Intervention skills

Question 1

• Teach diaphragmatic breathing using verbal, tactile, and auditory cues
o Purpose

Answer 1

♣ Breathing pattern is not efficient extra effort decreased functionality

Question 2

Teach diaphragmatic breathing using verbal, tactile, and auditory cues
Indications

Answer 2

♣ Pulmonary dysfunction, pain, nervousness, airway clearance dysfunction, congestive heart failure, edema, msk restriction ie. Scoliosis,kyphosis, obesity, etc.

Question 3

Teach diaphragmatic breathing using verbal, tactile, and auditory cues
Goals

Answer 3

♣ Decrease work of breathing
♣ Improve alveolar ventilation
♣ Increase strength, coordination of respiratory muscles
♣ Improve airway clearance by improving cough
♣ Relaxation

Question 4

Teach diaphragmatic breathing using verbal, tactile, and auditory cues
Muscles

Answer 4

♣ Primary muscles are diaphragm and intercostals
• In pulmonary dysfunction, accessory muscle use should be discouraged
• In NM disorder accessory muscle use may improve vital capcity and functionality

Question 5

o Diaphragmatic breathing – try simplest intervention first, then progress if necessary

Answer 5

1. relaxation technique
2. repatterining
3. sniffing
4. scoop
5. lateral costal breathing

Question 6

♣ Relxation Technique

Answer 6

1. 3-4 deep breaths, hold each deep breath for 3 sec.
2. Regular breathing
3. 3-4 deep breaths, hold each for 3 sec
4. regular breathing
5. FET

Question 7

♣ Repatterning Technique

Pursed lip

Answer 7

• Pursed lipped breathing: focus on relaxes slow, prolonged exhalation
o normal inhale
o Encourage a sssss sound
o Imagine a candle with a flame, make flicker but not go out
• Exhalantion, hold, and inhalation
o Hold for 1 or 2 seconds at top of inspiration, then pursed lips
♣ 3. Sniffing

Question 8

♣ Sniffing

Answer 8

• may want to choose gravity lessened position
• place pt hand on abdomen for feedback
• “sniff 3 times’ note if more abdominal rise and less chest expansion if not draw attention
• “sniff 2 times, but deeper”
• “one long sniff”
• progress with quieter, longer sniffs

Question 9

♣ Scoop Technique

Answer 9

• breathe into my hand

* scoop at end of exhalation

Question 10

♣ Lateral Costal Breathing

Answer 10

• assess bucket handle

* lower chcest lateral costal expansion facilitaties diaphragmatic/intercostal breathing

Question 11

• Perform a facilitated breathing technique (scope or lateral chest expansion with quick stretch)
o Lateral chest expansion quick stretch (unilateral or bilateral)

Answer 11

♣ Assess bucket handle
♣ As pt breathes out, apply firm downward pressure into ribs
♣ Just prior to inspiration, apply quick downward/inward stretch
• Stetches external intercostal to facilitate contraction
o Moves ribs outward and upward during inspiration
♣ Apply gentle resistance, Tell pt to expand lower ribs against hand as breathes in
• Provides feedback, sensory awareness
♣ Pt. may be taught to do independently with towel

Question 12

• Instruct effective cough and provide manual cues as needed – in strict in huff if cough not working

Answer 12

o pts with copd/asthma should not take a deep breath before a cough, can lead to distress
o Can you show me how you have been coughing?
♣ Have pt in good posture sitting, standing fowler
• Pt should choose position that lends itself to trunk flexion
♣ 4 Stages
• adequate inspiration necessary air for forceful cough
o begin with diaphragmatic breathing
• glottal closure increases pressure distal to vocal folds
o
• build intra-abdominal pressure
• glottal opening and expulsion

Question 13

• Transfer supping to sit for sternal precautions, or chest tube precautions
o Sternal Precautions for 6-8 weeks

Answer 13

o Sternal Precautions for 6-8 weeks
♣ No pulling, no pushing, no lifting more than 10lbs
♣ No shoulder flexion greater than 90 degrees
♣ Keep hands in visual field
♣ Hug pillow to chest when coughing
o Chest Tube precautions
♣

Question 14

• Instruct pt how to coordinate breathing w/ daily activities, such as getting out of chair
o Ventilation

Answer 14

♣ Inspiration
• Trunk extension, shoulder flexion, abduction, external rotation, upward eye gaze
♣ Exhlation
• Trunk flexion, shoulder extension, adduction, internal rotation, downwatrd eye gaze
♣ can incorporate positions into breathing techniques

Question 15

Instruct pt how to coordinate breathing w/ daily activities, such as getting out of chair
o activities

Answer 15

♣ Coming up to sitting from sidelying
♣ Dressing
• LE items: exhale while reaching down, inhale while pulling up
• UE items: pair shoulder flexion with inspiration
♣ Coming up to standing
• Breathe in with rear rocking, exhale out rock forward
• Do several cycles
• Inhale as coming up to standing

Question 16

• Instruct stretch and breathing coordinated with upper extremity movement to increase chest expansion; instruct in static positioning to facilitate increased ventilation (i.e. Towel under spine suping) consider ventilation/perfusion ratio if indicated
o Vertical Towel Roll or Foam Roller

Answer 16

o Vertical Towel Roll or Foam Roller
♣ Improves anterior wall mobility by allowing gravity to pull shoulder back
♣ Stretches intercostal and pc muscles for easier chest expansion
♣ Can incorporate active stretching with arms
o Sidelying
♣ “lay on good lung”
♣ lateral chest expansion
♣ 1-3 pillows under ribs 8-10
♣ can incorporate active stretching with arms

Question 17

• Demonstrate manual technique to increase intraabdominal force during coughing (towel/pillow)
o Heimlich-Type

Answer 17

♣	Pt supine or sidelying
♣	Aka abdominal thrust assist
♣	Pt hand at navel level, not on ribs
♣	Breathe in  
♣	apply upward pressure as coughing

Question 18

• Perform an airway clearance technique for lower segment (position, percussion, vibration)
• Teach Autogenic drainage or active cycle of breathing airway clearance technique
o Autogenic Drainage: uses breathe to move mucus from smaller airways to central airways

Answer 18

♣ 3 Phases
• Unsticking in smaller airways by breathing in base of lungs
• Collecting from middle airways by breathing at low-mid lung levels
• Evacuating the mucus from central airways by breathing at mig-high levels
•

Question 19

Placement of EKG electrodes

Answer 19

RA=right arm
LA- left arm
RH- right hip
LH- left hip
• V1 = 4th intercostal space to the right of sternum
• V2 = 4th intercostal space to the left of sternum
• V3 = in between V2 and V4
• V4 = 5th intercostal space, mid-clavicular
• V5 = left anterior axillary line, level with V4
• V6 = left mid-axillary line, level with V4 and V5

Question 20

• Teach phase 1 and phase 2 cardiac rehab

o Goals of Rehab

Answer 20

♣ Improve functional capacity
♣ Control cadiac symptoms
♣ Mitigate physiological and psychological affets of cardiac illnes

Question 21

o Phase 1: Inpatient, Cardiac Unit, ICU

♣ For

Answer 21

• Post MI
• Post surgery
• Post-stent
• transplant

Question 22

o Phase 1: Inpatient, Cardiac Unit, ICU

May begin if:

Answer 22

• MD approval
• No chest discomfort for 8 hours
• No new signs of decompensated heart failure
• No abnormal EKG for 8 hours

Question 23

o Phase 1: Inpatient, Cardiac Unit, ICU

Goal:

Answer 23

• Normal CV response to changes in position and ADL

Reach 3-4 MET activity level by discharge

Question 24

o Phase 1: Inpatient, Cardiac Unit, ICU

Activity

Answer 24

• Start at 2 MET, Increase 1 MET/day, starting with 3-5 minutes
• AROM for DVT prevention
• Changing positiongs
• Avoid isometrics, Valsalva (especially during bowel)
• Avoid head down position

Question 25

o Phase 2:

Answer 25

♣ Supervised 6-8 week outpatient program
♣ Exercise test performed prior to rehab
♣ EKG every session

Question 26

Phase 2 goals:

Answer 26

o Increase exercise capacity to 5 MET

o Patient education on HR, exercise, symptoms

Question 27

Phase 2: when you can begin

Answer 27

o Minimum of 5 week post MI & 3 weeks in cardiac rehab
o Minimum of 8 week post CABG, 3 weeks of cardiac rehab
o Resistance training greater than 50% 1RM

Question 28

Phase 2 component

Answer 28

o 50% HRR
o 3x/week
o 60 minute sessions including warm-up and cool-down