Pulmonary Exam and Treatment Flashcards
What populations might benefit from inspiratory muscle testing?
- Patients with COPD
– Emphysema, Chronic Bronchitis, Asthma - Neuromuscular conditions
– ALS, MS, Parkinson’s disease, SCI - Cardiac conditions
– Heart failure - Anyone with a weak diaphragm
Guidelines: Inspiratory Muscle Training
- Mode:
– Inspiratory resistive traininer or threshold-type trainer - Frequency:
– Number of sessions/day: 1-2 a day (depending on patient exercise capacity)
– Number of days/week: 4-6 days of training sessions per week (according to patient tolerance) - Intensity:
– 30-70% Percentage of PI (inspiratory pressure) max
– A lower initial intensity is recommended for severe COPD - Progression:
– Up to 5% per week of PI max (as tolerated) - Retesting
– PI should be measured at least monthly
– Training intensity adjusted accordingly - Duration
– 30 min per day divided over 1-2 sessions
– Initially as short as 3-5 minutes
– Number of weeks: indefinently to maintain benefits (Functional improvement and adaptive structural changes occur after 5 weeks of training; training lost after 6 months of deconditioning)
Plan of Care Development for Pulmonary Patient - Program Planning
- Review history, physical, diagnosis, Chest X Ray, lab results and vital signs data
- Perform a physical assessment
- Is this a medical (Pathology) or a surgical or combination – patient?
- Determine – Obstructive or Resistive
- Is the patient at high risk of developing retained secretions?
- Are there retained secretions? Is the cough effective?
- Is the cough effective?
- Is this a chronic condition/disease that might require long –term home therapy? (If so need additional help)
- What areas of the lungs have evidence or retained secretions? (X Ray or Ascultation)
- If there is indication for postural drainage, percussion, vibration – consider “major” and “minor rule”
- Sequence of treat plan…
- Frequency depends on patient acuity
- Documentation
Physical Assessment - Pulmonay Patient
- Observe, auscultate, palpate, describe respiratory symptoms, cough, assess mobility or need for assistance
When do you need to consider when determining obstructive and restricitve pulmonary disorders for POC?
Obstructive:
* Can you change the pattern of breathing? Yes
* For what reason? Expansion, efficency, decreased air-trapping and localized expansion
* What breathing pattern will you teach? Diaphragmatic, abdominal pursed lip breathing, segmental
When a patient is at high risk of developing retained secretions what should you consider?
Limitations in:
* Positional rotation
* Deep breathing
* Coughing
When considering if someone has retained secretions and an effective cough, what should you examine?
- Positional rotation
- Deep breathing
- Coughing acuitiy
What should be done if a cough is ineffective?
Postural drainage, percussion, vibration and coughing instruction
Anyone with an obstructive pulmonary disease needs to be reminded about what at discharge?
Abdominal Pursed Lip Breathing (Gentle to Crescendo Huff Cough)
IF there is indication for postural drainage percussion vibration - consider ____ and ____ rule.
- Major and minor
- Plan positions you will use working superior to inferior and least involved to most involved
When should pulmonary rehabilitation that involves postural drainage/percussion/vibration be performed? What can be used to help open airways?
- Bronchodilator first then steroid or mucolytic nebulizers
– These treatments will help relax and open airways, increasing lung expansion to get air behind secretions
– Frequency: Upon waking, before meals, before bed (Cystic Fibrosis)
What should be documented in pulmonary patient rehab?
- Positional tolerance, duration, outcome and it’s effective: Yes or No
- Expectorated (color, consistency, amount, odor), adverse reactions
- Assessment of intervention (HR, BP, O2sat, RR, observation)
- Plan for next session
Surgical Considerations - Pulmonary
- Does pt have underlying Hx of pulmonary disease?
* Smoking Hx
* Stroke, Neuromuscular - Location of surgery; indicates how much risk and area.
- In healthy pts the closer to the diaphram the increased risk - Anesthesia - shallow, 100% oxygen - washed out nitrogren and can lead to atelectasis (effects cilia)
- The longer the surgery the higher risk - Pre-op teaching: explaining different techniques
- Post-op
Pre-op teaching
- Incisional splinting – to help with pain (when coughing, moving, laughing
- Coughing – explain why it is important, and be honest – it will hurt
- Deep breathing – to prevent atelectasis. Use an incentive spirometer to encourage pt to deep breathe at least 10 times every hour awake
- Positional rotation, posture and return to activity
- Ankle pumping to prevent DVT
- Educate: Explain what you will do to help if retained secretions develop
- Thoracotomy patients –assessment of ROM of involved surgery side
- Goal: return to normal pre-op posture and ROM (avoid a frozen shoulder / adhesive capsulitis)
Post Op Considerations
- Deep breathing pattern, positional rotation and splinting with coughing, ankle pumping and mobility.
- Assess for signs of retained secretions
- Treat the patient with drainage, percussion and vibration observing precautions and contradictions (i.e. N-G tube)
– You can percuss lateral to incision-gently. Begin very softly and gradually build up force to tolerance
– Where the site of the fracture is you need to be gentle but on the opposite side can be more aggressive – rib fracture. - Assist patient with splinting, tissues, expectoration, supporting tubes with position changes, etc
- Thoracotomy patient- PROM or AAROM to 90º forward flexion, abduction and int/ext rotation
– Bed mobility and transitions: bed, sitting and standing posture
– Chest tube is inserted into pleural space between the ribs-forcing the arm above 90º may hinge the chest tube against the lung
