COURSE MANUAL

NURSING PRACTICAL 1
NSG 231

University of Ibadan Distance Learning Centre

Open and Distance Learning Course Series Development

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Copyright © 2018 by Distance Learning Centre, University of Ibadan, Ibadan.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the copyright owner.

ISBN 978-021-567-0

General Editor: Prof. Oyesoji Aremu

University of Ibadan Distance Learning Centre

University of Ibadan,
Nigeria
Telex: 31128NG
Tel: +234 (80775935727)
E-mail: ssu@dlc.ui.edu.ng
Website: www.dlc.ui.edu.ng

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Vice-Chancellor’s Message
The Distance Learning Centre is building on a solid tradition of over two decades of
service in the provision of External Studies Programme and now Distance Learning
Education in Nigeria and beyond. The Distance Learning mode to which we are
committed is providing access to many deserving Nigerians in having access to higher
education especially those who by the nature of their engagement do not have the luxury
of full time education. Recently, it is contributing in no small measure to providing places
for teeming Nigerian youths who for one reason or the other could not get admission into
the conventional universities.
These course materials have been written by writers specially trained in ODL course
delivery. The writers have made great efforts to provide up to date information,
knowledge and skills in the different disciplines and ensure that the materials are user-
friendly.
In addition to provision of course materials in print and e-format, a lot of Information
Technology input has also gone into the deployment of course materials. Most of them
can be downloaded from the DLC website and are available in audio format which you
can also download into your mobile phones, IPod, MP3 among other devices to allow
you listen to the audio study sessions. Some of the study session materials have been
scripted and are being broadcast on the university’s Diamond Radio FM 101.1, while
others have been delivered and captured in audio-visual format in a classroom
environment for use by our students. Detailed information on availability and access is
available on the website. We will continue in our efforts to provide and review course
materials for our courses.
However, for you to take advantage of these formats, you will need to improve on your
I.T. skills and develop requisite distance learning Culture. It is well known that, for
efficient and effective provision of Distance learning education, availability of
appropriate and relevant course materials is a sine qua non. So also, is the availability of
multiple plat form for the convenience of our students. It is in fulfilment of this, that
series of course materials are being written to enable our students study at their own pace
and convenience.
It is our hope that you will put these course materials to the best use.

Prof. Abel Idowu Olayinka

Vice-Chancellor

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Foreword
As part of its vision of providing education for “Liberty and Development” for
Nigerians and the International Community, the University of Ibadan, Distance Learning
Centre has recently embarked on a vigorous repositioning agenda which aimed at
embracing a holistic and all encompassing approach to the delivery of its Open Distance
Learning (ODL) programmes. Thus we are committed to global best practices in distance
learning provision. Apart from providing an efficient administrative and academic
support for our students, we are committed to providing educational resource materials
for the use of our students. We are convinced that, without an up-to-date, learner-friendly
and distance learning compliant course materials, there cannot be any basis to lay claim
to being a provider of distance learning education. Indeed, availability of appropriate
course materials in multiple formats is the hub of any distance learning provision
worldwide.
In view of the above, we are vigorously pursuing as a matter of priority, the provision of
credible, learner-friendly and interactive course materials for all our courses. We
commissioned the authoring of, and review of course materials to teams of experts and
their outputs were subjected to rigorous peer review to ensure standard. The approach not
only emphasizes cognitive knowledge, but also skills and humane values which are at the
core of education, even in an ICT age.
The development of the materials which is on-going also had input from experienced
editors and illustrators who have ensured that they are accurate, current and learner-
friendly. They are specially written with distance learners in mind. This is very important
because, distance learning involves non-residential students who can often feel isolated
from the community of learners.
It is important to note that, for a distance learner to excel there is the need to source and
read relevant materials apart from this course material. Therefore, adequate
supplementary reading materials as well as other information sources are suggested in the
course materials.
Apart from the responsibility for you to read this course material with others, you are also
advised to seek assistance from your course facilitators especially academic advisors
during your study even before the interactive session which is by design for revision.
Your academic advisors will assist you using convenient technology including Google
Hang Out, You Tube, Talk Fusion, etc. but you have to take advantage of these. It is also
going to be of immense advantage if you complete assignments as at when due so as to
have necessary feedbacks as a guide.
The implication of the above is that, a distance learner has a responsibility to develop
requisite distance learning culture which includes diligent and disciplined self-study,
seeking available administrative and academic support and acquisition of basic
information technology skills. This is why you are encouraged to develop your computer

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skills by availing yourself the opportunity of training that the Centre’s provide and put
these into use.
In conclusion, it is envisaged that the course materials would also be useful for the regular
students of tertiary institutions in Nigeria who are faced with a dearth of high quality textbooks.
We are therefore, delighted to present these titles to both our distance learning students and the
university’s regular students. We are confident that the materials will be an invaluable resource
to all.
We would like to thank all our authors, reviewers and production staff for the high
quality of work.

Best wishes.

Professor Oyesoji Aremu

Director

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Course Development Team
Content Authoring Ms Lucia Ojewale,

Content Editor Prof. Mildred Edet John

Language Editor Prof. Remi Raji-Oyelade
Production Editor Prof. David Okurame
Learning Design/Assessment Authoring Dara Abimbade
Managing Editor Ogunmefun Oladele Abiodun
ODL Expert Prof. A. Fadoju
General Editor Prof. Oyesoji Aremu

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Study Guide
Course Information

Learners are expected to register for this course within the time frame specified on the student’s
information board, available on www.dlclms.ui.dlc.edu.ng

Course Code & Course Name: NSG 231 - NURSING PRACTICAL

Credit Points: 2

Year: 200-Level

Semester: First Semester

About the Course

This course introduces students to the clinical aspect of nursing and teaches nursing management
of common clinical conditions.

Lecturer Information:

Facilitators: Ms Lucia Y. Ojewale

Email: luciayetunde@gmail.com

Consultation: Through whatsApp, telegraph, email and blogging.

Introduction to the Course

You are welcome to NSG 217. This is an online course that runs in the distance learning mode. It
is a compulsory course for nursing students.

It is a 3 unit Study Session course that has 15 or more hours of interaction among teachers and
learners for the period of the course.

The course aims at teaching nursing students assessment, diagnosis and management of common
conditions in the clinical setting

This course will help students to identify the common symptoms patients present with, and how
to carry out interventions to manage them.

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Aim

At the end of the course, students will be able to identify, assess and diagnose common medical
symptoms presented by patients in acute care settings. They must also be able to carry out
interventions to resolve these symptoms, properly reassess and document findings appropriately.

Learning Objectives

The objectives are to help students to understand:

The concept, meaning, components and purpose of health assessment

How to conduct a quick head to toe assessment and general survey of the client

The concept of carrying out system by system assessment for the patient

Performing postural drainage

The correct use of the incentive spirometer by patients

The concept of chest physiotherapy, indications and contra-indications

The definition, purpose and indications for oxygenation and the various methods of oxygen
administration

The procedure for carrying out pursed lip breathing, coughing and deep breathing exercised by
patients

The concept, definition, indications and contra-indications for nasopharyngeal suctioning

The types, indicators and methods of administering bronchodilators

Taking the Course

There will be 12 lectures presented in 6 study session format and arranged into 6 sections.

The course will be taught by blended training methods to include face-to-face (20%),
synchronous (CD) and asynchronous (whatsApp, email, blogging, Facebook, wordpress, etc)
(80%) methods. On weekly basis for 12 weeks, a lecture Study Session will be uploaded on the

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Course Blog for the students to access. Support CDs for synchronous training will be made
available on registration.

Practice test will be administered at the end of each lecture Study Session for students’ self-
assessment and revision.

At a particular period in each week, learners will be expected to participate in a chat or

discussion forum. Time will be communicated to the learners.

List of frequently asked questions (FAQs) and answers will be made available.

List of suggested readings will be provided at the end of each lecture Study Session.

You must participate in 75% Taking the practice The tutor-marked

of the forum to be qualified tests improves your assignments
to write the final exam. chances of success. account for 20% of
the final grade.
Submit promptly.

How to prepare for the Final Examination

Learners are encouraged to read and understand the entire content to ensure good performance in
this course.

Learners should make good use of the provided supplemental CD as this will expand the
knowledge of the learners.

Learners should note that the sample questions and practice tests provided at the end of each
lecture will help each learner to assess him/herself and promote revision before taking the final
examination.

Prerequisites for Examination

For any learner to be eligible to sit for the final examination in this course, he/she must have:

Participated in at least 75% of on-line interactions

Submitted all the tutor-marked tests

Paid all the recommended fees

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Preparatory Questions - Ms Lucia Y. Ojewale

The correct procedure for assessment is:

(a) Palpation, inspection, percussion, auscultation (b) Inspection, palpation, percussion,

auscultation (c) Inspection, percussion, palpation, auscultation (d) Auscultation,
inspection, palpation, percussion

Indications for postural drainage include the following except

(a) Bronchiectasis (b) Cystic Fibrosis

(c) Chronic obstructive pulmonary disease (COPD) (d) Liver Cirrhosis
Incentive spirometry helps to

(a) Supply blood to the whole body (b) To improve body temperature

(c) Loosen respiratory secretions (d) To ensure adequate digestion

Oxygen administration by nasal cannula delivers 100% oxygen to the patient true or false?

Assessment

Assessment in this course will be done considering active participation of learners in all
interactive sessions, quality of written assignments, records of materials used as references in all
assignments, regular feedback from teachers and learners and performance in examinations.
Details of assessment strategies are as follow:

Part A

1. Continuous Assessment:

a. Participation in group discussions/chat room: (10%) with contributions showing thoughtful

preparation for the classes.

a. Assignment: individual term papers, group reports: (10%).

b. Short end of topic tests in forms of multiple choice questions: (20%).

2. End of course examination:

a. This comprises 50 multiple choice questions covering all topics covered in the course (60%)

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Examination arrangements

All examinations are conducted online. The site for end of course examination may be decided
by the institution but candidates will be given information about this ahead of time

Continuous assessment

a. Assignments: individual term papers, group reports: List of assignments for each topic is
available on the content area of the course;

End of topic short tests comes with seven days of completing the topic. End of course test takes
one hour and students will be informed of when to log on to do the test. Questions are withdrawn
at the end of one hour after the questions would have been presented online.

The results are released automatically

End of course examination:

This comprises 50 multiple choice questions covering all topics covered in the course (60%)

Time allotted for this examination is 1 hour 30 minutes and it follows the same format as done
with the end of topic tests.

Feedback and advice:

Feedback will be from teachers to learners and learners to teachers.

The course has a feedback blackboard available on dlclms.ui.edu.ng

All assignments have information about deadlines for submission after which submissions by
students will be automatically rejected.

Results of all assignments (scores) will be released within 72 hours of the deadlines.

Summary of records of learners’ participation in all online sessions will be presented on the
feedback blackboard for the course.

Learners can also share information with peers on the feedback blackboard.

Students are required to submit their proposed topics for term papers on the assignment.

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All students have a course adviser that can be contacted through their e-mail address for
information, clarifications and support.

Verification of Integrity of Submitted Assignments and Guidelines for Written

Assignments

The integrity of submitted written assignments would be determined by the following

A. Compliance with standards of writing considering English (grammar and tenses,

construction), Appropriate formatting, Adoption of appropriate referencing format,
Adequate referencing and documentation of all materials used in doing the assignment).

B. Copying of each other’s work by students automatically imply zero scores for the
students involved.

C. Avoidance of Plagiarism: Plagiarism involves using the work of another person and
presenting it as one's own.’ (The Open Distance Learning _____)

• Plagiarism is a serious breach of the ODL’s rules and carries significant penalties.
Penalties in this course would result to

– failure in the course, and/or

– referral to the Open Distance Learning Disciplinary Committee.

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Table of Contents
Course Guide ........................................................................................................7
Table of Contents ......................................................................................................................13
Study Session 1: Health assessment ..........................................................................................20
Introduction ..........................................................................................................................20
Learning Outcomes for Study Session 1 .................................................................................20
1.1 The Meaning and components of health assessment ..................................................20
1.1.2 Components of Health assessment ......................................................................20
1.2 The reasons/purpose for carrying out health assessment ................................................22
1.2.1 Types of data in health assessment ......................................................................22
1.3 Physical and psychological preparation of clients for health assessment .....................22
1.3.1 Preparing the client physically and psychologically ...................................................22
1.3.2 Prepare the environment..........................................................................................23
1.3.3 Preparation of equipment/instrument ......................................................................23
1.4 Assessment Techniques ...................................................................................................25
Summary of Study Session 1 ..................................................................................................27
Self-Assessment Questions (SAQs) ........................................................................................28
SAQ 1.1 .............................................................................................................................28
SAQ 1.2 .............................................................................................................................28
SAQ 1.3 .............................................................................................................................28
SAQ 1.4 .............................................................................................................................28
Note on Self-Assessment Questions (SAQs) ...........................................................................28
SAQ 1.2 .................................................................................................................................28
The reasons/purpose for carrying out health assessment......................................................28
Preparation of equipment/instrument ..............................................................................28
Assessment Techniques.........................................................................................................29
References/Further Reading ..................................................................................................29

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 Study Session 2: A Quick Head - To - Toe Assessment and General Survey ............................30
Expected duration: 1 week or 2 contact hour ........................................................................30
Introduction ..........................................................................................................................30
Learning Outcomes for study session 2 .................................................................................30
2.1 General Survey ................................................................................................................30
2.2. Steps of head to toe and general survey assessment ......................................................32
2.3. System by system method of head to toe assessment ....................................................33
Summary of Study Session 2 ..................................................................................................34
Self-Assessment Questions (SAQs) ........................................................................................34
SAQ 2.1 .............................................................................................................................34
SAQ 2.2 .............................................................................................................................34
SAQ 2.3 .............................................................................................................................34
Note on Self-Assessment Questions (SAQs) ...........................................................................35
Study Session 3: Respiratory system assessment.......................................................................36
Expected duration: 1 week or 2 contact hour ........................................................................36
Introduction ..........................................................................................................................36
Learning Outcomes for study session 3 .................................................................................36
3.1 Overview of respiratory assessment ................................................................................36
3.2 Chest landmarks ..............................................................................................................37
3.2.1 Position/Lighting/Draping .........................................................................................38
3.3 Chest wall deformities .....................................................................................................40
3.4: Practical Steps for Respiratory Assessment.....................................................................42
Steps to the Procedure ..........................................................................................................44
Summary of Study Session 3 ..................................................................................................47
Self-Assessment Questions (SAQs) ........................................................................................47
SAQ 3.1 (Test learning outcome 3.1)..................................................................................47
SAQ 3.2 (Test learning outcome 3.2)..................................................................................47

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 SAQ 3.3 (Test learning outcome 3.3)..................................................................................47
SAQ 3.4 (Test learning outcome 3.4)..................................................................................47
SAQ 3.5 (Test learning outcome 3.5)..................................................................................47
Note on Self-Assessment Questions (SAQs) ...........................................................................48
SAQ 3.1 .................................................................................................................................48
SAQ 3.2 .................................................................................................................................48
SAQ 3.3 .................................................................................................................................48
See section 3.3 ......................................................................................................................48
SAQ 3.5 .................................................................................................................................48
Practical Steps for Respiratory Assessment ...........................................................................48
Study Session 4: Performing Postural Drainage .........................................................................49
Expected duration: 1 week or 2 contact hour ........................................................................49
Introduction ..........................................................................................................................49
Learning Outcomes for study session 4 .................................................................................49
4.1 Postural drainage ............................................................................................................49
4.2 Positions for Draining Different Areas of Lungs ................................................................51
4.3 Step-By-Step Technique of Postural Drainage ..................................................................52
Special Considerations ..........................................................................................................54
Summary of Study Session 4 ..................................................................................................54
Self-Assessment Questions (SAQs) ........................................................................................55
SAQ 4.1 (test learning outcome 4.1) ..................................................................................55
SAQ 4.2 (test learning outcome 4.2) ..................................................................................55
SAQ 4.3 (test learning outcome 4.3) ..................................................................................55
Notes on Self-Assessment Questions (SAQs) .........................................................................55
References ............................................................................................................................55
Study Session 5: Assisting the Patient with the use of an Incentive Spirometer .........................56
Expected duration: 1 week or 2 contact hour ........................................................................56

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 Introduction ..........................................................................................................................56
Learning Outcomes ...............................................................................................................56
5.1 Incentive Spirometry .......................................................................................................56
5.1.1 Who are the clients who needs incentive spirometry i.e Indications ....................56
In-text Question ................................................................................................................57
In-text Answer ...................................................................................................................57
5.2 Types of incentive spirometer. ........................................................................................57
In-text Question ................................................................................................................58
In-text Answer ...................................................................................................................58
5.3 Step-By-Step Technique of Incentive Spirometry .............................................................58
Summary of study session 5 ..................................................................................................60
Self-Assessment Questions (SAQs) ........................................................................................60
SAQ 5.1 .............................................................................................................................60
SAQ 5.2 .............................................................................................................................60
SAQ 5.3 .............................................................................................................................60
Study Session 6: Performing Chest Physiotherapy .....................................................................61
Expected duration: 1 week or 2 contact hour ........................................................................61
Introduction ..........................................................................................................................61
Learning Outcomes for Study Session 6 .................................................................................61
6.1 chest physiotherapy ........................................................................................................61
Why is Chest Physiotherapy necessary i.e. Purpose/Reasons.............................................61
The clients that require chest physiotherapy i.e. Indications includes: ..................................61
6.1.1 The clients who cannot have a chest physiotherapy i.e. Contraindications includes: .62
6.2 The process of chest physiotherapy .................................................................................62
6.3 Step-By-Step Technique of Chest Physiotherapy ..............................................................64
Special Considerations ..........................................................................................................66
Pediatric Variations ...............................................................................................................67

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 Summary of study session 6 ..................................................................................................67
Self-Assessment Questions (SAQs) ........................................................................................67
SAQ 6.1 (test learning outcome 6.1) ..................................................................................67
SAQ 6.2 (test learning outcome 6.2) ..................................................................................67
SAQ 6.3 (test learning outcome 6.3) ..................................................................................67
Notes on Self-Assessment Questions (SAQs) .........................................................................68
References/Further Reading ..................................................................................................68
Study Session 7: Oxygenation I & II............................................................................................69
Expected duration: 1 week or 2 contact hour ........................................................................69
Introduction ..........................................................................................................................69
Learning Outcomes for Study session 7 .................................................................................69
7.1 Oxygenation ....................................................................................................................69
7. 1.1 The Clients who will need Oxygen Therapy i.e. Indications .......................................70
7.2 Definition of Terminologies .............................................................................................70
7.3 The Various Methods of Oxygen Administration ..............................................................70
Purposes ...............................................................................................................................73
A. Facemask........................................................................................................................75
B. Oxygen Conserving Cannula ...........................................................................................77
C. Oxygen Panel..................................................................................................................77
Summary of Study Session 7 ..................................................................................................79
Self-Assessment Questions (SAQs) for Study Session 7 ..........................................................79
SAQs 7.1 (tests learning outcomes 7.1) ..............................................................................79
SAQs 7.2 (tests learning outcomes 7.2) ..............................................................................79
SAQs 7.3 (tests learning outcomes 7.3) ..............................................................................80
Notes ON SAQs .....................................................................................................................80
Study Session 8: OXYGENATION III ............................................................................................81
Expected duration: 1 week or 2 contact hour ........................................................................81

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 Introduction ..........................................................................................................................81
Learning Outcome for Study Session 8 ..................................................................................81
8.1 Administration of Oxygen by Tent ...................................................................................81
8.2 Step-by-Step Technique of Oxygen Therapy via Tent .......................................................83
8.2.1 Special Considerations ..............................................................................................84
Summary of Study Session 8 ..................................................................................................85
Self-Assessment Questions (SAQs) for Study Session 8 ..........................................................85
SAQs 8.1 (tests learning outcomes 8.1) ..............................................................................85
SAQs 8.2 (tests learning outcomes 8.2) .................................................................................85
Notes on SAQs.......................................................................................................................85
References/Further Reading ..................................................................................................85
Study Session 9: Pursed Lip Breathing, Coughing and Deep Breathing Exercises. .....................86
Expected duration: 1 week or 2 contact hour ........................................................................86
Introduction ..........................................................................................................................86
Learning Outcomes for Study Session 9 .................................................................................86
9.1 Why is Breathing Exercise Necessary i.e. Purpose ............................................................86
9.1.1 Breathing Exercises ...................................................................................................87
9.2 The various types of breathing exercises .....................................................................87
Summary of Study Session 9 ..................................................................................................88
Self-Assessment Questions (SAQs) for Study Session 9 ..........................................................89
SAQs 9.1 (tests learning outcomes 9.1) ..............................................................................89
SAQs 9.2 (tests learning outcomes 9.2) ..............................................................................89
Notes on Self Assessments Questions (SAQs) ........................................................................89
References/Further Reading ..................................................................................................89
Study Session 10: Oral and Nasopharyngeal Suctioning .............................................................90
Expected duration: 1 week or 2 contact hour ........................................................................90
Introduction ..........................................................................................................................90

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 Learning Outcomes for Study Session 10 ...............................................................................90
10.1 Suctioning ......................................................................................................................90
10.1.1 Types of suctioning .................................................................................................91
10.2 Importance of Suctioning...............................................................................................91
10.3 Steps by Step Technique. ...............................................................................................91
Summary of Study Session 10 ................................................................................................96
Self-Assessment Questions (SAQs) for Study Session 10 ........................................................97
SAQ 10.1 (tests learning outcomes 10.1) ...........................................................................97
SAQ 10.2 (tests learning outcomes 10.2) ...........................................................................97
Notes on Self-Assessment Questions (SAQs) .........................................................................97
References/Further Reading ..............................................................................................97
Study Session 11: Using Bronchodilators ...................................................................................98
Expected duration: 1 week or 2 contact hour ........................................................................98
Introduction ..........................................................................................................................98
Learning Outcomes for Study session 11 ...............................................................................98
11.1 Bronchodilators .............................................................................................................98
11.2 The types of Bronchodilators .........................................................................................99
11.3The methods of administering Bronchodilators ..............................................................99
Summary of Study Session 11 ..............................................................................................101
Self-Assessment Questions (SAQs) for Study Session 11 ......................................................101
SAQs 11.1 (tests learning outcomes 11.1) ........................................................................101
SAQs 11.2 (tests learning outcomes 11.2) ........................................................................101
SAQs 11.3 (tests learning outcomes 11.3) ........................................................................101
Notes on Self-Assessment Questions (SAQs) .......................................................................102
Glossary of Terms....................................................................................................................103

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Study Session 1: Health assessment

Introduction
Can you remember any of your visits to the hospital where the doctor brings out some little
instrument to check your body or touch some parts of your body for assessment? The doctor or
health worker may even ask some funny questions about your physical self. This is called health
assessment

In this study session you will learn about the aims and components of client health assessment
and the preparation of the client before this procedure. We will also discuss the equipment
needed and the positions which can be assumed by the client during the assessment process. This
study session will conclude with a general survey of a client (a volunteer/ a mannequin).

Learning Outcomes for Study Session 1

When you have studied this session, you should be able to:
1.1 Explain the meaning and components of Health Assessment (SAQ 1.1)
1.2 State the reasons and purpose for carrying out health assessment (SAQ 1.2)
1.3 Describe the physical and psychological preparation of clients for health assessment (SAQ
1.3)
1.4 Explain assessment techniques in health assessment (SAQ 1.4)

1.1 The Meaning and components of health assessment

Let us now consider the meaning of assessment. Assessment is the collection of data about an
individual health state. Assessment and examination are terms which are sometimes used
interchangeably. Both refer to a critical investigation and evaluation of client status. Many times,
nurses are the first to detect changes in client’s condition, regardless of the setting (Perry and
Potter, 1998).
The skills of physical assessment and examination are powerful tools with which to detect subtle
as well as obvious changes in client health. By practising and developing the knowledge and
skills of health assessment, you will develop confidence in understanding and responding to each
client’s situation.

1.1.2 Components of Health assessment

Health assessment involves physical examination and health history/ history taking.
The health history is a lengthy interview with a client/ an informant to gather subjective data
about any presenting conditions.
When the patient is seen for the first time by a member of the health care team, the first
requirement is a database (except in emergency situations). The sequence and format of

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obtaining data about the patient vary, but the content, regardless of format, usually addresses the
same general topics. A traditional approach includes the following:

1. Biographical data
2. Chief complaint
3. Present health concern (or present illness)
4. Past history
5. Family history
6. Review of systems
7. Patient profile
However, a more popular and widely accepted approach, even though lacking a general consensus,
is the functional health patterns assessment tool developed by Gordon. This consists of 11
functional health patterns:
1. Health Perception and Management Nutritional metabolic
2. Elimination
3. Activity exercise
4. Sleep rest
5. Cognitive-perceptual
6. Self-perception/self-concept
7. Role relationship
8. Sexuality reproductive
9. Coping-stress tolerance
10. Value-Belief Pattern
11. Role/relationship pattern

In physical examination, you may carry out a brief head to toe assessment, or a general survey
such as when you meet a client for the first time (during admission); or you may decide to assess
a particular system( e.g. musculoskeletal) following a complaint of pain on the foot by a
hospitalized client.

ITQ: Simply define health history

ITA: The health history is a lengthy interview with a client/ an informant to gather subjective
data about any presenting conditions
Although the sequence of physical examination depends on the circumstances and on the
patient’s reason for seeking health care, the complete examination usually proceeds as follows:
1. Skin
2. Head and neck
3. Thorax and lungs
4. Breasts
5. Cardiovascular system
6. Abdomen
7. Rectum
8. Genitalia
9. Neurologic system

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 10. Musculoskeletal system
It is anticipated that you have learnt “health history”, a prerequisite in basic nursing course. You
may therefore review the course as necessary.

1.2 The reasons/purpose for carrying out health assessment

What do nurses use physical assessment for? Nurses use physical assessment to:
• Develop (obtain baseline data) and expand the data base from which subsequent phases
of the nursing process can evolve
• To identify and manage a variety of patient problems (actual and potential)
• Evaluate the effectiveness of nursing care
• Enhance the nurse-patient relationship
• Make clinical judgments

1.2.1 Types of data in health assessment

• Subjective data – as explained by the client and obtained during health history (S)
• Objective data - Observed by the nurse and obtained during the physical examination (O)

1.3 Physical and psychological preparation of clients for health assessment

Pre- examination preparations- This involves three aspects viz:
• Preparation of client
• Preparation of environment
• Preparation of equipment

1.3.1 Preparing the client physically and psychologically

Almost everyone appreciates, and indeed needs an explanation of the physical examination.
Clients are often anxious about what the nurse will find. A tense, anxious client will not be able
to go through many of the physical manoeuvres required during an examination or to cooperate
with the instructions of the nurse.

You can reduce client’s anxiety and fear by conveying an open, receptive and professional
approach. Your facial expression and the tone of your voice should be relaxed to put client at
ease. They can be reassured during the examination by providing explanations at each step.

You should also remember to explain- using simple terms- when and where the examination will
take place, why it is important and what will happen. Assure the client that all information
obtained and documented is kept confidential. This means that only health professionals who
have legitimate need to know the client’s information will have access to it.
The clients are also prepared physically by encouraging the client to empty bladder and change
his/her cloths. You should also help the client assume proper positions during the examination so
that body parts are accessible and the client stays comfortable (See Figure 1.1)

22
 Figure 1.1: Positions used during physical examination (Photo by repositories)

1.3.2 Prepare the environment

In order to promote the comfort of the client and ensure an efficient examination, you should
ensure that the examination room / area has the following characteristics: privacy; a warm
comfortable ambient temperature; proper examination clothing for the client; natural and
artificial lights sources (natural lights can be controlled by drawing the curtain.
An instance in which you will need to vary natural/artificial lighting is during assessment of the
eye in testing pupil reaction to light, and when using ophthalmoscope); control of outside noises;
measures to prevent interruptions by visitors or other health care personnel; and a bed or table
set at examiner’s waist level.
1.3.3 Preparation of equipment/instrument
Equipment necessary for physical assessment should all be clean, in good working order and
readily accessible (Berman, Snyder, Kozier and Erb, 2008). Equipment is usually already placed
on trays or trolley ready for use. Some of the equipment used includes:
• Tape measure
• Tuning fork

23
 • Patellar hammer
• Pen light
• ophthalmoscope

Figure 1.2: Equipment used for health assessment/physical examination (Photo by repositories)

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1.4 Assessment Techniques
The techniques of health assessment are four: They are:
• Inspection
• Palpation
• Percussion
• Auscultation
The acronym for this is (IPPA)

1. Inspection: This means critical observation using the senses, most often the eyes. You
can inspect with the naked eye and using lighted instrument such as ophthalmoscope
(used to view the eye). Other senses can also be used in addition to visual observation.
See Figure 1.3. When you are using the sense of hearing, it is important that you have a
quiet environment for accurate hearing.

Figure 1.3: Using senses to assess client (Photo by repositories)

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 2. Palpation: This involves using the sense of touch for assessment. You can use the back
of hand to assess skin temperature, while fingers can be used to assess texture, moisture,
areas of tenderness, pulsation, presence of pain on pressure (See table 3). There are two
types of palpation: light and deep. Light (superficial) palpation should always precede
deep palpation because heavy pressure on the fingertips can dull the sense of touch.

Check the link below for a video of light and deep palpation:
http://www.youtube.com/watch?feature=player_detailpage&v=5MW1L7JRZz4

In light palpation, extend the fingers of your dominant hand parallel to the client’s skin and
press gently. The depression is only slight. In deep palpation, you make use of the pads of
one/both (bimanual) hands. When using one hand for deep palpation, the finger pads of the
dominant hand press over the area to be palpated, while the other hand is often used to support a
mass or an organ from below (Figure 1.4 ).
In bimanual palpation, one hand is placed over the other. You will extend the dominant hand as
for light palpation, the place the finger pads of the non-dominant hand on the dorsal surface of
the distal interphalangeal joint of the middle three fingers of the dominant hand.
The top hand applies pressure while the lower hand remains relaxed to perceive the tactile
sensations (Figure 1.5). Deep palpation is not done routinely because it requires caution as
pressure can damage internal organs.

Figure 1.4: Light Palpation (Photo by repositories)

3. Percussion is the act of striking the body surface to elicit sounds.

The note produced when you percuss (strike) a body surface depends on the quality of the
underlying mass. The sound varies and could be dull or resonant (booming, echoing,
reverberating, resounding) or flat or tympany.
The sound you hear when you strike the body surface will help you determine the size and shape
of underlying structures by being able to establish their borders and indicate if tissue/organ is air-
filled, fluid-filled, or solid.

26
ITQ: What is palpation?
ITA: This involves using the sense of touch for assessment

4. Auscultation – This means listening to sounds produced by the body

Direct auscultation – sounds are audible without stethoscope
Indirect auscultation – uses stethoscope
-Know how to use stethoscope properly (practice)
-Fine-tune your ears to pick up subtle changes (practice)
-Describe sound characteristics (frequency, pitch intensity, duration, and quality) (practice)
• Flat diaphragm picks up high-pitched respiratory sounds best
• Bell picks up low pitched sounds such as heart murmurs
• Practice using BOTH diaphragms
Practice
Nursing history is subjective - includes things like biographic data, the chief complaint, source of
the data, history of present illness, past medical history, immunization history, allergies, habits
(tobacco, ETOH), stressors, family history including genogram, patterns of health care, and a
review of the body’s systems

Activity 1.1
Take a moment to reflect on what you have read so far. Based on your nursing experience, and
knowing that physical assessment can be time consuming, what are the components?

Summary of Study Session 1

In this study session, you have learnt that:
1. Assessment is the collection of data about an individual health state. Assessment and
examination are terms which are sometimes used interchangeably
2. Health assessment involves physical examination and health history/ history taking.
3. A traditional approach includes the following:
• Biographical data
• Chief complaint
• Present health concern (or present illness)
• Past history
4. Nurses use physical assessment to:
• Develop (obtain baseline data) and expand the data base from which subsequent phases
of the nursing process can evolve
• To identify and manage a variety of patient problems (actual and potential)
• Evaluate the effectiveness of nursing care
5. Pre- examination preparations- This involves three aspects viz:
• Preparation of client
• Preparation of environment
• Preparation of equipment
6. The techniques of health assessment are four: They are:
• Inspection
• Palpation
• Percussion
• Auscultation

27
Self-Assessment Questions (SAQs)
Now that you have completed this study, you can assess how well you have achieved its
Learning outcomes by answering the following questions. Write your answers in your study
Diary and discuss them with your Tutor at the next! Support meeting.
SAQ 1.1
Explain what you understand by assessment
SAQ 1.2
Give reasons for conducting health assessment
SAQ 1.3
Give short explanations of the three pre-examination preparations
SAQ 1.4
Explain the assessment techniques

Note on Self-Assessment Questions (SAQs)

SAQ 1.1
Assessment is the collection of data about an individual health state. Assessment and
examination are terms which are sometimes used interchangeably. Both refer to a critical
investigation and evaluation of client status. Many times, nurses are the first to detect changes in
client’s condition, regardless of the setting (Perry and Potter, 1998).
SAQ 1.2

The reasons/purpose for carrying out health assessment

What do nurses use physical assessment for? Nurses use physical assessment to:
• Develop (obtain baseline data) and expand the data base from which subsequent phases
of the nursing process can evolve
• To identify and manage a variety of patient problems (actual and potential)
• Evaluate the effectiveness of nursing care
• Enhance the nurse-patient relationship
• Make clinical judgments

SAQ 1.3

Preparation of equipment/instrument
Equipment necessary for physical assessment should all be clean, in good working order and
readily accessible (Berman, Snyder, Kozier and Erb, 2008). Equipment is usually already placed
on trays or trolley ready for use. Some of the equipment used includes:
• Tape measure
• Tuning fork
• Patellar hammer
• Pen light
• ophthalmoscope

28
SAQ 1.4

Assessment Techniques
The techniques of health assessment are four: They are:
• Inspection
• Palpation
• Percussion
• Auscultation
The acronym for this is (IPPA)

References/Further Reading
Fundamentals of nursing
Clinical Nursing kills and techniques
www.nvcc.edu/.../physical%20assessment/...

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Study Session 2: A Quick Head - To - Toe Assessment and General Survey

Expected duration: 1 week or 2 contact hour

Introduction
In this study session, you will learn how to assess a client from head to toe. You will also learn
how to carry out a general survey. Of course, you must have learnt these in your basic nursing
course. However, this course will assist you to review your practice. It is a practical based
course.

Learning Outcomes for study session 2

When you have studied this session, you should be able to:
2.1 Describe the meaning of general survey (SAQ 2.1)
2.2 Describe the steps of head to toe and general survey assessment (SAQ 2.3)
2.3 Explain the action and rationale in head to toes assessment (SAQ 2.2)

2.1 General Survey

The general survey is the first step in a head to toe assessment. Information gathered during
general survey offers clues about the overall health of the client. When you meet the client for
the first time, try to observe the characteristics of the client and form an overall impression if
possible before interacting with the client.
The survey begins a review of the client’s primary health problems. It also includes the
assessment of the client’s vital signs, height and weight, and general behaviour and appearance.
The survey will provide you information about characteristic of an illness, client’s hygiene, and
body image, emotional state, recent changes in weight, and developmental status. Assessment of
vital signs, height and weight will not be dealt with during this course since this study session is
for trained nurse.

30
Table 2.1
Equipment Image
Stethoscope

Sphygmomanometer and cuff

Thermometer

Standing platform scale or stretcher scale

Table model/basket scale

31
 Digital watch or watch with second hand

Tape measure

2.2. Steps of head to toe and general survey assessment

ACTION RATIONALE
1. Introduce yourself and verify the client’s This action ensures that the client cooperates
identity. Explain to the client what you throughout the procedure
are going to do, why it is necessary, and
how she can cooperate
2. Perform hand hygiene and observe other This prevents transmission of infection to the
appropriate infection control procedures client
3. Provide for client privacy This minimizes client embarrassment

4. Observe body build, height, and weight This helps determine whether these
in relation to the client’s age, lifestyle, parameters are within the normal limit
and health
5. Observe the client’s overall hygiene and Grooming may reflect activity level prior to
grooming. Relate these to the person’s examination, resources available to purchase
activities prior to the assessment. grooming supplies, client’s mood, and self
care practices
6. Observe the client’s posture and gait, Normal posture should be erect and relaxed.
standing, sitting, and walking.

7. Note body and breathe odour in relation There should be absence of breath and body
to activity level. odour
8. Observe for signs of distress in posture This may reveal musculoskeletal problem,
or facial expression. mood or pain
9. Note obvious signs of health or illness This gives an idea of the present state of
(e.g in skin colour or breathing) client’s health status

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 10. Assess the client’s attitude. Reflects client’s feelings and emotional
Note the client’s affect/mood; assess the status
appropriateness of the client’s responses.

11. Listen for quantity, quality, and Speech should be understandable, at

organization of speech. moderate pace with clear tone and inflection.
Client should exhibit thought association.
Any deviation may reflect neurological
impairment, injury or impairment of mouth,
or indifferences in dialect and language.
12. Listen for relevance and organization of Thought should follow a logical sequence,
thoughts. make sense with sense of reality
13. Document findings in the client record. Provides means of determining changes in
client’s condition over time.

Note if client is in any acute distress: difficulty breathing, pain, anxiety. If these are present defer
general examination till later.

2.3. System by system method of head to toe assessment

1. Observe the general appearance – This involves checking recent weight change,
fatigue, and fever
2. Inspect the skin – This involves checking for rashes, lesions, changes, dryness, itching,
color change, hair loss, and change in hair or nails
3. Eyes - Observe change in vision, presence of floaters, use of glasses, pain
4. Ears – Observe for pain, loss of hearing, vertigo, ringing, discharge, infections
5. Nose and sinuses –Ask the client about frequent colds, congestion, nosebleed
6. Mouth and throat -Observe condition of teeth and gums, last dental visit, hoarseness,
frequent sore throats
7. Neck - Observe lumps, stiffness, goiter
8. Breasts – Observe lumps, pain, discharge, BSE
9. Respiratory – Observe cough, sputum, wheezing, asthma, COPD, last PPD, and last
CXR, smoking history (can do here, or with “habits”)
10. Cardiac – Observe heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past
ECG, FH of heart disease <50 yrs of age
11. GI – Observe problems swallowing, heartburn, vomiting, bowel habits, pain, jaundice
12. Urinary – Observe frequency, incontinence, pain, burning, hesitancy, nocturia, polyuria
13. Genitalia – Observe lesions, discharge, sexual orientation, sexual function, menstrual
history, contraception, pregnancy history, TSE
14. Peripheral vascular –Observe intermittent claudication, varicose veins, blood clots
15. MS – Observe muscle or joint pain, redness, stiffness, warmth, swelling, family history
16. Neurology - fainting, blackouts, seizures, weakness
17. Endocrine -Observe sweats, skin change, heat or cold intolerance, excessive thirst
(polydipsia), excessive urination (polyuria), weight change, menstrual changes
18. Psychiatric -Observe mental illness, thoughts of harming self or others

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Activity 2.1
Head to toe assessment should follow a definite order. When might you change order of the
examination?

Activity 2.2
Is the nursing process of the hospital where you practice comprehensive? What problems do you
encounter when using the nursing process format available?

Summary of Study Session 2

In this study session, you have learnt that:
1. The general survey is the first step in a head to toe assessment. Information gathered
during general survey offers clues about the overall health of the client.
2. The survey begins a review of the client’s primary health problems. It also includes the
assessment of the client’s vital signs, height and weight, and general behaviour and
appearance.
3. The first step in general head to toe survey is to introduce you and verify the client’s
identity. Explain to the client what you are going to do, why it is necessary, and how she
can cooperate
4. The system to system survey involves observing general appearance, inspecting skin,
nose, ears, sinuses, mouth and throat, neck, breasts, respiratory, etc.

Self-Assessment Questions (SAQs)

Now that you have completed this study, you can assess how well you have achieved its
Learning outcomes by answering the following questions. Write your answers in your study
Diary and discuss them with your Tutor at the next! Support meeting.
SAQ 2.1
Explain general survey
SAQ 2.2
Explain the action and rationale in head to toes assessment
SAQ 2.3
Give detailed explanation of system by system head to toe assessment

34
Note on Self-Assessment Questions (SAQs)
SAQ 2.1
The general survey is the first step in a head to toe assessment. Information gathered during
general survey offers clues about the overall health of the client. When you meet the client for
the first time, try to observe the characteristics of the client and form an overall impression if
possible before interacting with the client.

SAQ 2.2
See section 2.2

SAQ 2.3
See section 2.3

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Study Session 3: Respiratory system assessment

Expected duration: 1 week or 2 contact hour

Introduction
The respiratory system is made up of the organs in your body that help you to breathe.
Remember, that Respiration enables breathing. The goal of breathing is to deliver oxygen to the
body and to take away carbon dioxide.

In this study session you will learn about the assessment of the respiratory system. This shall
focus specifically on description of chest landmarks; normal and abnormal breath sounds; and
assessment of the thorax and lungs.

The assessment of the respiratory system shall be in two parts. First, you will learn how to
obtain health history from clients with respiratory system complaints. Secondly, you will be
educated on the step – by - step technique of examination of the respiratory system. You will be
asked to carry out some activities which you can post on my blog. Extra marks shall be awarded
for the activities.

Learning Outcomes for study session 3

When you have studied this session, you should be able to:
3.1 Explain the overview of respiratory assessment (SAQ 3.1)
3.2 Describe some chest landmarks (SAQ 3.2)
3.3 Describe five abnormalities of the chest wall (SAQ 3.3)
3.4 Differentiate between normal and abnormal (adventitious) breath sounds (SAQ 3.4)
3.5 Describe how you will carry out respiratory assessment on a client (SAQ 3.5)

3.1 Overview of respiratory assessment

The assessment of the respiratory system (thorax and lungs) is fundamental to determining the
client’s oxygenation status. Changes in the respiratory system can happen suddenly or gradually.
Pneumonia for instance is sudden in onset. Chronic Obstructive Pulmonary Diseases (COPD)
such as asthma, chronic bronchitis and emphysema are gradual in onset.

36
 Figure 3.1: Organs of the Respiratory System (Photo by repositories)
The nurse must be conversant with the landmarks of the chest in order to identify the underlying
organ. This will also help the nurse to document abnormal assessment findings. It is furthermore
important for a nurse to be able to identify abnormal chest size and shape in clients as these
affect air exchange.
Familiarity with breath sounds will assist you as a nurse to detect changes in patient’s breathing
and manage the situation appropriately.

ITQ: The assessment of the respiratory system is fundamental to determining the client’s …
A. Oxygenation status
B. Carbonization status
C. Health status
D. Breathing status

ITA: Answer is A, Oxygenation status

3.2 Chest landmarks

Chest landmarks consist of a series of imaginary lines on the chest wall; the ribs; and some
spinous processes. The imaginary lines consist of three series of lines (anterior, lateral and
posterior).

Figure 3.1: Chest landmarks(Photo by repositories)

A. The anterior series of lines consist of the following:

37
 1. The midsternal line: This is a vertical line that runs through the centre of the sternum
2. The midclavicular line (right and left): These are vertical lines from the midpoints of the
clavicles.

B. The lateral series of lines consist of three lines:

1. Anterior axillary lines (right and left): They are vertical lines from the anterior
axillary fold
2. Midaxillary line : This is a vertical line from the apex of the axilla
3. Posterior axillary line: This is a vertical line from the posterior axillary fold.

C. The posterior series of lines consist of

1. The vertebral line: This is a vertical line along the spinous processes from C7 to
T12
2. The scapular lines (right and left) are vertical lines from inferior angles of the
scapulae

Establishing the position of each rib and specific spinous processes will help you determine the
underlying lobes of the lung. Before you can locate the rib anteriorly, you must first identify the
angle of Louis.

Angle of Louis is the junction between the body of the sternum (breastbone) and the manubrium
(the upper part of the sternum to which the clavicle is joined). You will recall that anteriorly,
most ribs are attached to the sternum.

The upper border of the second rib attaches to the sternum at this manubriosternal junction
(angle of Louis). If you want to locate the manubrium, you will first palpate the clavicle and
follow its course to where it attaches to the manubrium. Then, you can palpate and count distal
ribs and intercostal spaces (ICSs) from the second rib.
The ICS is named after the rib above the space. You should remember to palpate along the
midclavicular line when palpating for rib identification.

3.2.1 Position/Lighting/Draping
Position –
• Patient should sit upright on the examination table.
• The patient's hands should remain at their sides.
• When the back is examined the patient is usually asked to move their arms forward ( hug
themself position )so that the scapulae are not in the way of examining the upper lung
fields.
Lighting - adjusted so that it is ideal.
Draping - the chest should be fully exposed. Exposure time should be minimized.
The basic steps of the examination
Can be remembered with the mnemonic IPPA:
• Inspection
• Palpation
• Percussion
• Auscultation

38
Health history
1. Any risk factors for respiratory disease
2. Smoking
a. pack years ppd X # years
b. exposure to smoke
c. history of attempts to quit, methods, results
3. Sedentary lifestyle, immobilization
4. Age
a. environmental exposure
b. Dust, chemicals, asbestos, air pollution
5. Obesity
6. Family history

Cough
• Type : dry, moist, wet, productive, hoarse, hacking, barking, whooping
• Onset
• Duration
• Pattern : activities, time of day, weather
• Severity :effect on ADLs
• Wheezing
• Associated symptoms
• Treatment and effectiveness

SPUTUM
• Amount
• Color
• Presence of blood (hemoptysis)
• Odor
• Consistency
• Pattern of production

PAST HEALTH HISTORY

• Respiratory infections or diseases (URI)
• Trauma
• Surgery
• Chronic conditions of other systems
• Family Health History
• Tuberculosis
• Emphysema
• Lung Cancer
• Allergies
• Asthma

INSPECTION
• Tracheal deviation (can suggest of tension pneumothorax

39
3.3 Chest wall deformities
The following are examples of chest deformities
1. Kyphosis: This means curvature of the spine anterior-posterior

Figure 3.2: Kyphosis (Photo by repositories)

2. Scoliosis: This is the curvature of the spine lateral

Figure 3.3: Scoliosis (Photo by repositories)

3. Barrel chest: In this condition, chest wall increased anterior-posterior; normal in children;
typical of hyperinflation seen in COPD

40
 Figure 3.4: Barrel Chest (Photo by repositories)

4. Pectus excavatum (cobbler’s chest): Pectus excavatum, also known as sunken or funnel
chest, is a congenital chest wall deformity in which several ribs and the sternum grow
abnormally, producing a concave, or caved-in, appearance in the anterior chest wall

Figure 3.5: Pectus excavatum (cobbler’s chest) (Photo by repositories)

5. Pectus carinatum (pidgeon chest): Pectus carinatum may occur as a solitary abnormality
or in association with other genetic disorders or syndromes. The condition causes the
sternum to protrude, with a narrow depression along the sides of the chest. This gives the
chest a bowed-out appearance similar to that of a pigeon.

Figure 3.6: Pectus carinatum (Photo by repositories)

ITQ: Pectus excavatum is also known as ………

ITA: Cobbler’s chest

41
3.4: Practical Steps for Respiratory Assessment
Tactile fremitus
This is vibration felt by palpation. Place your open palms against the upper portion of the
anterior chest, making sure that the fingers do not touch the chest. Ask the patient to repeat the
phrase “ninety-nine” or another resonant phrase while you systematically move your palms over
the chest from the central airways to each lung’s periphery.
You should feel vibration of equally intensity on both sides of the chest. Examine the posterior
thorax in a similar manner. The fremitus should be felt more strongly in the upper chest with
little or no fremitus being felt in the lower chest.

Assessment of expiration

Chest expansion during inspiration

Percussion over the anterior chest

42
 Direct percussion of the clavicles for disease in the lung apices

Auscultation
 To assess breath sounds, ask the patient to breathe in and out slowly and deeply through
the mouth.
 Begin at the apex of each lung and zigzag downward between intercostal spaces. Listen
with the diaphragm portion of the stethoscope.

 Normal breath sounds

 Note
 Pitch
 Intensity
 Quality
 Duration

Normal breath sound

 Bronchial :Heard over the trachea and mainstem bronchi (2nd-4th intercostal spaces
either side of the sternum anteriorly and 3rd-6th intercostal spaces along the vertebrae
posteriorly). The sounds are described as tubular and harsh. Also known as tracheal
breath sounds.

43
  Bronchovesicular :Heard over the major bronchi below the clavicles in the upper of the
chest anteriorly. Bronchovesicular sounds heard over the peripheral lung denote
pathology. The sounds are described as medium-pitched and continuous throughout
inspiration and expiration.
 Vesicular :Heard over the peripheral lung. Described as soft and low- pitched. Best heard
on inspiration.
 Diminished :Heard with shallow breathing; normal in obese patients with excessive
adipose tissue and during pregnancy. Can also indicate an obstructed airway, partial or
total lung collapse, or chronic lung disease.

Steps to the Procedure

S/N ACTION RATIONALE
1. Introduce yourself and verify the client’s This shows respect for the client,your
identity. Explain to the client what you are going professionalism,makes the client feel
to do, why it is necessary, and how the client can comfortable and relaxed and trust
cooperate your actions.
2. Perform hand hygiene and observe other This reduces the spread of
appropriate infection control procedures microorganisms
3. Provide for client privacy This ensures confidentiality and
respect for the client.
4. Inquire if client has any history of the following: This serves as a baseline data during
• Family history of illness, including cancer assessment.
• Allergies
• Tuberculosis
• Lifestyle habits, such as smoking, and
occupational hazards
• Any medications being taken

• Current problems such as swellings, coughs,

wheezing, pain
5. Assessment This indicates any deviation from
Posterior thorax: Inspect the shape and normal such as barrel chest (there is
symmetry of the thorax from posterior and increased anteroposterior to transverse
lateral views. Compare the anteroposterior diameter).
diameter to the transverse diameter. Also shows thorax asymmetric.
6. Inspect the spinal alignment for deformities: This indicates any deviation from
Have the client stand. From a lateral position, normal such as exaggerated
observe the three normal curvatures: cervical, curvatures(kyphosis,lordosis)
thoracic, and lumbar
7. To assess for lateral deviation of the spine This indicates any deviation from
(scoliosis), observe the standing client from the normal such as the deviation of the
rear. Have the client bend forward at the waist spine to one side which is noticeable
and observe from behind. when bending over and the uneven
shoulders or hips.
8. Palpate the posterior thorax: For clients who This indicates any deviation from
have no respiratory complaints, rapidly assess normal such as skin lesions or areas of

44
 the temperature and integrity of all chest skin hyperthermia.
ii. For clients who do have respiratory
complaints, palpate all chest areas for bulges, This indicates any
tenderness, or abnormal movements. Avoid deep lumps,bulges,depressions,areas of
palpation for painful areas, especially if a tenderness,movable structures such as
fractured rib is suspected. ribs
9. Palpate the posterior chest for respiratory This indicates any deviation from
excursion: Place the palms of both your hands normal such as asymmetric and/or
over the lower thorax, with your thumbs adjacent decreased thorax expansion.
to the spine and your fingers stretched laterally.
Ask the client to take a deep breath while you
observe the movement of your hands and any lag
in movement.
10. Palpate the chest for vocal (tactile) fremitus.: This indicates any deviation from
Place the palmar surfaces of your fingertips or normal such as decreased or absent
the ulnar aspect of your hand or closed fist on fremitus which is associated with
the posterior chest, starting near the apex of the pneumothorax.
lungs Also increased fremitus which is
Ii. Ask the client to repeat such words as “blue associated with consolidated lung
moon” or “one, two, three.” tissue as seen in pneumonia
iii. Repeat the two steps, moving your hands
sequentially to the base of the lungs.
11. Percuss the thorax. This determines if the lung tissue is
filled with air.liquid,or solid material
and to observe the positions of the
internal organs
12. Percuss for diaphragmatic excursion.
13. Auscultate the chest using the flat-disc The diaphragm of the stethoscope is
diaphragm of the stethoscope best for transmitting high- pitched
breath sounds. Adventitious sounds
such as crackles, wheezes, gurgles can
be detected.
14. Use the systematic zigzag procedure used in
percussion
15 Ask the client to take slow, deep breaths through
the mouth. Listen at each point to the breath
sounds during a complete inspiration and
expiration.
16 Compare findings at each point with the
corresponding point on the opposite side of the
chest.
17 Anterior Thorax This determines abnormal breathing
Inspect breathing patterns. patterns.
Inspect the costal angle and the angle at which This indicates abnormality such as
the ribs enter the spine. widened coastal angle as seen in
COPD.

45
ACTION RATIONALE

18. Palpate the anterior chest. This determines asymmetry in the

Place the palms of both your hands on the lower anterior chest.
thorax, with your fingers laterally along the lower
rib cage and your thumbs along the costal margins
Ask the client to take a deep breath while you
observe the movement of your hands.

Same as for posterior fremitus

19. Palpate tactile fremitus in the same manner as
for the posterior chest.
If the breasts are large and cannot be retracted
adequately for palpation, this part of the examination This determines asymmetry in the
usually is omitted. anterior chest as well as areas of
dullness or flatness over the lung
tissue.

This determines adventitious breath

sounds.

20.Percuss the anterior chest systematically. This determines adventitious breath

Begin above the clavicles in the supraclavicular sounds.
space, and proceed downward to the diaphragm.
This provides detailed information
about the client for further
management.

21. Compare one side of the lung to the other.

Displace female breasts for proper examination.

22. Auscultate the trachea.

23. Auscultate the anterior chest.

Use the sequence used in percussion,
beginning over the bronchi between the
sternum and the clavicles.
24. Document findings in the client record.

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Summary of Study Session 3
In this study session, you have learnt that:
1. The assessment of the respiratory system (thorax and lungs) is fundamental to
determining the client’s oxygenation status.
2. Chest landmarks consist of a series of imaginary lines on the chest wall; the ribs; and
some spinous processes. The imaginary lines consist of three series of lines (anterior,
lateral and posterior).
3. Examples of chest wall diseases are kyphosis, scoliosis, barrel chest, Pectus excavatum
(cobbler’s chest), Pectus carinatum (pigeon chest)

Self-Assessment Questions (SAQs)

Now that you have completed this study, you can assess how well you have achieved its
Learning outcomes by answering the following questions. Write your answers in your study
Diary and discuss them with your Tutor at the next! Support meeting.
SAQ 3.1 (Test learning outcome 3.1)
Explain the practical steps to respiratory assessment
SAQ 3.2 (Test learning outcome 3.2)
Describe some chest landmarks
SAQ 3.3 (Test learning outcome 3.3)
Describe five abnormalities of the chest wall

SAQ 3.4 (Test learning outcome 3.4)

Differentiate between normal and abnormal (adventitious) breath sounds

SAQ 3.5 (Test learning outcome 3.5)

Describe how you will carry out respiratory assessment on a client

47
Note on Self-Assessment Questions (SAQs)
SAQ 3.1
The assessment of the respiratory system (thorax and lungs) is fundamental to determining the
client’s oxygenation status. Changes in the respiratory system can happen suddenly or gradually.
Pneumonia for instance is sudden in onset. Chronic Obstructive Pulmonary Diseases (COPD)
such as asthma, chronic bronchitis and emphysema are gradual in onset.

SAQ 3.2
Chest landmarks consist of a series of imaginary lines on the chest wall; the ribs; and some
spinous processes. The imaginary lines consist of three series of lines (anterior, lateral and
posterior).

SAQ 3.3

See section 3.3

SAQ 3.5
Practical Steps for Respiratory Assessment
Tactile fremitus
This is vibration felt by palpation. Place your open palms against the upper portion of the
anterior chest, making sure that the fingers do not touch the chest. Ask the patient to repeat the
phrase “ninety-nine” or another resonant phrase while you systematically move your palms over
the chest from the central airways to each lung’s periphery.

You should feel vibration of equally intensity on both sides of the chest. Examine the posterior
thorax in a similar manner. The fremitus should be felt more strongly in the upper chest with
little or no fremitus being felt in the lower chest.

48
Study Session 4: Performing Postural Drainage

Expected duration: 1 week or 2 contact hour

Introduction
Postural drainage is an airway clearance technique that drains secretions from specific lung and
bronchi segment into the trachea. It is also called segmented bronchial drainage.

This study session will enable you to know about postural drainage, reasons for a postural
drainage, how to determine the areas to be selected for postural drainage, clients who should
have postural drainage as well as clients who cannot have postural drainage. It also includes the
articles needed for postural drainage and the step-by-step technique.

Learning Outcomes for study session 4

At the end of this study session, you should be able to:
4.1. Explain the meaning of postural drainage (SAQ 4.1)
4.3.State the positions for draining different areas of lungs (SAQ 4.2)
4.4.State the step-by-step technique of postural drainage (SAQ 4.3)

4.1 Postural drainage

Postural drainage is the gravitational clearance of secretions from specific bronchial segments by
using one or more of ten different positions.
Each position drains a specific corresponding section of the tracheobronchial tree, either from the
upper, middle or lower lung field into the trachea. Coughing or suctioning can then remove
secretions from the trachea.

The Reasons for postural drainage are as follows:

 The presence of accumulated secretions can promote bacterial growth leading to
infection.
 The secretions can obstruct the smaller airway passages and can cause actelectasis.

Areas for drainage can be selected based on:

49
 Knowledge of patient’s
condition, and disease
process.

Physical assessment of
the chest.

Chest X-ray
examination results

Figure 4.1: Basis for area of drainage (Photo by repositories)

What kind of people can have postural drainage i.e. indications

The following are the class of people who can have postural drainage
1. Bronchiectasis
2. Cystic Fibrosis
3. Chronic obstructive pulmonary disease (COPD)

What kind of people would postural drainage be harmful to i.e. contraindications?

Postural drainage would be harmful to the following group of people, with health conditions
listed below:
1. Increased intracranial pressure (ICP)
2. Unstable head or neck injury
3. Active hemorrhage with hemodynamic instability
4. Recent spinal surgery or injury
5. Empyema
6. Bronchopleural fistula
7. Rib fractures or flail chest
8. Lung tumor
9. Diseases of chest wall
10. Hemorrhage in respiratory tract
11. Painful chest conditions
12. Tuberculosis
13. Osteoporosis.

ITQ: The postural drainage involves one of the following

A. Two or more of ten different positions
B. Three or more of five different positions
C. One or more of four different positions
D. One or more of ten different positions

ITA: Answer is D, One or more of ten different positions

50
4.2 Positions for Draining Different Areas of Lungs
1. Left and right upper lobe anterior apical bronchi: you will have patient sit in chair
leaning back. Percuss with cupped hands and vibrate with heels of hands at shoulders and
with fingers over collarbone. Both sides can be done at the same time. Note body posture
and arm position of nurse. Nurse’s back is kept straight and elbows and knees are slightly
flexed.

2. Left and right upper lobes posterior apical bronchi: you will have patient sit in chair
leaning forward on pillow or cardiac table. Percuss and vibrate with hands on either side of
the upper spine, can do both sides at the same time.

4. Right and left anterior upper lobe bronchi: you will have patient lie flat on back with
small pillow under knees. Percuss and vibrate just below clavicle on either side of
sternum.

5. Left upper lobe lingular bronchus: you will have patient lie on right side with arm over
head in Trendelenburg position with foot of bed raised 30cm. Place pillow behind back
and roll patient one-fourth on to pillow Percuss and vibrate lateral to left nipple below
axilla.

6. Right middle lobe bronchus: you will have patient lie on left side, raise foot of bed
30cm. Place pillow behind back and roll patient one-fourth turned on to pillow. Percuss
and vibrate area of right nipple below axilla.

7. Left and right anterior lower lobe bronchi: you will have patient lie on back in
Trendelenburg position, with foot of bed elevated 45 – 50cm. Have knees bent on pillow.
Percuss and vibrate over lower anterior ribs on both sides.

8. Right lower lobe lateral bronchus: you will have patient lie on left side in
Trendelenburg position with foot of bed raised to 45 to 50cm. Percuss and vibrate right
side of the chest below scapula posterior to mid axillary line.

9. Left lower lateral bronchus: you will have patient lie on right side in Trendelenburg
position with foot of bed raised to 45 to 50cm. Percuss and vibrate left side of the chest
below scapula posterior to mid axillary line.

10. Right and left lower lobe superior bronchi: you will have patient lie flat on stomach
with pillow under stomach. Percuss and vibrate below scapulae on either side of spine.

11.Left and right posterior basal bronchi: you will have patient lie on stomach in
Trendelenburg position with foot of bed elevated 40 to 50cm. Percuss and vibrate over
posterior ribs on either side of spine.

51
 Figure 4.2: Positions for draining different areas of the Lungs. (Photo by repositories)

Articles needed
1. A comfortable surface, that can be slanted such as hospital beds in Trendelenburg’s
position or tilt table and chair for draining upper lobe areas.
2. One to four pillows, depending on patient’s posture and comfort.
3. A glass with water.
4. Tissues and paper bag.
5. Sputum cup.

4.3 Step-By-Step Technique of Postural Drainage

Nursing Action Rationale
1. Identify patient and check physician’s order Performs correct procedure for the right
for specific instructions for postural patient.
drainage.
2. Assess for possible impairment of airway Certain circumstances, disease process, and
clearance. conditions place patient at risk for impaired

52
 airway clearance.

3. Identify signs and symptoms that indicate X-ray film data and signs and symptoms
need to perform postural drainage such as indicate accumulation of pulmonary
changes in X-ray film consistent with secretions.
atelectasis, pneumonia, bronchiectasis,
ineffective coughing with thick sticky
tenacious sputum and abnormal breath
sounds such as wheezing, crackling and
gurgling

4. Identify which bronchial segments need to Area of lung congestion and postures for
be drained by reviewing chest X-ray reports. drainage will vary depending on disease
Auscultate over all lung fields for wheezes, process, patient condition and patient
crackles and gurgles, palpate over all lung problem. Areas most in need of and
fields for crepitus, fremitus and chest responsive to postural drainage usually can
expansion be easily identified by presence of early
inspiratory crackles and gurgles.
5. Wash hands Reduces transmission of microorganisms.

6. Select congested areas to be drained based To be effective, treatment must be

on assessment of all lung fields, clinical data individualized to treat specific areas
and chest X-ray data involved.
7. Place patient in position to drain congested Specific positions are selected to drain each
areas. Area selected may vary from patient area involved.
to patient. Help patient assume position as
needed. Teach patient correct posture and
arm and leg positioning, place pillows for
support and comfort.
8. Have patient maintain posture for 10 to 15 In adults, draining each area takes time.
minutes
9. During 10 to 15 minutes of drainage in each These maneuvers provide mechanical
posture, perform chest percussion and forces that aid in mobilization of airway
vibration over areas being drained. secretions.
10. After 10 to 15 minutes of drainage in first Secretions mobilized into central airways
posture, have patient sit up and cough. Save should be removed by coughing or
expectorated secretions in clear container. If suctioning before placing patient into next
patient cannot cough suctioning to be drainage position. Coughing is most
performed. effective when patient is sitting up and
leaning forward.
11. Have patient rest briefly if necessary. Short rest periods between postures can
prevent fatigue and help patient for better
tolerance to therapy
12. Have patient take sips of water Keeping mouth moist aids in expectoration
of secretions.
13. Repeat procedure until all congested areas

53
 selected have been drained. Each treatment Postural drainage is used only to drain areas
should not exceed 20 to 30 minutes. involved and is based on individual
assessment.
14. Wash hands Reduces transmission of microorganisms.

15. Record in nurse’s notes baseline and post Helps to evaluate outcomes and need for
therapy assessment of chest, frequency and changes in therapy.
duration of treatment, postures used and
bronchial segments drained, cough
effectiveness, need for suctioning, color,
amount and consistency of sputum,
hemoptysis or other unexpected outcome,
patient’s tolerance and reactions.

Special Considerations
 Client may be given bronchodilators or nebulisation before a postural drainage to loosen
secretions.
 The procedure is usually done 1hour before meal or 3hours after meal. Shortly after
meals can induce vomiting.
 The frequency of the procedure is usually 2-4times/day

Activity 4.1
Discuss the positions for draining different areas of the lungs.

Summary of Study Session 4

1. Postural drainage is the gravitational clearance of secretions from specific bronchial
segments by using one or more of ten different positions.
The Reasons for postural drainage are as follows:
 The presence of accumulated secretions can promote bacterial growth leading to
infection.
 The secretions can obstruct the smaller airway passages and can cause
actelectasis.

2. The following are the class of people who can have postural drainage
 Bronchiectasis
 Cystic Fibrosis
 Chronic obstructive pulmonary disease (COPD)

3. The positions for draining different areas of the lungs are:

 Left and right upper lobe anterior apical bronchi
 Left and right upper lobes posterior apical bronchi
 Right and left anterior upper lobe bronchi
 Left upper lobe lingular bronchus

54
Self-Assessment Questions (SAQs)
Now that you have completed this study, you can assess how well you have achieved its
Learning outcomes by answering the following questions. Write your answers in your study
Diary and discuss them with your Tutor at the next! Support meeting.

SAQ 4.1 (test learning outcome 4.1)

Explain postural drainage, and the reason why it is done

SAQ 4.2 (test learning outcome 4.2)

Explain some of the positions for draining.

SAQ 4.3 (test learning outcome 4.3)

Explain some of the steps by step techniques involved in postural drainage

Notes on Self-Assessment Questions (SAQs)

SAQ 4.1
Postural drainage is the gravitational clearance of secretions from specific bronchial segments by
using one or more of ten different positions.
The Reasons for postural drainage are as follows:
 The presence of accumulated secretions can promote bacterial growth leading to
infection.
 The secretions can obstruct the smaller airway passages and can cause
actelectasis.
SAQ 4.2

The positions for draining different areas of the lungs are:

 Left and right upper lobe anterior apical bronchi
 Left and right upper lobes posterior apical bronchi
 Right and left anterior upper lobe bronchi
 Left upper lobe lingular bronchus

SAQ 4.3
See section 4.3

References
1. Fundamentals of Nursing
2. Medical&Surgical Nursing-Assessment and Management of Clinical problems.
3. Brunner & Suddarth Medical&Surgical Nursing.

55
Study Session 5: Assisting the Patient with the use of an Incentive
Spirometer

Expected duration: 1 week or 2 contact hour

Introduction
Incentive Spirometry is a method of deep breathing that provides visual feedback to encourage
the patient to inhale slowly and deeply to maximize lung inflation and prevent or reduce
actelectasis. It is also referred to as sustained maximal inspiration.

In this study session, you will learn about Incentive Spirometry, the reasons why it is performed
and the clients who need incentive spirometry types of incentive spirometer will be discussed as
well as the necessary requirements and the steps involved.

Learning Outcomes
At the end of this study session, you should be able to:
5.1 Define the term incentive spirometry (SAQ 5.1)
5.2 State the types of incentive spirometer (SAQ 5.2)
5.3 State the step-by-step technique of incentive spirometry (SAQ 5.3)

5.1 Incentive Spirometry

Incentive spirometry means assisting the patient for voluntary deep breathing by providing visual
feedback about inspiratory volume by using a specially designed apparatus called spirometer.
The following are the reasons for incentive spirometry i.e Purposes
1. To improve pulmonary ventilation.
2. To counteract the effects of anesthesia or hypoventilation.
3. To loosen respiratory secretions
4. To facilitate respiratory gaseous exchange.
5. To expand collapsed alveoli.
6. To prevent postoperative respiratory complications.

5.1.1 Who are the clients who needs incentive spirometry i.e Indications
The following types of client’s needs incentive spirometry
1. Patients on long-term bed rest.
2. Patients with chronic obstructive and restrictive lung diseases.
3. Patients on medications that depress respiration.
4. Postoperative patients.

56
In-text Question
……… is the instrument used in performing incentive spirometry?
A. Thermometer
B. Barometer
C. Spirogyte
D. Spirometer

In-text Answer
Answer is D, Spirometer

5.2 Types of incentive spirometer.

The following are the types of incentive spirometer
1. Volume-oriented spirometers: The tidal volume of the spirometer is set according to the
manufacturer’s instructions.
Purposes: To ensure that the volume of air initiated is increased gradually as the patient
takes deeper and deeper breaths.

Figure 5.1: Volume-oriented spirometers (Photo by repositories)

2. Flow-oriented spirometers: This type of spirometer has no preset volume. The spirometer
contains a number of movable balls that are pushed up by the force of the breath and held
suspended in the air while the patient inhales. The amount of air inhaled and the flow of the
air are estimated by how long and how high the balls are suspended.

Figure 5.2: Flow-oriented spirometers (Photo by repositories)

57
Articles Needed
1. Stethoscope
2. Incentive spirometer with appropriate mouthpiece.
a. Flow-oriented or
b. Volume-oriented
3. Tissue paper
4. Emesis basin
5. Pillow if needed.

In-text Question
Flow-oriented spirometers are types of spirometer with no preset volume. TRUE OR FALSE
In-text Answer
TRUE

5.3 Step-By-Step Technique of Incentive Spirometry

Nursing action Rationale
1. Explain the reason and objective for the therapy Helps in obtaining cooperation of
that the inspired air helps to inflate the lungs. patient.
The ball or weight in the spirometer will rise in
response to the intensity of the intake of air. The
higher the ball rises, the deeper the breath.
2. Assess the patient’s respiratory status by general * Helps in comparison after procedure.
observation, auscultation of breath sounds and
percussion of thorax.
3. Review medical record for recent arterial blood
*Determines need for using incentive
gas. spirometer.
4. Remove dentures * Dentures interfere with performance of
procedure.
5. Wash hands *Reduces the transmission of
microorganisms.
6. Instruct patient to assume a semi Fowler’s or * Promotes optirnal lung expansion.
high Fowler’s position.

7. Set pointer on incentive spirometer at appropriate * Encourage patient to reach appropriate

level or point to level where disk or ball should reach. goal.

8. For the postoperative patient try as much as * More likely to have best results in
possible to avoid discomfort with the treatment. using incentive spirometry when patient
Co-ordinate treatment with administration of has as little pain as possible.
pain relief medications. Instruct and assist the
patient with splinting of incision.

9. Demonstrate the technique to the patient *Practice increases inspiratory volume,

a. Hold or place the spirometer in an upright maintains alveolar ventilation and

58
 position. A tilted flow-oriented device prevents atelectasis.
requires less effort to raise the balls or disks.
A volume oriented device will not function
correctly unless upright.
b. Demonstrate how to steady device with one
hand and hold mouthpiece with the other
hand.
c. Instruct the patient to exhale normally and
then place lips securely around mouthpiece.
d. Instruct to take a slow, deep breath to elevate
the balls or cylinder and then hold the breath
for 2 seconds initially increasing to 6 seconds
to keep the balls or cylinder elevated if
possible.
e. Instruct patient not to breathe through his or
her nose. Use a nose clip if necessary.
f. Tell patient to remove lips from mouthpiece
and exhale normally.

10. Instruct patient to relax and repeat procedure Provides enough strength for each repeat
several times and then four or five times procedure and this will give best results.
hourly

.
11. Instruct patient to cough after the procedure. Deep ventilation can loosen secretions
and coughing can facilitate removal.

12. Clean the mouthpiece with water and shake it Prevents transmission of
dry. Change disposable mouthpieces every microorganisms.
24hours.

13. Record lung volume in cubic centimeters. Acts as a communication between staff
Respiratory assessment (rate and depth of members.
respiration, the amount of secretions
expectorated.)

Special Consideration
Patient should take several normal breaths before attempting another one with the incentive
spirometer. Usually one incentive breath per minute minimizes patient fatigue. No more than
four or five maneuvers should be performed per minute to minute to minimize hypocarbia.

59
Summary of study session 5
In this study session, you have learnt that:
1. Incentive spirometry means assisting the patient for voluntary deep breathing by
providing visual feedback about inspiratory volume by using a specially designed
apparatus called spirometer.
2. The following are the reasons for incentive spirometry i.e Purposes
i. To improve pulmonary ventilation.
ii. To counteract the effects of anesthesia or hypoventilation.
iii. To loosen respiratory secretions
3. Types of incentive spirometer are
i. Volume-oriented spirometers
ii. Flow-oriented spirometers

Self-Assessment Questions (SAQs)

Now that you have completed this study, you can assess how well you have achieved its
Learning outcomes by answering the following questions. Write your answers in your study
Diary and discuss them with your Tutor at the next! Support meeting.

SAQ 5.1
Explain incentive spirometry.
State the reasons for incentive spirometry

SAQ 5.2
Mention and explain types of incentive spirometry

SAQ 5.3
Explain the action and rationale behind the step by step technique of incentive spirometry

References/Further Reading
Fundamentals of Nursing
Medical&Surgical Nursing-Assessment and Management of Clinical problems.
Brunner & Suddarth Medical&Surgical Nursing.

60
Study Session 6: Performing Chest Physiotherapy

Expected duration: 1 week or 2 contact hour

Introduction
Chest Physiotherapy is a technique used to loose secretions in the lungs and the respiratory tract.
This study session will provide you with details on chest physiotherapy, the reasons for chest
physiotherapy, the type of clients who needs chest physiotherapy, those clients who cannot have
chest physiotherapy, the process of chest physiotherapy, the required articles needed and the
step-by-step technique of chest physiotherapy.
The Paediatric considerations for chest physiotherapy will be discussed as well.

Learning Outcomes for Study Session 6

At the end of this study session, you should be able to:
6.1 Define the term chest physiotherapy (SAQ 6.1)
6.2 State the process of chest physiotherapy (SAQ 6.2)
6.3 State the step-by-step technique of chest physiotherapy (SAQ 6.3)

6.1 chest physiotherapy

Chest physiotherapy is defined as a method of facilitating respiratory function by removing
thick, tenacious secretions from the respiratory system us techniques of percussion, vibration and
postural drainage

Why is Chest Physiotherapy necessary i.e. Purpose/Reasons

The following are the purpose/reasons for chest physiotherapy
I. To remove tenacious secretions from bronchial walls in conditions like bronchiectasis
and chronic bronchitis.
II. To standardize the use of chest physiotherapy as a form of therapy using one or more
techniques to optimize the effects of gravity and external manipulation of the thorax by
postural drainage, percussion, vibration and cough. A mechanical percussor may also be
used to transmit vibrations to lung tissues.

The clients that require chest physiotherapy i.e. Indications includes:

1. Patients who bring out copious sputum.
2. Patients who are at risk of atelectasis.

61
ITQ: One of the following is related to chest physiotherapy
A. Spirometry
B. Tenacious secretions
C. Kiss of life
D. Dialysis
ITA: Answer is B, Tenacious secretions

6.1.1 The clients who cannot have a chest physiotherapy i.e. Contraindications includes:
1. Undrained lung abscess
2. Lung tumor
3. Pneumothorax
4. Diseases of chest wall
5. Lung hemorrhage/hemoptysis
6. Painful chest condition, e.g. pleural effusion
7. Tuberculosis
8. Osteoporosis
9. Increased intracranial pressure
10. Spinal injuries.

6.2 The process of chest physiotherapy

The process of chest physiotherapy involves the following:

1. Postural drainage: is the drainage by gravity of secretions from various lung segments.
(Refer to Study Session 4)

2. Chest Percussion: is the forceful striking of the skin with cupped hands and it is
sometimes called clapping.

Figure 6.1: Correct hand position for chest percussion (Photo by repositories)

3. Vibration: is a series of vigorous quivering produced by hands that are placed flat
against the chest wall. It is used after percussion to increase the turbulence of the exhaled
air and thus loosen thick secretions.

62
 Figure 6.2: Correct hand position for vibration (Photo by repositories)

4. Coughing: is an effective technique to clear secretions with less likelihood of bronchial

collapse.

Articles Needed
Articles Image
Pillows

Sputum cup with disinfectant

Paper tissues

Adjustable bed

Kidney tray

63
Stethoscope

ITQ: ……… is the also referred as clapping

A. Postural drainage
B. Spirometer
C. Chest percussion
D. Coughing
ITA: Answer is C, Chest percussion

6.3 Step-By-Step Technique of Chest Physiotherapy

The table below explains the steps to follow in chest physiotherapy, and the rationale for each
steps.
Action Rationale
1. Identify patient and check instruction of physician * Ensures that right procedure is done
and nursing care plan. on the right patient.

2. Explain procedure to patient and check time of * Reassures patient and promotes co-
last meal. operation. Postural drainage should be
avoided immediately after meal times as
it can induce vomiting.

2 Wash hands and dry. *Reduces transmission of

microorganisms.

3 Instruct patient to perform diaphragmatic * This method of breathing helps patient

breathing. to relax and widens airways and also
strengthen the diaphragm during
breathing
a. Client should place one hand on the abdomen (just
below the ribs) and the other hand on the middle of the
chest to increase the awareness of the position of the
diaphragm and its function in breathing.
b. Client should breathe in slowly and deeply through
the nose, letting the abdomen protrude as far as
possible.
c. Client should breathe out through pursed lips while
contracting the abdominal muscles.
d. Client should press firmly inward and upward on
the abdomen while breathing out.

64
e. Client should repeat for 1 minute; follow with a rest
period of 2 minutes.
f. Client should gradually increase duration up to 5
minutes, several times a day (before meals and at
bedtime).

4 Position patient in prescribed postural drainage * Position should be selected according

position, after consulting with physician (refer to the area of lung that is to be drained.
postural drainage procedure).

5 Cover area with towel * Reduces discomfort to patient.

7. Percussion * Percussion helps in dislodging mucous

Clap with cupped hands over chest wall for 1 plugs and mobilizes secretions into main
to 2 minutes in each lung area. Percuss from stem bronchi and trachea. The air
a. Lower ribs to shoulder on the back trapped under cupped hand sets up
b. Lower ribs to top of chest in front Avoid vibration through chest wall freeing
clapping over spine, liver, kidney, spleen, secretions. Percussion over these areas
breast, clavicle or sternum. may cause injuries.

8. Vibration
Remove towel and place hand, palm down on * Vibration frees the mucus from
chest area to be drained with one hand over the bronchial walls.
other and fingers together or place hands side by
side.
9. Instruct patient to inhale deeply and exhale slowly
through pursed lips and perform abdominal
breathing.
10. Tense all the muscles of hand and arm and
vibrate the hand especially heels with moderate
pressure during exhalation.
11. Stop vibration and relieve pressure on * Pressure applied to chest wall inhibits
inspiration. chest expansion during inspiration.
12. Vibrate for 5 exhalations over each lung area * Coughing or huffing aids in the
which is affected. movement and expulsion of secretion
After 3 - 4 vibrations, encourage patient to from the respiratory tract.
cough/huff and expectorate sputum into sputum
cup.
a. Client should assume a sitting position and
bend slightly forward,this permits a stronger
cough.
b. Flex your knees and hips to promote relaxation
and reduce the strain on the abdominal muscles
while coughing.
c. Inhale slowly through the nose and exhale

65
 through pursed lips several times.
d. Cough twice during each exhalation while
contracting (pulling in) the abdomen sharply
with each cough.
e. Splint the incisional area, if any, with firm
hand pressure or support it with a pillow or
rolled blanket while coughing(you can initially
demonstrate this by using the patient’s hands.
C

14. Allow patient to rest for several minutes. * Presence of crackles/ rhonchi indicates
mucous in bronchi.

15. Auscultate with stethoscope for change in breath

sounds. This will give best results.

16. Repeat percussion and vibration cycles according * Reduces risk of transfer of
to patient’s tolerance and clinical condition, microorganisms.
usually for 10-15 minutes. This will provide safety and comfort.
16. Wash hands. * Promotes comfort by removing the
bad taste of sputum in the mouth.
17. Assist patient to comfortable position. * Enables communication between staff
18. Assist with oral hygiene. members.

19. Record procedure and patient’s response in nurse’s

record.

Check the link for a video of chest physiotherapy

http://www.youtube.com/watch?v=ErMTXJLE5es

Special Considerations
1. Perform chest physiotherapy one hour before meals or 1 -3 hours after meals.
2. Administer bronchodilator /Metered dose inhaler if ordered or nebulize 15 minutes before
procedure.
3. Observe patient during treatment for tolerance-like breathing pattern cyanosis, etc.
4. Splint incision area, so that pain is tolerable. Administer pain medications if ordered, 15
to 20 minutes before procedure.
5. Stop procedure if there is tachycardia; fall in BP, palpitation, dyspnea or chest pain which
indicates hypoxia

66
Pediatric Variations
1. For infants, a soft circular mask or a percussion cup is used for percussing small areas.
2. A popping, hollow sound should be the result and not a slapping sound.
3. The procedure is done over the rib cage only and should be painless.

Activity 6.1
Test your knowledge of Chest Physiotherapy by discussing with a colleague.

Summary of study session 6

In this study session, you have learnt that:
1. Chest physiotherapy is defined as a method of facilitating respiratory function by
removing thick, tenacious secretions from the respiratory system us techniques of
percussion, vibration and postural drainage.

2. The clients that require chest physiotherapy i.e. Indications includes:

a. Patients who bring out copious sputum.
b. Patients who are at risk of atelectasis.

3. The process of chest physiotherapy includes:

Postural drainage
Chest Percussion
Vibration
Coughing

Self-Assessment Questions (SAQs)

Now that you have completed this study, you can assess how well you have achieved its
Learning outcomes by answering the following questions. Write your answers in your study
Diary and discuss them with your Tutor at the next! Support meeting.

SAQ 6.1 (test learning outcome 6.1)

Explain chest physiotherapy.
What are the reasons for chest physiotherapy?

SAQ 6.2 (test learning outcome 6.2)

List and explain the process involved in chest physiotherapy

SAQ 6.3 (test learning outcome 6.3)

Explain the step by step technique involved in chest physiotherapy

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Notes on Self-Assessment Questions (SAQs)
SAQ 6.1
Chest physiotherapy is defined as a method of facilitating respiratory function by removing
thick, tenacious secretions from the respiratory system us techniques of percussion, vibration and
postural drainage.

SAQ 6.2
The clients that require chest physiotherapy i.e. Indications includes:
a. Patients who bring out copious sputum.
b. Patients who are at risk of atelectasis.

SAQ 6.3
The process of chest physiotherapy includes:
Postural drainage
Chest Percussion
Vibration
Coughing

References/Further Reading
1. Fundamentals of Nursing
2. Medical&Surgical Nursing-Assessment and Management of Clinical problems.
3. Brunner & Suddarth Medical&Surgical Nursing.
4. http://www.youtube.com/watch?v=ErMTXJLE5es

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Study Session 7: Oxygenation I & II

Expected duration: 1 week or 2 contact hour

Introduction
Oxygenation or Oxygen therapy is frequently used in the treatment of respiratory problems
associated with hypoxemia. Oxygen is a colourless, odourless, tasteless gas that makes up 21%
of atmosphere.

The goal of this therapy is to provide adequate transport of oxygen for proper functioning of all
living cells, otherwise the absence of oxygen leads to cellular, tissue and organism death. It is a
non-invasive therapy used in respiratory problems.

This study session will discuss oxygenation I and II which includes the purpose of oxygen
therapy, the indications of oxygen therapy and the definition of some terms, the parts of a
cylinder and the various methods of oxygen administration.

Learning Outcomes for Study session 7

At the end of this session, you should be able to:
7.1 Define Oxygenation or Oxygen therapy (SAQ 7.1)
7.2 Define various terminologies (SAQ 7.2)
7.3 Identify the Various Methods of Oxygen Administration (SAQ 7.3)

7.1 Oxygenation
Oxygenation or Oxygen therapy is the administration of oxygen at a concentration that increases
the partial pressure of oxygen in inspired air.Why is Oxygen Therapy Necessary i.e. Purpose
The oxygen therapy is necessary because of the following:
1. To relieve dyspnea.
2. To maintain the partial pressure of oxygen
3. To reduce the workload on the heart.
2. To administer low concentration of oxygen to patients.
3. To allow uninterrupted supply of oxygen during activities like eating, drinking, etc.

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7. 1.1 The Clients who will need Oxygen Therapy i.e. Indications
 Patients with Pneumonia
 Patients who had severe hemorrhage
 Patients in Shock
 Patients with severe anemia
 Patients who had cardiac failure
 Patients climbing high altitudes

ITQ: Oxygen can used for patient that suffer one of these sickness
A. Respiratory Distress Syndrome
B. Catarrh
C. Botulism
D. Herpes

ITA: The answer is A

7.2 Definition of Terminologies

 Eupnoea: normal respiration
 Tachypnea: abnormally high respirations.
 Bradypnea: abnormally slow respirations.
 Apnea: a complete absence of respirations
 Orthopnea: ability to breathe only in an upright position.
 Dyspnea: difficult or labored breathing.
 Hypoxia: insufficient oxygen in the body.
 Hypercapnia or Hypercarbia: accumulation of carbon dioxide in the blood.
 Cyanosis: a bluish tinge of skin color

The Parts of an Oxygen Cylinder are as follows:

 Humidifier: a calibrated container filled with water to prevent administration of dry
oxygen.
 Flow meter: a calibrated that states the litre of administered oxygen.
 Control valve/ Regulator: acts as the on/off knob for administering oxygen.
 Gauge: states the amount of oxygen in the cylinder.

7.3 The Various Methods of Oxygen Administration

The various methods of oxygen administration are as follows:
1. Nasal cannula or catheter or nasal prongs
2. Face mask which includes Simple face mask, Partial and Non-breathing masks, and
Ventura masks.
3. Oxygen tent
4. Ox hood
5. Oxygen conserving cannula

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 6. Oxygen panel
7. Oxygen concentrator
8. Tracheostomy collar
9. Tracheostomy T Bar

The various methods of oxygen therapy can be classified into

Low-Flow High- Flow

Delivery Delivery
devices Devices

Figure 7.1: Classification of Methods of Oxygen Therapy (Photo by repositories)

1. Low-Flow Delivery Devices

Low-flow systems contribute partially to the inspired gas the patient breathes, which means that
the patient breathes some room air along with the oxygen. These systems do not provide a
constant or known concentration of inspired oxygen.
The amount of inspired oxygen changes as the patient’s breathing changes. Examples include
nasal cannula, or pharyngeal catheter, simple mask, partial-rebreather, and non-rebreathed
masks.

2. High-Flow Delivery Devices

High-flow systems provide the total inspired air. A specific percentage of oxygen is delivered
independent of the patient’s breathing. High-flow systems are indicated for patients who require
a constant and precise amount of oxygen.
Examples include trans-tracheal catheters, Ventura masks, aerosol masks, tracheostomy collars,
T-pieces, and face tents.

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Table 7.1: Methods of Oxygen Administration and the Percentages

A. Nasal Cannula
This is a method by which oxygen is administered in low concentration through a cannula which
is a disposable device with two protruding prongs for insertion into the nostrils. Below is an
image example of Nasal Cannula.

Figure 7.2: Image showing Nasal Cannula (Photo by repositories)

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Purposes
 To relieve dyspnea
 To administer low concentration of oxygen.
 To allow uninterrupted supply of oxygen during activities like eating, drinking, etc.

Articles
1. Oxygen source
2. Nasal cannula with connecting tubes
3. Humidifier with distilled water
4. Flow meter
5. Gauze pads
6. “No smoking” signs.

ITQ: Why can Nasal Cannula be used for?

ITA: It is used to deliver oxygen when a low flow of oxygen is required

Step by Step Technique

Action Rationale
1. Determine need for oxygen therapy in patient. * Reduces risk of error in
Check physician’s order for rate, device used administration.
concentration, etc.
* Provides a baseline for future
2. Perform an assessment of vital signs, level of assessment.
consciousness, lab values, etc. and record.
* Reduces risk of danger to the
3. Assess risk factors of oxygen therapy in patient patient
and environment such as patients with hypoxia
drive, faulty electrical connection, etc.

4. Explain procedure to patient and relatives and * Reduces anxiety and ensures
inform them how to cooperate. cooperation

5. Post” no smoking” sign on the patient’s door in * Oxygen supports combustion;

view of patient and visitors and explain to them smoking in oxygen area can lead to
the dangers of smoking when oxygen is on flow fire hazards.

6. Wash hands * Reduces risk of transmission of

microorganisms.

7. Set up oxygen equipment and humidifier * Filling beyond this point will cause
a. Fill humidifier up to the level marked on it water to enter tubing.
with sterile water
b. Attach flow meter to source, set flow meter in * Flow meter helps in monitoring and
‘off’ position regulating oxygen flow to patient.

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 c. Attach humidifier to base of flow meter * Humidification helps in preventing
drying of mucous membranes and
d. Attach tubing and nasal cannula to humidifier promotes comfort of patient.
* Oxygen is a drug and is dangerous
e. Regulate flow meter to prescribed level. to administer at flow rates greater or
lesser than prescribed level.
f. Ensure proper functioning by checking for * Kinks in the tubing will obstruct
bubbles in humidifier or feeling oxygen at the flow of oxygen through tube.
outlet.
* Proper fixing ensures comfort and
8. Place tips of cannula to patient’s nares and adjust prevents chances of cannula slipping
straps around ear for snug fit. The elastic band may be from nostrils.
fixed behind head or under chin.

9. Pad tubing with gauze pads over ear and inspect * Constant pressure may cause skin
skin behind ear periodically for breakdown
irritation/breakdown
10. Inspect patient and equipment frequently for
flow rate, clinical condition, level of water in * Helps in identifying any
humidifier, etc. complications that may arise.
11. Ensure that safety precautions are followed.
12. Wash hands
13. Document time, flow rate and observations
made on patient.
14. Encourage patient to breathe through his/her * Provides for optimal delivery of
nose with mouth closed oxygen to patient
15. Remove and clean the cannula with soap and
water, dry and replace every 8hours.Assess nares at least * Presence of cannula causes
every 8hours. irritation and dryness of the mucous
membrane.

Special Precautions
1. Never deliver more than 2-3 liters of oxygen to patients with chronic lung disease, e.g.
COPD.
2. Check frequently that both prongs are in patient’s nares.
* Oxygen concentration will vary on many factors like patient’s tidal volume and ventilatory
pattern.

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 A. Facemask

Figure 7.3: Image Example Showing Facemask (Photo by repositories)

Purposes
 To relieve dyspnea
 To administer higher concentration of oxygen.

Articles
1. Oxygen source
2. Mask (simple/or with venture adaptor high flow device of appropriate size)
3. Humidifier with distilled water
4. Flow meter
5. Gauze pieces
6. “No smoking” signs.

Step by Step Technique

Action Rationale
1. Determine need for oxygen therapy in * Reduces risk of error in administration.
patient. Check physician’s order for rate,
device used concentration, etc. * Provides a baseline for future assessment.

2. Perform an assessment of vital signs, level * Reduces risk of danger to the patient.
of consciousness, lab values, etc. and Oxygen is a combustible gas. Hypoxic drive
record. in patients is essential for maintaining
respiration.
3. Assess risk factors of oxygen therapy in
patient and environment such as patients
with hypoxia drive, faulty electrical
connection, etc.

4. Explain procedure to patient and relatives * Reduces anxiety and ensures cooperation

75
 and inform them how to cooperate.
* Oxygen supports combustion; smoking in
5. Post” no smoking” sign on the patient’s oxygen area can lead to fire hazards.
door in view of patient and visitors and * Reduces risk of transmission of
explain to them the dangers of smoking microorganisms.
when oxygen is on flow * Filling beyond this point will cause water
to enter tubing.
6. Wash hands * Flow meter helps in monitoring and
7. Set up oxygen equipment and humidifier regulating oxygen flow to patient.
a. Fill humidifier up to the level marked * Humidification helps in preventing drying
on it with sterile water of mucous membranes and promotes
b. Attach flow meter to source, set flow comfort of patient.
meter in ‘off’ position * Oxygen is a drug and is dangerous to
c. Attach humidifier to base of flow meter administer at flow rates greater or lesser
d. Attach tubing and face mask to than prescribed level.
humidifier (if venture device is used, * The mask should mold to face so that very
attach color coded venture adapter to little oxygen escapes into eyes or around the
masks as appropriate) cheeks or chin
e. Regulate flow meter to prescribed level.

8. Guide mask to patient’s faced and apply it

from the nose downward. Fit the metal piece of
mask to conform to shape of the nose.

9. Secure elastic band around patients’ head. * Ensure comfort of the patient.

10. Apply padding behind ears as well as scalp Padding prevents irritation to skin around
where elastic band passes. area.
11. Ensure that safety precautions are
followed.
12. Inspect patient and equipment frequently
for flow rate, clinical condition, level of
water in humidifier, etc.
* Helps in identifying any complications
. that may arise.
13.Wash hands

14. Remove the mask and dry the skin every 2- Reduces the risk of transmission of
3hours if oxygen is administered continuously. Do microorganisms.
not put powder around the mask.
15. Document relevant data in patient’s record. * The tight fitting mask and moisture from
condensation can irritate the skin on the
face. There is danger of inhaling powder if
it is placed around,

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Special Precautions
1. The dosage of oxygen may be ordered as an FIO2 (fraction of inspired oxygen which is
expressed as percentage or as liters per minute.
2. . The venture mask will have color coded inserts that list the flow rate necessary to obtain
the desired percentage oxygen.

B. Oxygen Conserving Cannula

Oxygen-conserving devices include trans-tracheal catheters, reservoir cannulas, and demand
oxygen delivery systems. They are designed to extend the amount of time portable oxygen
cylinders will last and correct hypoxemia with a lower flow of oxygen.

Figure 7.4: Example of Oxygen Conserving Cannula (Photo by repositories)

C. Oxygen Panel
Oxygen control panel allow patient oxygen levels to be adjusted from the control room
and eliminates the need to intrude into the patient room to adjust the oxygen flow rate,
possibly disturbing the patients sleep.

Figure 7.5: Example of Oxygen Panel (Photo by repositories)

D. Oxygen Concentrator
An oxygen concentrator is a medical device used to deliver oxygen to those who require it.

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 Figure 7.6: Example of Oxygen Concentrator (Photo by repositories)

E. TRACHEOSTOMY T-BAR
Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent air
and are important for clinicians caring for patients with a tracheostomy.

Figure 7.7: Example of Tracheostomy –Bar (Photo by repositories)

F. Tracheostomy Collar.

Figure 7.8: Example of Tracheostomy Collar (Photo by repositories)

78
Summary of Study Session 7
In this study session, you have learnt that:
1. Oxygenation is the process of treating patients with oxygen. Oxygen therapy is vital because it
helps to relieve dyspnoea, reduce workload from the patient heart and to allow uninterrupted
supply of oxygen.
2. Patients that need oxygen are people that suffered cardiac failure, pneumonia, shock and
severe anaemia.
3. The parts of oxygen cylinder are as follows;
 Humidifier: a calibrated container filled with water to prevent administration of dry
oxygen.
 Flow meter: a calibrated that states the litre of administered oxygen.
 Control valve/ Regulator: acts as the on/off knob for administering oxygen.
 Gauge: states the amount of oxygen in the cylinder.
4. The various method of oxygen administration is listed in and explained in 7.3 above.

Self-Assessment Questions (SAQs) for Study Session 7

After you have completed reviewing this study session, you can assess how well you have
achieved its Learning Outcomes by answering the questions below. Write your answers in Study
Diary and discuss them with your Tutor at the next Contact Session

SAQs 7.1 (tests learning outcomes 7.1)

A client in the Intensive Care Unit is experiencing an alteration in pulmonary gas exchanged
caused by impaired ventilation. Which of the following could be reason for impaired ventilation?
A. Atelectasis
B. Pulmonary Embolism
C. Diagnosis of cervical cord Injury
D. Anaemia

SAQs 7.2 (tests learning outcomes 7.2)

The nurse is planning to directly assess a client’s oxygen consumption. Which of the following
methods will be used for the assessments?
A. utilize pulse oximetry
B. Evaluate serum lactate level
C. Perform arterial blood gas analysis
D. Rethink the method

79
SAQs 7.3 (tests learning outcomes 7.3)
If a patient is supposed to receive as much 02 as possible without being intubated, which face
mask should be used?
A. Venturi mask
B. Face tent
C. Partial rebreather
D. Non rebreathe

Notes ON SAQs
1. Pulmonary Embolism
2. C
3. Face tent

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Study Session 8: OXYGENATION III

Expected duration: 1 week or 2 contact hour

Introduction
This teaching session is a continuation of the previous session. It will teach you about one of the
methods of oxygen administration.

This study session will focus on administration of oxygen by tent and the step by step procedure
to administration of oxygen via tent.

Learning Outcome for Study Session 8

At the end of this session, you should be able to:

8.1 State the methods of oxygen administration via the oxygen tent (SAQ 8.1)
8.2 Explain the step by step Technique of Oxygen Therapy through Tent (SAQ 8.2)

8.1 Administration of Oxygen by Tent

The process of administering is usually done for infants to give maximum comfort and most
satisfactory results

Description
It consists of a canopy over the baby’s bed that may cover the baby fully or partially and is
connected to a supply of oxygen. The canopies are transparent and enable the nurse to observe
the sick baby. Below is the example of oxygen by tent.

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 Figure 8.1: Oxygen Tent (Photo by repositories)

Advantages
1. Provides an environment for the patient with controlled oxygen concentration,
temperature regulation and humidity control.
2. It allows freedom of movement in bed.

Disadvantages
1. It creates a feeling of isolation
2. It requires high level of oxygen(10-12litre per minute)
3. Loss of desired concentration occurs each time the tent is opened to provide care for the
infant.
4. There is an increased chance of hazards due to fire.
5. It requires much time and effort to clean and maintain a tent.

ITQ: Infant respiratory distress syndrome is caused by any of the following?

A. Lack of Alveoli
B. Lamella
C. Surfactant
D. Hyaline in membrane

ITA: The answer is C

Articles
Oxygen tent and oxygen source, humidifier.

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8.2 Step-by-Step Technique of Oxygen Therapy via Tent
The step by step techniques of oxygen therapy through tent are listed in table 9.1 below:

Table 8.1: Step by Step Techniques of Oxygen Therapy through Tent

Action Rationale
1. Explain and reassure the parents and child. * Helps in obtaining cooperation.

2. Select the smallest tent and canopy that will *Increases the efficiency of the unit.
achieve the desired concentration of oxygen and
maintain patient comfort

3. Tuck the edges of the tent under the mattress *Dislodgement of tent leads to oxygen
securely. This is especially important if the leakage.
child is restless and can dislodge the tent by
pulling the covers loose..
4. Pad the metal frame that supports the canopy. * Protects the child from injury.

5. Flush the tent with oxygen (increase the flow Oxygen is circulated in the tent to adjust
rate) after it has been opened for a period of the concentration
time to increase the concentration of the gas,
and then reset the flow meter to the original.

6. Analyze and record the tent atmosphere every * Concentration varies with the
1-2 hours. Concentrations of 30-50% can be efficiency of the tent, the rate of flow of
achieved in well-maintained tents. oxygen and the frequency with which
the tent is opened to the outside
7. Maintain a tight fitting canopy whenever environment.
possible; provide nursing care through the
sleeves or pockets of the tent.
* Prevents oxygen leakage and
disruption of the tent atmosphere.
8. Check child’s temperature routinely.

9. ‘No smoking’ sign should be pasted in the unit. * Moisture accumulation may result in
hypothermia
10. Record the flow rate of oxygen, alteration in
flow rate and child’s reaction, Oxygen helps in combustion

* Serves as a communication between

staff members.

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Note
1. Oxygen can be administered to babies using oxygen(oxy hood)
2. Oxygen hood is a plastic device which is kept over the head of the infant. It permits easy
access to the child without loss of oxygen .It helps in efficient delivery oxygen.
3. While placing hood over the head of the child ,the edges of the hood should not rub
against the child’s chin, neck and shoulders,

Figure 8.2: Image Example of Oxy hood (Photo by repositories)

8.2.1 Special Considerations

1. Mist is prescribed with oxygen therapy to liquefy secretions
2. Humidified air may condense into water droplets inside the walls of the tent, it is
important to examine the child’s clothing and bedding and change them as necessary to
prevent chilling.
3. Electrical equipment used within or near the tent should be grounded properly.
4. It is preferable to monitor the SPO2 of patient continuously.
5. Avoid the use of volatile, inflammable materials such as oils, grease, and alcohol. Ether
and acetone near the tent.
6. Nurses should be knowledgeable about the location and technique of fire extinguisher
7. For the baby in oxygen tent, toys selected should be such that they retard absorption, are
washable and will not produce static electricity. E.g. woolen and stuffed toys. This
ensures baby safety.

ACTIVITY 8.1: Oxygen Therapy

Allowed Time: 30 Minutes

Task: Try to recall all the teachings about oxygen therapy

84
Summary of Study Session 8
In this study, you have learnt that:
1. Administration of oxygen by tent is mainly for infant for their comfort etc. It consists of a
canopy over the baby’s bed that may cover the baby fully or partially and is connected to
a supply of oxygen. The canopies are transparent and enable the nurse to observe the sick
baby.
2. The administration involves step by step techniques which you can find at 8.2 of this
section
3. Oxygen therapy by tent allows free.

Self-Assessment Questions (SAQs) for Study Session 8

After you have completed reviewing this study session, you can assess how well you have
achieved its Learning Outcomes by answering the questions below. Write your answers in Study
Diary and discuss them with your Tutor at the next Contact Session

SAQs 8.1 (tests learning outcomes 8.1)

Which of the following equipment can be used to administer oxygen to babies?
A. Oxyhood
B. non-rebreather

SAQs 8.2 (tests learning outcomes 8.2)

All of these are special consideration when administering oxygen to patients EXCEPT
A. Nurses should be knowledgeable about the location and technique of fire extinguisher
B. Avoid the use of volatile, inflammable materials such as oils, grease, and alcohol
C. For the baby in oxygen tent, toys selected should be such that they retard absorption
D. you may not monitor the SPO2 of patient continuously

Notes on SAQs
1. A
2.D

References/Further Reading
Fundamentals of Nursing
Medical& Surgical Nursing-Assessment and Management of Clinical problems.
Brunner & Siddhartha Medical & Surgical Nursing.

85
Study Session 9: Pursed Lip Breathing, Coughing and Deep
Breathing Exercises.

Expected duration: 1 week or 2 contact hour

Introduction
Breathing exercises are exercises that assist the patient during rest and activity thus reducing
fatigue.

This study session will focus on teaching about breathing exercises. It will help you acquire the
skills to assist clients with respiratory conditions.

Learning Outcomes for Study Session 9

At the end of this session, you will be able to:

9.1 Identify the purpose of breathing exercises (SAQ 9.1)

9.2 Explain the various methods of breathing exercises (SAQ 9.2)

9.1 Why is Breathing Exercise Necessary i.e. Purpose

The process of breathing is the essence of life and it is a rhythmic process of expansion and
contraction. Breathing is one consistent polarity seen in nature such as night and day, wake and
sleep. This is the bodily function that you do both voluntarily and involuntarily.
Breathing is necessary because of the following reasons below;

 To decrease dyspnea
 To improve oxygenation
 To reduce respiratory rate

1. To Decrease Dyspnea
Dyspnea refers to the sensation of difficult or uncomfortable breathing. It is a subjective
experience perceived and reported by an affected patient. Dyspnea on exertion (DOE) may occur
normally, but is considered indicative of disease when it occurs at a level of activity that is
usually well tolerated.

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9.1.1 Breathing Exercises
General Instructions
• Breathe slowly and rhythmically to exhale completely and empty the lungs completely.
• Inhale through the nose to filter, humidify, and warm the air before it enters the lungs.
• If you feel out of breath, breathe more slowly by prolonging the exhalation time.
• Keep the air moist with a humidifier.

9.2 The various types of breathing exercises

The various type of breathing exercises is as follows:

Diaphragmatc
Breathing Coughhing

Pursed Lip
Breathing

Figure 9.1: Methods of Breathing Exercises (Photo by repositories)

1. Diaphragmatic Breathing
Diaphragmatic breathing, abdominal breathing, belly breathing or deep breathing is breathing
that is done by contracting the diaphragm, a muscle located horizontally between the chest cavity
and stomach cavity. Air enters the lungs and the belly expands during this type of breathing.
The purpose is to use and strengthen the diaphragm during breathing
b. Place one hand on the abdomen (just below the ribs) and the other hand on the
middle of the chest to increase the awareness of the position of the diaphragm and
its function in breathing.
c. Breathe in slowly and deeply through the nose, letting the abdomen protrude as
far as possible.
d. Breathe out through pursed lips while tightening (contracting) the abdominal
muscles.
e. Press firmly inward and upward on the abdomen while breathing out.
f. Repeat for 1 minute; follow with a rest period of 2 minutes.

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 g. Gradually increase duration up to 5 minutes, several times a day (before meals
and at bedtime).

2. Pursed-Lip Breathing
The purpose is to prolong exhalation and increase airway pressure during expiration, thus
reducing the amount of trapped air and the amount of airway resistance.
a. Inhale through the nose while slowly counting to 3—the amount of time
needed to say “Smell a rose.”
b. Exhale slowly and evenly against pursed lips while tightening the abdominal
muscles. (Pursing the lips increases intratracheal pressure; exhaling through
the mouth offers less resistance to expired air.)
c. Count to 7 slowly while prolonging expiration through pursed lips—the length
of time to say “Blow out the candle.”
d. While sitting in a chair: Fold arms over the abdomen. Inhale through the nose
while counting to 3 slowly. Bend forward and exhale slowly through pursed
lips while counting to 7 slowly.
e. While walking: Inhale while walking two steps. Exhale through pursed lips
while walking four or five steps

3. Coughing Technique
a. Client should assume a sitting position and bend slightly forward, this permits a stronger
cough.
b. Flex your knees and hips to promote relaxation and reduce the strain on the abdominal
muscles while coughing.
c. Inhale slowly through the nose and exhale through pursed lips several times.
d. Cough twice during each exhalation while contracting (pulling in) the abdomen sharply
with each cough.
e. Splint the incisional area, if any, with firm hand pressure or support it with a pillow or
rolled blanket while coughing (you can initially demonstrate this by using the patient’s
hands

Activity 9.1: Breathing Exercise

Allowed Time: 48 Hours

Task: Identify a client with ineffective airway clearance and assist with breathing exercises

Summary of Study Session 9

In this study session, you have learnt that:
1. Breathing exercise is necessary because it helps
 To decrease dyspnea
 To improve oxygenation
 To reduce respiratory rate
2. Breathing exercise has general instruction that must follow and it is located in 9.1 of this
session.

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3. Breathing exercise take place in three methods such as pursed-lip breathing, diaphragmatic
breathing and coughing techniques. You can read it up in 9.2 of this study session.

Self-Assessment Questions (SAQs) for Study Session 9

After you have completed reviewing this study session, you can assess how well you have
achieved its Learning Outcomes by answering the questions below. Write your answers in Study
Diary and discuss them with your Tutor at the next Contact Session

SAQs 9.1 (tests learning outcomes 9.1)

You inhale through the nose to achieve --------------------- before it enters the lungs.
A. Humidify the air
B. Filter the Air
C. Warm the air
D. Weak the air

SAQs 9.2 (tests learning outcomes 9.2)

The method of breathing exercise that reduces the amount of trapped air and the amount of
airway resistance is -----------------
A. Coughing
B. Diaphragmatic Breathing
C. Pursed Lip Breathing
D. Exhalation

Notes on Self Assessments Questions (SAQs)

SAQ 9.1
D
SAQ 9.2
C

References/Further Reading
Fundamentals of Nursing
Medical & Surgical Nursing-Assessment and Management of Clinical problems.
Brunner & Siddhartha Medical& Surgical Nursing.

89
Study Session 10: Oral and Nasopharyngeal Suctioning

Expected duration: 1 week or 2 contact hour

Introduction
Suctioning is a common nursing technique performed to remove accumulated secretions from the
airway that prevents gaseous exchange. In this study session, you will learn about suctioning,
how to recognize clients who needs suctioning, the purpose or reasons for suctioning and the
technique of suctioning.

Learning Outcomes for Study Session 10

At the end of this session, you will be able to:
10.1 Define Suctioning (SAQ 10.1)
10.2 State the Purpose of Suctioning (SAQ 10.2)
10.3 State the Complications of Suctioning (SAQ 10.3)

10.1 Suctioning
Suctioning is aspirating secretions through a catheter connected to a suction machine or wall
suction outlet.
This is a sterile technique that removes secretions from the upper respiratory tract.
The clients that need suctioning will have these signs shown in figure 10.1 below

Figure 10.1: Signs for Suctioning (Photo by repositories)

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ITQ: One of the following is indications for suctioning?
A. Dyspnea
B. Cyanosis
C. Deterioration of arterial blood gases
D. Fever

ITA: The answer is D

10.1.1 Types of suctioning

The most common types are :
 Oropharyngeal Suctioning.
 Nasopharyngeal suctioning
 Nasotracheal Suctioning
 Suctioning through an artificial airway
The portion of the airway that requires suctioning and whether or not the patient has an artificial
airway determine the type of suctioning you perform.

10.2 Importance of Suctioning

Suctioning is necessary because of the following reasons/purposes
 To remove secretions that obstructs the airway
 To facilitate ventilation
 To obtain secretions for diagnostic purposes
 To prevent infection that may result from accumulated secretions
Suctioning can cause harmful effects such as the following:
1. Trauma to the mucous lining of the respiratory tract
2. Haemorrhage
3. Hypoxemia
4. Infection to the lungs(pneumonia)
5. Atelectasis
6. Cardiac arrest

Articles
1. Clean gloves for Oropharyngeal suctioning
2. Yanker suction catheter
3. Sterile gloves
4. Sterile suction catheter
5. Water soluble lubricant

10.3 Steps by Step Technique.

Click the link below to see the procedure.
http://www.youtube.com/watch?v=TwNSNodYfEw

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ACTION RATIONALE
Assess for clinical signs indicating Provides standard for evaluation of
the need for suctioning: procedure and the need for suctioning
• Restlessness
• Gurgling sounds during
respiration
• Adventitious breath sounds when
the chest is auscultated
• Change in mental status
• Skin color
• Rate and pattern of respirations
• Pulse rate and rhythm
• Decreased oxygen saturation
Introduce yourself and verify the client’s Ensures cooperation
identity. Explain to the client what you are
going to do, why it is necessary, and how
the client can cooperate.
Perform hand hygiene and observe Limits transfer of infection
other appropriate infection control
procedures
Provide privacy This minimizes embarrassment
Position a conscious person who has This prevents aspiration
a functional gag reflex in the semi-
Fowler’s position, with head turned to
one side for oral suctioning or with
neck hyperextended for nasal
Suctioning.
Position an unconscious client in the
Lateral position, facing you.
Place the towel or moisture-resistant The bed line is protected from moisture
Pad over the pillow or under chin.
Set the pressure on the suction gauge, and This ensures age and condition of client is
turn on the suction. taken into consideration
This action reduces bruising of mucus
Open the lubricant (if performing membrane
Nasopharyngeal suctioning).
For oral and Oropharyngeal suction:
Moisten the tip of the Yankauer suction
catheter with the sterile water or saline.
Pull tongue forward, if necessary,
Using gauze.
Do not apply suction (leave your finger off
the port) during the insertion.
Advance the catheter about 10–15
cm (4–6 inches) along one side of the
mouth into the oropharynx.

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It may be necessary during
or pharyngeal suctioning to apply suction
to secretions that collect in the vestibule of
the mouth and beneath the tongue.
For nasopharyngeal and Nasotracheal
suction:
Open the lubricant, if performing
Nasopharyngeal /Nasotracheal suctioning.
Open the sterile suction package:
Set up the cup or container, touching only
the outside.
Pour sterile water or saline into the
container.
Put on the sterile gloves, or put a non-
sterile
glove on the no dominant
hand and then a sterile glove on the
Dominant hand.
With your sterile-gloved hand, pick up the
catheter, and attach it to the suction unit.
Make an approximate measure of the depth Approximating the depth ensures that the
for the insertion of the catheter, and test the mucus is properly cleared.
equipment.
Measure the distance between the tip of the
client’s nose and the earlobe.
Mark the position on the tube with the
fingers of the sterile-gloved hand.
Test the pressure of the suction and the
patency of the catheter by applying your
sterile-gloved finger or thumb to the port or
open branch of the Y-connector (the
suction control) to create suction.
If needed, increase supplemental oxygen.
7. Lubricate and introduce the catheter.
Lubricate the catheter tip with sterile
water, saline, or water-soluble
Lubricant.
Remove oxygen with your
No dominant hand, if appropriate.

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Without applying suction, insert the
catheter the premeasured or recommended
distance into either naris, and advance it
along the floor of the nasal cavity.
Never force the catheter against the
obstruction. If one nostril is obstructed, try
the other.

8. Perform suctioning.
Apply your finger to the suction control
port to start suction, and gently rotate the
catheter.
Apply suction for 5–10 seconds while
slowly withdrawing the catheter, then
remove your finger from the control and
remove the catheter.

A suction attempt should last only

10–15 seconds. During this time, the
catheter is inserted, the suction
applied and discontinued, and the
Catheter removed.

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9. Rinse the catheter, and repeat suctioning
as above.
Rinse and flush the catheter and tubing
with sterile water or saline.
Rubricate the catheter, and repeat
suctioning until the air passage is clear.
Allow sufficient time between each
Suction, and limit suctioning to 5minutes in
total.
Encourage the client to breathe deeply and
to cough between suctions.

Obtain a specimen, if required. Use

a sputum trap as follows:
Attach the suction catheter to the tubing of
the sputum trap.
Attach the suction tubing to the sputum
trap air vent.
Suction the client. The sputum trap will
collect the mucus during suctioning.
Remove the catheter from the client.
Disconnect the sputum trap tubing from the
suction catheter. Remove the suction
tubing from the trap air vent.
Connect the tubing of the sputum trap to
the air vent.
Connect the suction catheter to the tubing.
Flush the catheter to remove secretions
from the tubing.
11. Promote client comfort.
Offer to assist the client with oral or nasal
hygiene.
Assist the client to a position that facilitates
breathing.
12. Dispose of equipment and ensure
availability for the next suction.
Dispose of the catheter, gloves, water, and
waste container. Wrap the catheter around

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 your sterile-gloved hand and hold the
catheter as the glove is removed over it for
disposal.
Rinse the suction tubing as needed by
Inserting the end of the tubing into the used
water container. Empty and rinse the
suction collection container as needed or
indicated by protocol.
Change the suction tubing and
container daily
Ensure that supplies are available for the
next suctioning.
13. Assess the effectiveness of suctioning.
Auscultate the client’s breath sounds to
ensure they are clear of secretions.
Observe skin color, dyspnea, level of
anxiety, and oxygen saturation levels.
14. Document relevant data.
Record:
• The amount, consistency, color, and odor
of sputum.
• The client’s breathing status before and
after the procedure.
• Frequency of suctioning must be
recorded.

Summary of Study Session 10

In this study session, you have learnt that:
1. Suctioning is the removal of mucus or fluids from a child that he or she is unable to
cough up, which may block air passages.
2. Clients that need suctioning are patients that suffer dyspnea, decreases SPO2level and
cynaosis
3. Types of suctioning are as follows:
 Oropharyngeal Suctioning.
 Nasopharyngeal suctioning
 Nasotracheal Suctioning
 Suctioning through an artificial airway
4. The importance of Suctioning and the step by step techniques are found in 10.2 and 10.3
of this study session.

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Self-Assessment Questions (SAQs) for Study Session 10
After you have completed reviewing this study session, you can assess how well you have
achieved its Learning Outcomes by answering the questions below. Write your answers in Study
Diary and discuss them with your Tutor at the next Contact Session
SAQ 10.1 (tests learning outcomes 10.1)
When should suctioning be performed?
SAQ 10.2 (tests learning outcomes 10.2)
One of the following is not the effect of suctioning
A. Stooling
B. Hypoxemia
C. Infection to the lungs (pneumonia)
D. Atelectasis

Notes on Self-Assessment Questions (SAQs)

SAQ 10.1
When there are signs of respiratory distress, inability to expectorate secretions, dyspnea,
bubbling/rattling (breath sounds), ineffective cough (nothing comes up), poor skin color,
decreased oxygen sat.

SAQ 10.2
The answer A.

References/Further Reading
Fundamentals of Nursing http://www.atitesting.com/ati_next_gen/skillsmodules content /airway
management/equipment/types-of-suctioning.html
http://www.youtube.com/watch?v=TwNSNodYfEw

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Study Session 11: Using Bronchodilators

Expected duration: 1 week or 2 contact hour

Introduction
In people with respiratory disorders that lead to obstruction of the airway, inhaled medicines are
the first choice. They begin to work within 5 minutes and have fewer side effects. The medicine
goes right to the lungs and does not easily go into the rest of the body. These medicines are
called Bronchodilators.

Bronchodilator is an agent that causes widening of the air passages by relaxing bronchial smooth
muscle. It allows increased oxygen distribution throughout the lungs and improving alveolar
ventilation.

In this study session, you will learn about bronchodilators, the clients who need bronchodilators,
the types of bronchodilators, and the method of administering bronchodilators.

Learning Outcomes for Study session 11

At the end of this session, you will be able to:

11.1 Define bronchodilators (SAQ 11.1)

11.2. State the types of bronchodilators (SAQ 11.2)
11.3 State the method of administering bronchodilators (SAQ 11.3)

11.1 Bronchodilators
A bronchodilator is a substance that dilates the bronchi and bronchioles, reducing resistance in
the respiratory airway and increasing airflow to the lungs. Bronchodilators are either endogenous
(originating naturally within the body), or exogenous i.e. they may be medications administered
for the treatment of breathing difficulties. They are most helpful in obstructive lung diseases.
Typical examples of these are thus:
 Asthma
 Chronic obstructive Pulmonary disease

The clients who need bronchodilators are:

a. Patients who have Chronic Obstructive Pulmonary Disease
b. Patients who have Asthma

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11.2 The types of Bronchodilators
Bronchodilators have three types and they are as follows:

Figure 10.1: Types of Bronchodilators (Photo by repositories)

Betaadrenergic
Beta-adrenergic agonists or Beta-agonists are medications that relax muscles of the airway,
which widens the airways and results in easier breathing. They are a class of sympathomimetic
agents which act upon the beta adrenoceptors. In general, pure beta-adrenergic agonists have the
opposite function of beta blockers.

Anticholinergics
Anticholinergics are a class of drugs that block the action of the neurotransmitter acetylcholine in
the brain. They are used to treat diseases like asthma, incontinence, gastrointestinal cramps, and
muscular spasms. They are also prescribed for depression and sleep disorders.

Methylxanthines
Methylxanthines are bronchodilators used in the treatment of asthma and chronic obstructive
pulmonary disease (COPD). Filter by: Apnea of Prematurity, Asthma, and Asthma, acute.

11.3The methods of administering Bronchodilators

The methods of administering bronchodilators are as follows:
1. A metered-dose inhaler (MDI) is a device that delivers a specific amount of
medication to the lungs, in the form of a short burst of aerosolized medicine that is
usually self-administered by the patient via inhalation. Below are the examples of
meter-dose inhaler.

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Metered dose inhaler with spacer Metered dose inhaler

Oral
Figure 10.2: Examples of different Samples of Inhaler (Photo by repositories)

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Summary of Study Session 11
In this study session, you have learnt that:
1. A bronchodilator is a substance that dilates the bronchi and bronchioles, reducing resistance in
the respiratory airway and increasing airflow to the lungs.
2. Types of bronchodilators are beta-adrenergic, anticholinergics and methylxanthines
3. The method of administering bronchodilators using meter-dose inhaler can be seen in 10.3 of
this study session.

Self-Assessment Questions (SAQs) for Study Session 11

After you have completed reviewing this study session, you can assess how well you have
achieved its Learning Outcomes by answering the questions below. Write your answers in Study
Diary and discuss them with your Tutor at the next Contact Session

SAQs 11.1 (tests learning outcomes 11.1)

What is bronchodilator?

SAQs 11.2 (tests learning outcomes 11.2)

Isoprel which is Beta 1 and Beta 2 sympathomimetic drug, also has its name as------------
A. Albuterol
B. Metaproteranol
C. Formoteral
D. Isopoterenol

SAQs 11.3 (tests learning outcomes 11.3)

When evaluating a patient's use of a metered dose inhaler, the nurse notes that the patient is
unable to coordinate the activation of the inhaler with her breathing. What intervention would be
most appropriate at this time?
A. Notify the doctor that the patient is unable to use the inhaler.
B. Obtain an order for a peak flow meter.
C. Obtain an order for a spacer device.
D. Ask the physician if the medication can be given orally.

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Notes on Self-Assessment Questions (SAQs)
SAQ 11.1
A bronchodilator is a substance that dilates the bronchi and bronchioles, reducing resistance in
the respiratory airway and increasing airflow to the lungs.

SAQ 11.2
The answer is D

SAQ 11.3
The answer is C. The use of a spacer may be indicated with metered dose inhalers, especially if
success with inhalation is limited. The other options are not appropriate interventions.

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Glossary of Terms
Apnea: a complete absence of respirations
Auscultation: listening to sounds produced by the body
Bradypnea: abnormally slow respirations.
Bronchodilator: A drug used to dilate and relax the bronchial passages and ease the flow of air
to the lungs
Chest physiotherapy: a technique used to loose secretions in the lungs and the respiratory tract.
Cyanosis: a bluish tinge of skin color
Diaphragmatic breathing: breathing to use and strengthen the diaphragm

Dyspnea: difficult or labored breathing

Eupnoea: normal respiration
Hypercapnia or Hypercarbia: accumulation of carbondioxide in the blood.
Hypoxia: insufficient oxygen in the body.
Incentive spirometry: a method of deep breathing that provides visual feedback to encourage
the patient to inhale slowly and deeply to maximize lung inflation and prevent or reduce
actelectasis
Inspection: The act of critical observation using the senses, most often the eyes.
Othopnea: ability to breathe only in an upright position.
Oxygen therapy: therapy to provide adequate transport of oxygen for proper functioning of all
living cells
Palpation: This involves using the sense of touch for assessment.
Percussion: This is the act of striking the body surface to elicit sounds
Postural drainage: an airway clearance technique that drains secretions from specific lung and
bronchi segment into the trachea
Pursed lip breathing: breathing to prolong exhalation and increase airway pressure during
expiration, thus reducing the amount of trapped air and the amount of airway resistance
Suctioning: a technique performed to remove accumulated secretions from the airway that
prevents gaseous exchange.
Tachypnea: abnormally high respirations.
Tactile fremitus: This is vibration felt by palpation

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