-ray b. Thick, sticky, tenacious, green secretions noted in the nurse's notes c. Multiple rib fractures noted on chest x-ray d. Chest x-ray report indicating pneumonia with collapse of right lower lobe

ANS: A, B, D Chest x-ray film changes consistent with atelectasis, lobar collapse pneumonia, or bronchiectasis indicate a need for postural drainage. Other signs are ineffective coughing and thick, sticky, tenacious, discolored secretions that are difficult to cough up. Rib fractures are a contraindication for postural drainage.

A patient has retained secretions in the right and left lower lobe superior bronchi. A nurse is demonstrating to family members how to perform percussion and vibration. Which action by the nurse is appropriate? a. Positioning the patient in a chair leaning forward on a table b. Asking the patient to lie flat on the stomach with a pillow under the stomach c. Assisting the patient to the right side with the arm overhead and the feet elevated d. Asking the patient to lie on the left side with the head elevated

ANS: B Have the patient lie flat on the stomach with a pillow under the stomach. Percuss and vibrate below the scapula on either side of the spine. Sitting up and leaning forward is the position for drainage of the left and right upper lobe posterior apical branch. Having the patient lying on the right side in Trendelenburg's position with the arm overhead facilitates drainage of the left upper lobe lingular bronchi. On the left side with the head elevated is not a correct position for any drainage procedure.

The nurse is planning to perform postural drainage on a patient who is receiving continuous tube feedings. What should the nurse do before performing the treatment? (Select all that apply.) a. Stop the tube feedings for 1 to 2 hours before and after postural drainage. b. Check for residual feeding in the patient's stomach and hold treatment if greater than 100 mL. c. Give the prescribed inhaled bronchodilator 20 minutes before the procedure. d. Auscultate all lung fields, assess vital signs, and draw arterial blood gas levels (ABG).

ANS: B, C Stop all continuous gastric tube feedings for 30 to 45 minutes before postural drainage. Check for residual feeding in the patient's stomach; if greater than 100 mL, hold treatment. If the patient is receiving inhaled bronchodilator, nebulizer, or aerosol treatment, postural drainage is performed 20 minutes after such therapy is provided. Assessing lung sounds and vital signs, but not blood gas levels, is routinely done. Instead, pulse oximetry readings can be assessed.

The nurse receives orders on several patients for chest percussion, vibration, and shaking. The nurse is aware that chest physiotherapy maneuvers are indicated for which patient? a. 18-year-old who sustained thoracic trauma from a motor vehicle accident b. 75-year-old with osteoporosis who is underweight c. 15-year-old with cystic fibrosis d. 20-year-old with a fractured clavicle

ANS: C Chest physiotherapy (CPT) and coughing maneuvers assist with airway clearance of mucus in patients with retained tracheobronchial secretions. Secretions accumulate in the airways of patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Thoracic trauma, osteoporosis, and fracture of rib cage structures such as the clavicle contraindicate percussion, vibration, and shaking.

The nurse is teaching family members how to perform postural drainage at home for a patient with chronic bronchitis. What instruction should the nurse provide? a. Plan to perform postural drainage 3 times a day about 1 hour after meals. b. Don't give any pain medication within 2 hours of performing postural drainage. c. Perform postural drainage 20 minutes after the patient uses the inhaler. d. Encourage the patient to remain in each position for 30 minutes to adequately drain the area.

ANS: C Patients receiving inhaled bronchodilators, nebulizers, or aerosol treatments should have postural drainage performed 20 minutes after such therapy. If a patient's pain is 4 or greater, analgesics should be administered 20 minutes before chest physiotherapy (CPT) maneuvers. Pain control is essential for the patient to actively participate and cough forcefully to clear the airways. Treatments should not overlap with meals. Avoid postural drainage 1 to 2 hours before and after meals. The patient should maintain each position for 10 to 15 minutes.

The nurse auscultates the patients' lung fields and notes congestion in several patients. The nurse anticipates that postural drainage may be used for the patient with which condition? a. Congestive heart failure (CHF) with pulmonary edema b. History of cigarette smoking with recent hemoptysis c. Chronic bronchitis with frequent coughing d. Pulmonary embolism after a long international flight

ANS: C Secretions accumulate in patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Contraindications for postural drainage include pulmonary edema associated with congestive heart failure, active hemoptysis, and pulmonary embolism.

Percussion and vibration is ordered on a patient with retained pulmonary secretions. Which action by the student nurse should the nursing instructor question? a. Performs percussion for 3 to 5 minutes in each position as tolerated. b. Uses the wrist and elbow to create movement when performing percussion. c. While the patient inhales, gently pushes down and vibrates the chest wall with the flat part of the hand. d. Repeats the vibration 3 times and then instructs the patient to take a deep breath and cough while exhaling.

ANS: C Vibration is performed while the patient is exhaling, not inhaling. Percussion is performed for 3 to 5 minutes in each position. When clapping, most arm movement comes from the elbow and wrist joints. Vibration is repeated 3 times and then the patient cascade coughs by taking a deep breath and doing a series of small coughs until the end of the breath.

The nurse is teaching a patient how to use an Acapella device. What instruction should the nurse give to the patient? a. Take a full deep breath in and fill your lungs. b. Hold your breath for 5 to 10 seconds after placing the mouthpiece in your mouth. c. Cough forcefully to clear your lungs while maintaining a tight seal on the mouthpiece. d. Exhale slowly for 3 to 4 seconds through the device while it vibrates.

ANS: D Instruct the patient to try not to cough and to exhale slowly for 3 to 4 seconds through the device while it vibrates. The patient should be instructed to take in a breath that is larger than normal, but not to fill the lungs completely—about 75% of inspiratory capacity. Hold the breath for 2 to 3 seconds, and try not to cough.

The nurse receives orders for an Acapella device on several patients. The nurse should question the order on the patient with which condition? a. Chronic bronchitis b. Asthma c. Cystic fibrosis (CF) d. Pleural effusion

ANS: D The Acapella device is a respiratory rehabilitation device designed to aid sputum clearance. Patients with chronic conditions such as cystic fibrosis, chronic bronchitis, and asthma appear to receive the greatest benefit from this type of treatment. Chest physiotherapy (CPT) is contraindicated in patients with pleural effusion.

A patient has received instructions on the use of an Acapella device. Which action by the patient indicates an understanding of the teaching? a. Complains of not being able to use an aerosol drug with the device. b. Turns the frequency adjustment dial to medium resistance. c. After completing one cycle, repeats for 2 more breaths. d. After removing the mouthpiece, performs 1 to 2 forceful exhalations and "huff" coughs.

ANS: D When the cycles are completed, the mouthpiece is removed and 1 to 2 forceful exhalations and "huff" coughs are performed. If aerosol drug therapy is ordered, a nebulizer is attached to the end of the Acapella device. For the initial setting, the frequency adjustment dial should be set at the lowest resistance setting. The cycle should be repeated for 5 to 10 breaths as tolerated.