NCM 112 The only preparation needed for chest physical

therapy is an evaluation of the patient's condition

Chest Physiotherapy and determination of which chest physical therapy
techniques would be most beneficial.
What is chest physiotherapy?
What are the risks or possible complications chest
 Chest physical therapy is the term for a group of physiotherapy?
treatments designed to improve respiratory
efficiency, promote expansion of the lungs,  Chest physiotherapy should be not used on
strengthen respiratory muscles, and eliminate every patient. Patients with brittle bones or
secretions from the respiratory system. broken rib bones should not receive chest
 The purpose of chest physical therapy, also physiotherapy. This may cause the bone problem
called chest physiotherapy, is to help patients to become worse.
breathe more freely and to get more oxygen into  Chest physiotherapy should not be performed
the body. when a patient is unstable. This may lead ad to
 Chest physical therapy includes to the the patient condition becoming more
1. postural drainage serious.
2. chest percussion  Chest physiotherapy should not be used if the
3. chest vibration patient has increased pressure in their skull. If
4. Turning the patient is coughing up b up blood, has a lot
5. deep breathing exercises of pain, has just eaten, vomiting, chest
6. coughing physiotherapy should is vomiting, be postponed
 It is usually done in conjunction with other until these conditions present are no longer
treatments to rid the airways of secretions. present.
These other treatments include suctioning,
nebulizer treatments, and the administration of Does chest physiotherapy work?
expectorant drugs
 Although chest physiotherapy has only been
Why chest physiotherapy would be shown to work in patients with cystic fibrosis, it
recommended? is felt to be useful in patients in the intensive
care unit who are not very mobile after heart
 Chest physiotherapy is used for different surgery or for other reasons when they are
reasons. When patients cannot bring up unable to keep all areas of the lung open.
secretions, chest physiotherapy may be helpful. Chest physiotherapy has been successful in
 Chest physiotherapy is also used for patients some patients in preventing the need for more
with pneumonia or patients with cystic fibrosis. aggressive treatment (i.e., mechanical
Patients may have trouble taking deep breaths ventilation).
after surgery. When this happens, the lungs may  The patient is considered to be responding
not fully inflate. Chest physiotherapy has been positively to chest physical therapy if some, but
helpful in treating this condition. not necessarily all, of these changes occur:
• Increased volume of sputum secretions
Who orders or performs chest Physiotherapy • Changes in breath sounds
and where is the treatment performed? When • Improved vital signs
or how often is the treatment done? • Improved chest x ray
• Increased oxygen in the blood as measured by
• The doctor taking care of the patient will order
arterial blood gas values
chest physiotherapy. The respiratory therapist or the
• Patient reports of eased breathing.
nurse will perform the treatment.
Percussion
• Chest physiotherapy is done at the patient’s bed,
which is made to be positioned for this type of • Percussing lung areas involves the use of a cupped
treatment. palm to loosen pulmonary secretions. Pt. is in supine
or prone position
• The treatment may be performed as often as every
two hours. Most of the time, the treatment is done • Cupping is never done in bare skin or performed
four times every day over surgical incisions, below the ribs, or over the
spine or breast.

• Each area is percussed for 30 to 60 seconds several

times a week. If pt has tenacious secretions, the area
Preparation may be percussed for up to 3 to 5 min several times
a day.

Hanna Cornelio BSN-3

Vibration  The abdomen is then contracted, and the patient
exhales. Deep breathing exercises are done
 The purpose of vibration is to help break up lung several times each day for short periods.
secretions so that they can be expectorated with
ease. Aftercare
 It is performed as the patient breathes deeply.
When done manually, the person performing the  Patients practice hygiene procedures oral to
vibration places his or her hands against the lessen the bad taste or odor of the secretions
patient’s chest and creates vibrations by quickly they spit out.
contracting and relaxing arm and shoulder
muscles while the patient exhales. The Assessment of CVS
procedure is repeated several times each day for
ASSESSMENT
about five exhalations.
 200/min  Health History
 Postural drainage  Demographic information
 Postural drainage uses the force of gravity to  Family/genetic history
assist in effectively draining secretions from the  Cultural/social factors
lungs and into the central airway where they can  Current health history
either be coughed up or suctioned out.
 The patient is placed in a head or chest down Risk factors
position and is kept in this position for up to 15
minutes.  Modifiable
 Critical care patients and those depending on  Nonmodifiable
mechanical ventilation receive postural drainage
CARDIAC SYSTEM ASSESSMENT: SYMPTOM
therapy four to six times daily. Percussion and
ANALYSIS
vibration may be performed in conjunction with
postural drainage.  Chest pain or discomfort-(AP, ACS, VHD,
Dysrhtmias)
Turning
 Irregularities of heart rhythm-palpitations, (ACS,
 Turning from side to side permits lung expansion. caffeine or other stimulants, electrolyte
Patients may turn themselves or be turned by a imbalances, stress, VHD, ventricular aneurysm)
caregiver. The head of the bed is also elevated  Respiratory manifestations-dyspnea (ACS,
to promote drainage if the patient can tolerate cardiogenic shock, HF,VHD)
this position. Critically ill patients and those  Exertional dyspnea and orthopnea
dependent on mechanical respiration are turned  Paroxysmal nocturnal dyspnea
once every one to two hours round the clock.  Fatigue
 Cyanosis
Coughing  Edema -HF
 Syncope hypotension, cardiogenic shock, CVD,
 Coughing helps break up secretions in the lungs postural hypotension, vasovagal episode,
so that the mucus can be suctioned out or Dysrhythmias
expectorated.  Weight gain and dependent edema
 Patients sit upright and inhale deeply through  Other manifestations
the nose. They then exhale in short puffs or
coughs.
 Coughing is repeated several times a day. ASSESSING CHEST PAIN

Angina Pectoris-acute coronary syndrome (unstable

angina, myocardial infarction [MI])

Usual distribution of pain with myocardial ischemia

 Right side
Deep breathing  Jaw
 Back
 Deep breathing helps expand the lungs and
 Epigastrium
forces better distribution of the air into all
 Less common sites of pain with myocardial
sections of the lung.
ischemia
 The patient either sits in a chair or sits upright in
bed and inhales, pushing the abdomen out to
force maximum amounts of air into the lung.

Hanna Cornelio BSN-3

 -Degree of tenderness
 Level of consciousness
 Head, neck, nails, and skin
 Edema
 Blood pressure
-Postural blood pressure
-Paradoxical blood pressure
 Pulse and respirations
 Head and neck
 Neck veins
 Carotid arteries
ASSESSMENT
 Chest
 Nutrition and metabolism  Precordium
 Activity and exercise  Heart sounds
 Elimination  SI – 1st heard sound “lub”
 Sleep and rest  S2-2nd heard sound “dub”
 Cognition and perception  S3 – heard immediately after S2 “lub-
 Self-perception and self- concept dubDUB”
 Roles and relationships  S4 – occurs just before SI – “LUB lub-
 Sex and reproduction dub”
 Coping and stress  Lung
 Past medical history Tachypnea
 Post surgical history Crackles -HF, atelectasis
 Allergy Blood-tinged sputum -pulmonary edema
 Medications Cheyne-Stokes respirations
Cough - HF
PHYSICAL EXAMINATION Wheezes - interstitial pulmonary edema
 Abdomen
 General appearance Abdominal distention
 Physical assessment: head to toe Hepatojugular reflux
 Inspection Bladder distention
 Observe:
- Color DIAGNOSTIC EVALUATION
- Shape
-Size Objective findings that confirm the data obtained by
-Symmetry the history and physical assessment.
-Position
Nursing responsibilities during diagnostic evaluation.
-Movement
 Compare bilateral structures  Scheduling the procedure.
-Auscultation  Explaining the purpose and the procedure
- Intensity (loud or soft) and answering any questions.
-Pitch (high or low)  Obtaining consent form
-Duration (length)  Obtaining any necessary preliminary care.
-Quality (musical, crackling, raspy)  promoting maximal emotional and physical
 Percussion comfort
-Percussion determination  Providing post procedure care and
- Eliciting pain instructions for home care, returning to work
-Determining location, size, shape, and and general after care.
density
-Detecting abnormal masses LABORATORY TESTS
-Eliciting reflexes (direct, blunt, indirect
 Palpation  Cardiac biomarkers
-Palpation determination CK and CK-MB
-Texture (rough/smooth) Troponin T and I
-Temperature (warm/cold) Myoglobin
-Mobility (fixed/movable/still/vibrating)  Brain (B-type) natriuretic peptide
-Consistency (soft/hard/fluid filled)  C-reactive protein
-Strength of pulses  Homocysteine
(strong/weak/thready/bounding)  D - Dimer
-Size (small/medium/large)  Blood coagulation test
-Shape (well defined/irregular)  Lipid profile

Hanna Cornelio BSN-3

  CBC  Increase blood level of Homocysteine is thought
 SERUM electrolytes to indicate high risk of CAD, stroke, and
peripheral vascular disease.
CARDIAC BIOMARKERS  12 hours fasting
 N.V.-5-15 umol/L
 Cardiac enzymes are present in high
 Moderate - 16 to 30 umol/L
concentration in myocardial tissue.
 Intermediate-31-100 umol/L
 Cardiac enzyme level reflect myocardial
 ,Severe more than 100 umol/L
damage and to identify Ml. (cellular death).
 Creatine Kinase (CK) D-Dimer
 CK – MB – is specific for myocardial injury.
Most specific enzyme analyzed in Acute MI.  levels reflects plasma breakdown of fibrin
It increases 2 -6 hours after Ml, peaks in 12 – 48 (indicating thrombolysis)
hrs  If elevated pulmonary embolus is a suspicion.
 Troponin T & 1
 Have several advantages over traditional Blood Coagulation test
enzymes studies such as CK – MB
 Evaluate prothrombin time and partial
 Are found only in cardiac muscle
thromboplastin time in people with tendency to
 It is detected within 3 to 4 hour; they
form thrombi
peak in 4 -24 hours and remain
 Ordered to guide dosage of antithrombotic
elevated for I to 3 weeks.
drugs.
Myoglobin is a useful marker of myocardial necrosis.  Prothrombin time - is done to evaluate
It is an early marker of Ml. It is rapidly released from the blood for its ability to clot. Normal
circulation with in I to 2 hours. PT Values: 10-12 seconds (this can vary
slightly from lab to lab)
 This enzyme is not cardiac specific and  Partial thromboplastin time - is
although it increases early it is not most performed primarily to determine if
reliable indicator of MI because if there is heparin (blood thinning) therapy is
evidence of muscle damage, trauma or effective. It can also be used to detect
renal failure it may give false tests result. the presence of a clotting disorder.
Positive Normal PTT Values: 30 to 45 seconds
(this can value slightly from lab to lab)
Lactate Dehydrogenase (LDH)
Serum lipids
LDHI specific for cardiac damage. Increases 24 to 48
hours after MI; peaks in 48 to 72 hours and return to  measured to evaluate a person's risk of
normal 5 to 10 days. developing atherosclerotic disease, especially if
there is a family history of premature heart
B-type Natriuretic Peptide (BNP) disease.
 Cholesterol and triglycerides are substances
 Neurohormone that helps regulate BP and fluid
called lipids. Fat-like
volume.
 Cholesterol is used to build cell membranes and
 Excellent diagnostic, monitoring, & prognostic
hormones. The body makes cholesterol and gets
tool in the setting of Heart Failure.
it from food. Triglycerides provide a major source
 BNP level of 51.2 pg/ml or greater is correlated
of energy to the body tissues.
with mild HF and levels greater than 100 pg/ml
 Both cholesterol and triglycerides are vital to
are associated with severe HF.
body function, but an excess of either one,
C – Reactive Protein especially cholesterol, puts a person at risk of
cardiovascular disease.
 A protein produced by the liver in response to  Cholesterol value
systemic inflammation. Less than 200 mg/dL: Desirable
 Used as an adjunct to other tests to predict CVD 200-239 mg/dL: Borderline-High Risk
risks. 240 mg/dL and over: High Risk
 Elevated CRP places a patient with  Your triglyceride level will fall into one of these
AcuteCoronary Syndrome (ACS) at higher risk for categories:
recurrent cardiac events including unstable Normal: less than 150 mg/dL
angina and Acute Ml and high mortality. Borderline-High: 150-199 mg/dL
High: 200-499 mg/dL
Homocysteine Very High: 500 mg/dL
 LDL, often called “bad” cholesterol, is formed
 assess patients risk for CVD.
primarily by the breakdown of VLDL.

Hanna Cornelio BSN-3

 LDL carries cholesterol in the blood and deposits  Pharmacologic stress testing
it in body tissues and in the walls of blood  Radiographic cardiac test
vessels, a condition known as atherosclerosis.  CXR
The amount of LDL in a person’s blood is directly  Radionuclide Imaging
related to his or her risk of cardiovascular  CT angiography
disease  CT scan
 In general, LDL levels fall into these categories:  MRI
LDL Cholesterol Levels  MRA
Less than 100 mg/dL- Optimal  PET Scan
 100 to 129 mg/dL - Near Optimal/ Above
Optimal Chest X-ray
 130 to 159 mg/dL - Borderline High
 Assist in assessing the heart, lungs and aorta.
 160 to 189 mg/dL -High
 Assess anatomic changes.
 190 mg/dL and above - Very High
 Radionuclide imaging
 HDL is often called "good" cholesterol. HDL
 Involves the use of radioisotopes to evaluate
removes excess cholesterol from tissues and
coronary artery perfusion non invasively to
vessel walls and carries it to the liver, where it is
detect myocardial ischemia and infarction.
removed from the blood and discarded. The
lower the HDL level, the greater the risk; the CT angiography
higher the level, the lower the risk.
 An HDL cholesterol of 60 mg/dL or higher gives  Allows a non-invasive way to evaluate the
some protection against heart disease. coronary arteries, great vessels, aorta, renal
 Low HDL cholesterol (less than 40 mg/dL for arteries, and lower extremity arteries through 2
men, less than 50 mg/dL for women) puts you at or 3 dimensional images
higher risk for heart disease

Complete Blood Count

 Is evaluated to carefully monitor patients with

CVD.
 Clients with anemia have a significant reduction
in RBC mass and oxygen carrying capacity.
 Anemia can be manifested as angina or it can
exacerbate heart failure and produce murmur.
 WBC is commonly seen after Ml because of large
number of WBC’s are necessary to dispose of the
necrotic tissue resulting from the infarction.

Serum Electrolytes

 F & E regulation maybe affected by

cardiovascular disorders or medications
 Electrolyte level contraction. can alter
cardiac muscle
 Potassium, calcium, sodium, magnesium,
phosphorous, kidney function test, serum
glucose.

ELECTROCARDIOGRAPHY

 12-lead ECG
 Holter Monitor or Ambulatory ECG
 Event Monitor
 Signal-averaged ECG
 Transtelephonic monitoring
 Wireless mobile monitoring
 Cardiac stress testing
 Exercise stress testing

Hanna Cornelio BSN-3