Care of patient with respiratory problems

Fundamentals of Nursing- Patient with Respiration Problems

1. CARE OF PATIENT WITH RESPIRATORY PROBLEMS PREPARED BY JANNET REENA PURANI

2. TERMINOLOGIES Dyspnea derives from Greek for “hard breathing”. It is often also described as “shortness of breath”. This is a subjective sensation of breathing, from mild discomfort to feelings of suffocation. Hypoxia: decreased oxygen supply in the tissues Hypoxemia: decreased oxygen supply in the blood. Apnea: absence of breathing Tachypnoea: increased respiratory rate Bradypnoea : decreased respiratory rate

3. COMMON CAUSES OF RESPIRATORY PROBLEMS Cardiac or Pulmonary diseases Allergies like asthma, wheezing Nasal obstruction Hypoxemia Anxiety causing hyperventilation, panic attack Chest trauma Occupational exposure to dust, chemicals Smoking

4. COMMON RESPIRATORY SIGNS AND SYMPTOMS Dyspnoea/ shortness of breathing Wheezing Chest pain Cough Haemoptysis Sputum production Hyperventilation

5. COMMON DIAGNOSTIC EVALUATIONS Pulmonary function tests ABG analysis Sputum analysis Pulse oximetry Thoracentesis Imaging studies Chest X-ray CT scan/MRI Fluoroscopic studies Bronchoscopy

6. ASSESSMENT Health History: Allergies, Occupation, Lifestyle, Health Habits Inspection: Skin color , Level of consciousness, emotional state, characteristics of respiration Palpation: Tenderness, Mass Percussion: Resonance of sounds Auscultation: Normal and Adventitious breath sounds

7. MANAGEMENT Positioning of the patient Oxygen Therapy Dry & Moist Inhalation Oronasal Suctioning Pulmonary rehabilitation Deep breathing & coughing exercises Spirometry

8. MANAGEMENT OF A PATIENT WITH DYSPNEA Treatment of dyspneoa is directed at cause Positioning (sitting up/Fowlers) Increasing air movement via fan, open window Bedside relaxation Quit smoking Provide medications like bronchodilators, anti- tussives , anti- cholinergics Oxygen supplementation

9. Pulmonary Rehabilitation Pulmonary rehabilitation is a program incorporating exercise and education to help patients with respiratory illnesses manage breathing problems, increase stamina, raise energy levels, and decrease breathlessness. Depending on an individual’s ability to exercise and the level of which they are able to do exercise or physical activity, this treatment may be altered. There are a number of treatments within this plan that can be incorporated, many of which can be done in the comfort of a home. It mainly consists of exercise training, energy-conserving techniques, breathing strategies, nutritional counseling and group support.

10. BREATHING AND COUGHING EXERCISES

11. GOALS OF BREATHING & COUGHING EXERCISES Improve ventilation Increase the effectiveness of cough and promote airway clearance To pre v en t pos t op erat i ve p u l m onary complications To improve the strength endurance coordination of the muscles of ventilation Maintain and improve chest and thoracic spine mobility Promote relaxation and relive stress To teach the patient how to deal with episodes of dyspnea Assisting in removal of secretions. Correct abnormal breathing patterns and decrease the work of breathing. Aid in bronchial hygiene---Prevent accumulation of pulmonary secretions, mobilization of these secretions, and improve the cough mechanism.

12. TYPES OF BREATHING EXERCISES Abdominal breathing Diaphragmatic breathing Glossophryngeal breathing Pursed lip breathing Segmental breathing(costal expansion exercise) Apical breathing Lateral costal expansion Posterior basal expansion

13. DIAPHRAGMATIC BREATHING Diaphra gm is the primary muscle for breathing (inspiration) This technique can be used for patients with COPD and relax the accessory muscles It can also be used to mobilize lung secretions.

14. PROCEDURE Prepare the patient in relaxed and comfortable position in which the gravity assist the diaphragm such as semifowlers position. If you notice any accessory muscle activation stop him and do relaxation techniques (shoulder roll or shrugs coupled with relaxation) Place your hands over the rectus abdominis just below the ant: costal margin ask the patient to breath slowly and deeply via nose by keeping the shoulder relaxed and upper chest quiet allowing the abdominal to rise now ask him to slowly let all the air out using controlled expiration through mouth. Have him to practice this for 2-4 times if he finds any difficulty in using diaphragm have the patient inhale several times in succession through the nose by using sniffing action this facilitates the diaphragm For self monitor have the patients hand over the ant costal margin and feel the movt : (hand rise and fall) by placing one hand over abdomen he can also feel the contraction of abdominal muscles which occurs with controlled expiration or coughing After he understands and able to do the controlled breathing using a diaphragmatic pattern keep the shoulder relaxed and practice in verity of positions (supine sitting standing) and during activity (walking and climbing stair).

15. Resisted diaphragmatic breathing Patient may use small weight, such as sandbag to strengthen and improve the endurance of the diaphragm Have the patient in a head up position Place a small weight (1.30- 2.20 kg or 3-5 lb ) over the epigastric region of his abdomen. Tell the patient to breath in deeply while trying to keep the upper chest quiet Gradually increase the time that the patient breaths against the resistance of weight Weight can be increased when he can sustain diaphragmatic breathing pattern with out the use of any accessory muscles of inspiration for 15minuts.

16. Glossopharyngeal breathing It is a means of increasing a patients inspiratory capacity when there is a severe weakness of the muscle of inspiration It is taught to patients who have difficulty in deep breathing. It is used primarily for ventilatory dependent patients due to absent or incomplete innervation of diaphragm because of high cervical cord injury or neuromuscular disorders. Glossopharyngeal breathing with inspiratory action of neck muscles can reduce ventilatory dependence or can be used as an emergency procedure for malfunctioning of ventilator.

17. PROCEDURE Patient take several gulp of air (6 to 10), then by closing the mouth the tongue pushes the air back and trap it in the pharynx the air is then forced to lungs when the glottis is opened. This increases the depth of inspiration & patient’s inspiratory & vital capacity.

18. PURSED LIP BREATHING Pursed-lip breathing is a strategy that involves lightly pursing the lips together during controlled exhalation. Taught to patients with COPD to deal with episodes of dyspnea. It help s to Im p ro v e s ventil a tio n and Releases trapped air in the lungs. Keep s th e airw a y s o p e n long e r and Pr o lon g ed exhalation slows the breathing rate. It moves old air out of the lungs and allow new air to enter the lungs.

19. PROCEDURE Patient in a comfortable position and relaxed, explain the patent about the expiration phase (it should be relaxed and passive). Abdominal muscle contraction must be avoided (therapist hand over the patients abdominal to check for contraction). Ask the patient to breathe in slowly and deeply through the nose and then breathe out gently through lightly pursed lips (blowing on and bending the flame of a candle ). By providing slight resistance an increased positive pressure will generate with in the airway which helps to keep open small bronchioles that otherwise collapse. It can be applied as a 3-5 minutes “rescue exercise” or an Emergency Procedure to counteract acute exacerbations or dyspnea (shortage of air or breathlessness) in COPD and asthma.

20. SEGMENTAL BREATHING It is performed on a segment of lung, or a section of chest wall that needs increased ventilation or movement. Hypoventilation occur in certain areas of the lungs because of chest wall fibrosis, pain after surgery, atelectasis , trauma to chest wall, pneumonia and post mastectomy scar Therefore, it will be important to emphasize expansion of such areas of the lungs and chest wall ADVANTAGES OF SEGMENTAL BREATHING: Prevent accumulation of pleural fluid and secretions Decreases paradoxical breathing Decrease panic episode Improve chest mobility

21. Techniques Lateral costal expansion Posterior basal expansion Right middle lobe or lingula expansion Apical expansion

22. Lateral costal expansion This is sometimes called lateral basal expansion and may be done unilaterally or bilaterally. The patient may be sitting or in a hook lying position. Place your hands along the lateral aspect of the lower ribs. Ask the patient to breathe out, and feel the rib cage move downward and inward. As the patient breathes out, place firm downward pressure into the ribs with the palms of your hands. Just prior to inspiration, apply a quick downward and inward stretch to the chest. This places a quick stretch on the external intercostals to facilitate their contraction. These muscles move the ribs outward and upward during inspiration.

23. Apply light manual resistance to the lower ribs to increase sensory awareness as the patient breathes in deeply and the chest expands. When the patient breathes out, assist by gently squeezing the rib cage in a downward and inward direction. The patient may then taught to perform the maneuver independently, ask him to apply resistance with his hand or with a towel. Bilateral lateral costal expansion-supine Bilateral lateral costal expansion-sitting

24. BELT EXERCISES TO REINFORCE LATERAL COSTAL BREATHING by applying resistance during inspiration by assisting with pressure along the rib cage during expiration.

25. Posterior basal expansion This form of segmental breathing is important for the post surgical patients who is in bed in a semi- reclining position for an extended period of time. Secretion often accumulate over the posterior segments of lower lobes. Procedure Have the patient sit and lean forward on a pillow, slightly bending the hips. Place the PT hand over the posterior aspect of the lower rib and do the same procedure in lateral costal expansion.

26. Right middle lobe or lingula expansion While the patient in sitting place your hand at either the right or left side of the patient’s chest just below the axilla, and follow the same procedure in lateral costal expansion.

27. Apical expansion

28. Coughing and Sputum Clearance Cough and sputum are two other symptoms of your disease. Coughing is important because it helps remove sputum from your lungs. When sputum is removed you can breathe easier. It is helpful to cough early in the day to remove the sputum that has built up during the night. It is also helpful to cough well, about a half an hour before lunch and supper; it may help make your meal more enjoyable. Before going out, cough to clear any sputum. You will be less likely to cough while you are out. There are also devices that may be suitable for you. These devices help in the movement of sputum. Consult a health care professional about the use of these.

29. Controlled Cough Technique Practice 1. Sit comfortably with your feet resting firmly on the floor, and lean forward slightly. 2. Take three to four deep diaphragmatic breaths before coughing. 3. Take a deep breath, hold your breath for three seconds, tighten your abdominal muscles and cough twice. The first cough will loosen your sputum. The second cough will move the sputum high in your throat. 4. Spit it into a piece of tissue and check the color. If it is a yellow, green or red in colour , talk to your doctor. Throw the tissue away. 5. Take a break and repeat once or twice if you do not cough up any sputum.

30. Watch a video on Breathing and coughing exercises https://youtu.be/KQCQHHRWCms

31. Relaxation Positions to Reduce Shortness of Breath

32. COPING WITH SHORTNESS OF BREATH