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Provide Advanced Nursing Care (HLT NUR4 01222) : For Regular Nursing (Level Iv - TVET) Students AAMBC, January 2022

This document provides guidance on performing postural drainage, a technique used to clear mucus from the lungs. It involves positioning patients in various positions to use gravity and techniques like percussion and vibration to drain mucus from different lung segments. Specific positions drain different segments of the lungs. Percussion involves rhythmic tapping on the chest to loosen mucus, while vibration involves gentle shaking. Deep breathing and coughing help clear drained mucus. Postural drainage requires various equipment and should be performed carefully with attention to patient safety and comfort.

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100% found this document useful (3 votes)
973 views56 pages

Provide Advanced Nursing Care (HLT NUR4 01222) : For Regular Nursing (Level Iv - TVET) Students AAMBC, January 2022

This document provides guidance on performing postural drainage, a technique used to clear mucus from the lungs. It involves positioning patients in various positions to use gravity and techniques like percussion and vibration to drain mucus from different lung segments. Specific positions drain different segments of the lungs. Percussion involves rhythmic tapping on the chest to loosen mucus, while vibration involves gentle shaking. Deep breathing and coughing help clear drained mucus. Postural drainage requires various equipment and should be performed carefully with attention to patient safety and comfort.

Uploaded by

Abel
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Provide advanced nursing care

(HLT NUR4 01222)


For Regular Nursing (Level Iv – TVET) Students
AAMBC, January 2022

Performing and assisting advanced  nursing procedures


Abel Yalew (PHO, MSc in AHuNu)
Performing postural
drainage
What is Postural drainage?
• A technique used to mobilize large amounts of secretions in people
with respiratory conditions
• Gravitational clearance of secretions from specific bronchial
segments by using one or more of different positions
• Needs positioning of a patient with an involved lung segment such
that gravity has a maximal effect of facilitating the drainage of
broncho – pulmonary secretions from the tracheobronchial tree
• Unclogging the airways is critical to reducing the severity of lung
infections
GOAL

• Clear mucus from each of the five lobes of the lungs


by draining mucus into the larger air-ways so that it
can be coughed out
EXTERNAL ANATOMY OF LUNG
• The right lung is composed of three lobes:
• The upper lobe
• The middle lobe
• The lower lobe
• The left lung is made up of only two lobes:
• The upper lobe
• The lower lobe.
• The lobes are divided into smaller divisions called segments
• The upper lobes on the left and right sides are each made up of
three segments:
• Apical
• Posterior
• Anterior
• The left upper lobe includes the lingual, which corresponds to the middle
lobe on the right.
• The lower lobes each include four segments:
• superior, anterior, basal, lateral basal and posterior basal.
• Each segment of the lung contains a network of air tubes, air sacs and blood
vessels.
• These sacs allow for the exchange of oxygen and carbon dioxide between the
blood and air.

It is these segments that are being drained


Indications
• Evidence or suggestion of difficulty with secretion clearance
• Difficulty clearing secretions with expectorated sputum production greater
than 25-30 mL/day (adult)
• Evidence or suggestion of retained secretions in the presence of an artificial
airway
• Presence of atelectasis caused by or suspected of being caused by mucus
plugging
• Diagnosis of diseases such as cystic fibrosis, bronchiectasis or cavitating lung
disease
• Presence of foreign body in airway
Assessment
The following should be assessed and reported to establish a need for PD:-
• A recent radiograph or bronchogram if available, is a useful adjunct in isolating
the affected areas.
• Pulmonary Function Test
• Excessive sputum production
• Effectiveness of cough
• History of pulmonary problems treated successfully with PDT (e.g.,
bronchiectasis, cystic fibrosis, Lung Abscess)
• Decreased breath sounds or crackles or rhonchi suggesting secretions in the
airway
• Change in vital signs
• Abnormal chest x-ray consistent with atelectasis, mucus plugging, or infiltrates
• Deterioration in arterial blood gas values or oxygen saturation
Mechanism of postural drainage

• During vertical position, only the segments of the right upper lobe and a
non-singular portion of the left upper lobe receive gravitational force

• Whereas the segment of the middle, verbal of left upper lobe, and lower
lobe segments of both lungs must drain anti-gravity.

• In the normal healthy lobe, the mucociliary muscle clears the bronchial
secretions
• In an unhealthy lobe, they get to meet each other, and secretions
get accumulated especially in the smaller airways
• That cannot be evacuated without gravity position which can further lead
to inflammation and scarring.
• The natural methods of evacuating the tracheobronchial tree of
the cumulus of mucus are on the whole extremely empty.
• Mucociliary muscle action removes dust or bacteria and is not
sufficient when there is much mucus
• In a common aspect, the upper lobe state has the benefit of gravity
drainage both in upright as well as in horizontal positions,
• So postural drainage can be applied in sitting or lying posture
• The middle and lower lobes do not have the supremacy of gravity
drainage in upright, horizontal, or supine postures.
Scheduling of treatment

• The treatment protocol should be in the early morning because secretion


builds up during the night.

• Treatment can be done at night to minimalize coughing during sleep.

• Start treatment at least 1-2 hours after eating.


• This minimizes nausea and vomiting.

• Don’t do PD before meals because it will cause tiredness and appetite


SETTING:

PDT can be performed in a wide variety of settings.


• Critical care
• In-patient acute care
• Extended care and skilled nursing facility care
• Home care
• Outpatient/ambulatory care
• Pulmonary diagnostic (bronchoscopy) laboratory
General guidelines of postural drainage
• Use specific positions
• So the strength of the gravity can assist in the removal of mucus from affected lung
segments to central airways utilizing coughing and suctioning.
• The patient is positioned
• So that the diseased area is in a near upright position, and gravity is used to assist the
drainage of a particular segment.
• The positions assumed are determined by
• The location, severity, and duration of the secretion deterrent.
• The exercises are performed
• Three to four times a day, before meals and bedtime.
• Each position is done for 4-10 minutes.
• The procedure should be stopped if tachycardia, dyspnea, or chest
tightness occurs.
• These symptoms may show hypoxemia.
• Stop if hemoptysis occurs.
• Bronchodilators, mucolytics agents, water, or saline may be
dispensed and drink before postural drainage to
• Decrease bronchospasm,
• Decrease the thickness of mucus and sputum,
• Decrease conflict edema of the bronchial walls
• Enhance secretion removal
• Should be done before eating
• Make sure the patient is relaxed before the procedure starts and as
comfortable as possible he or she assumes each position.
• Auscultate the chest to decide the areas of needed drainage.
• Ask the patient to deep breathe and cough after spending a particular time in
each position
• Ask the patient for diaphragmatic breathing throughout postural drainage:
this helps widen airways so secretions to be drained.
Equipment
Bed or table that can be adjusted for a range of positions
Pillows for supporting patient
Light towel for covering area of chest during percussion
Tissues and/or basin for collecting expectorated sputum
Suction equipment for patients unable to clear secretion
Gloves, goggles, gown, and mask as indicated for caregiver protection
Oxygen delivery device
Stethoscope for auscultation
Performing Postural Drainage
The performance of PD involves a combination of techniques including:
Multiple bronchial drainage positions
Percussion
Rhythmic striking the thorax with cupped hand or mechanical device
directly over the lung segment(s) being drained
Vibration
Tremorous action (manually performed by pressing in the direction that the ribs
and soft tissue of the chest move during expiration) over the draining area.

Deep breathing
Coughing
• Once the person is in one of several prescribed bronchial drainage positions,
the caregiver performs percussion on the chest wall.
• This treatment usually is given for a period of three to five minutes
• Sometimes followed by vibration over the same lung segment for
approximately 15 seconds (or during five exhalations)
• The person is then encouraged to cough or huff vigorously to get rid of
mucus, clearing the lungs
• It is important to know that for some infants, toddlers, children and adults,
certain postural drainage positions may worsen heartburn and cause
vomiting
• Specifically, when some people lay with their heads down (lower than the
stomach), they can get reflux
• This is stomach acid (heartburn) or food coming up from the stomach
• It can cause discomfort, wheezing or vomiting. Reflux may also lead to
earlier lung infection or damage
• There are other positions or Airway Clearance Techniques (ACTs) that might
be better
Description of PD Techniques
• Postural drainage uses gravity to help move mucus from the lungs up to the
throat
• The person lies or sits in various positions so that the segment to be drained is
uppermost on the patient’s body
• The segment is then drained using percussion, vibration and gravity
• Percussion or clapping by the caregiver on the chest wall over the lung segment
to be drained forces secretions into the larger airways

• The hand is cupped as if to hold water but


with the palm facing down as in Figure
• The cupped hand conforms to the chest wall and traps a cushion of air to
soften the clapping.

• Percussion is done vigorously and rhythmically, but should not be painful or


sting if the hand is cupped properly.

• Each percussion also should have a hollow sound.

• The majority of the movement is in the wrist with the arm relaxed, making
percussion less tiring to perform.

• Percussion should be done only over the ribs.


Special attention must be taken to avoid percussing over the
Spine
Breastbone
Stomach and
Lower ribs or back
To prevent trauma to
The spleen on the left
The liver on the right and
The kidneys in the lower back
• Vibration gently shakes secretions into the larger airways.
• Place a hand firmly on the chest wall over the appropriate segment and tense
the muscles of the arm and shoulder to create a fine shaking motion
• Then, apply a light pressure over the area being vibrated
• You may also place one hand over the other, then press the top and bottom
hand into each other to vibrate
• Vibration is done with the flattened hand,
not the cupped hand, as in the figure

• Exhalation should be as slow and as complete as possible


• Deep breathing moves the loosened mucus and may stimulate coughing
• Diaphragmatic breathing/belly breathing or lower chest breathing is used to
encourage deep breathing to move air into the lower lungs.
• The belly moves outward when the person breathes in and sinks in when he
or she breathes out.
• Coughing is essential in clearing the airways.
• A forced but not strained exhalation, following a deep inhalation, may
stimulate a productive cough.
• The mucus can then be coughed out.
• To increase the cough’s effectiveness while decreasing the strain to the
person,
• coughing may be assisted by supporting the sides of the lower chest with
the hands or elbows
Huffing
• At the end of each drainage position, the person can take a deep breath, and
then expel it quickly in a “huff”
• This “huff” forces the air and mucus out, making the cough more effective

Timing of PD
• Generally, each treatment session can last for 20 to 40 minutes
• PD is best done before meals or one and a half to two hours after eating to
minimize the chance of vomiting
• Early morning and bedtime sessions usually are recommended
• The length of PD and the number of treatment sessions may need to be
increased if the person is more congested
ENHANCING PD & P FOR THE PERSON AND CAREGIVER
• Both the person and the caregiver should try to be comfortable during PD
• Before beginning PD, the person should remove tight clothing, jewelry,
buttons and zippers around the neck, chest and waist.
• Light, soft clothing, such as a T-shirt, may be worn and an extra towel or layer
of clothing can be used to lessen any sting from percussion.
• Do not perform PD & P on bare skin
• The caregiver should remove rings and other bulky jewelry such as watches
or bracelets
• An ample supply of tissues or a place to cough out the mucus should be
provided
Performing PD Comfortably and Carefully

• If the head down position is recommended, the person’s head should be well
supported

• The person can bend at the hips and knees to allow for both a stronger
cough and a more comfortable position

• The caregiver should not lean forward when treating the person, but should
remain in an upright position to protect his or her back

• To achieve this, the table on which the person lies should be positioned at a
comfortable height for the caregiver
Making PD More Enjoyable
• PD offers a specific time for you to enjoy each other’s company
• To enhance the quality of the time you spend with your patient, do one of the
following: -
• Schedule PD & P around a favorite TV show
• Play a favorite tape of songs or stories
• Spend time playing, talking or singing before, during and after PD & P
• For kids, encourage blowing or coughing games during PD, such as blowing
pinwheels or coughing the deepest cough
• Minimize interruptions

• Identifying ways that make PD & P more enjoyable at all ages can help you keep a
regular routine and get maximum health benefits
Postural Drainage Positions
Position #1 – Apical drainage position – upper lobe
• The patient should sit upright, with slight variations according to the position
of the lesion which may necessitate leaning slightly j backward, forward or
sideways.
• The position is usually only compulsory for infants or patients being in a flat
position,
• But sometimes maybe compulsory if there is an abscess or stenosis in the
bronchus in the apical region
• Vibration and percussion can be performed between the clavicle and the top
of the scapula on either side, if ordered.
Position #2 – Posterior drainage position – upper lobe
• The patient should lie on his left side and then turn on to his face,
comfortable with a pillow with another helping his head.
• He should place his left arm comfortably backward of his back with his right
arm placed on the supporting pillow the right knee should be flexed
• Vibration and percussion can be performed over the upper portion of the
back on either side, if ordered.
Position #3 – Anterior drainage position – upper lobe
• Patient lies supine with a pillow under the knees, which enables the
abdominal muscles to relax and makes breathing easier
• Vibration and percussion can be performed between the clavicle and nipple
of a male patient on either side, if ordered
• It may not be possible in a female patient
Position #4 – Lingula lobe
• The conjunction of the superior segment and inferior segment of the lobe is
called the lingula lobe
• The patient should lie on his back with his body quarter turned to the right
maintained by a pillow under the left side from shoulder to hip and the arms
relaxed by his side
• The foot of the bed should be raised 35cm (14in) from the ground
• The chest is tilted to an angle of 15°
• Percuss and vibrate with the heel of hand
under the armpit and fingers extended
forward beneath the breasts
Position #5 – Lateral segment: medial segment: Middle lobe
• The patient should lie on his back with his body quarter turned to the left
maintained by a pillow under the right side from shoulder to hip and the
arms relaxed by his side;
• The foot of the bed should be raised 35cm (14in) from the ground.
• The chest is tilted to an angle of 15°

• Percuss and vibrate with the heel of hand


under the armpit and fingers extended
forward beneath the breasts
Position #6 – Anterior Basal Segment: Lower lobe
• The patient should lie supine position on his back with the buttocks resting
on a pillow and the knees flexed position
• The foot of the bed should be raised 46cm (i8in) from the ground.
• The chest position should be 20 angle degree
• Percuss and vibrate over the lower ribs
on the right side of the chest
Position #7 – Posterior basal segment – Lower lobe
• The patient should lie prone with his head turned to one side, his arms in a
comfortable position by the side of the head and a pillow under his hips.
• The foot of the bed should be raised 46cm (i8in) from the ground.
• The chest is tilted to an angle of 20°
• Do not percuss or vibrate over the
spine or lower ribs
Position # 8&9 – Lateral component: Lower lobe
• The patient should lie on the converse side (right/left side) with a pillow
below the hips and
• The bed should be raised 42cm from the surface.
• The chest is lean at 18 degree of angle
• Percuss and vibrate over the
uppermost portion of the lower ribs
Position #10 – Superior segment: Lowe lobe
• The patient lies on his or her abdomen on a flat drainage table with two
pillows under the hips.
• Percuss and vibrate over the middle part of the back at the bottom of the
shoulder blade on both the left and right side of the spine.
• Do not percuss or vibrate over the spine.
ASSESSMENT OF OUTCOME OF PDT
• These represent individual criteria that indicate a positive response
to therapy (and support continuation of therapy).
• Not all criteria are required to justify continuation of therapy
• Eg, a ventilated patient may not have sputum production > 30 mL/day,
but have improvement in breath sounds, chest x-ray, or increased
compliance or decreased resistance
ASSESSMENT OF OUTCOME OF PDT CONT…
1. Change in sputum production
• If sputum production in an optimally hydrated patient is less than 25 mL/day
with PDT the procedure is not justified.
• Some patients have productive coughs with sputum production from 15 to 30
mL/day (occasionally as high as 70 or 100 mL/day) without postural drainage.
• If postural drainage does not increase sputum in a patient who produces > 30
mL/day of sputum without postural drainage, the continuation of the therapy
is not indicated.
• Because sputum production is affected by systemic hydration, apparently
ineffective PDT probably should be continued for at least 24 hours after
optimal hydration has been judged to be present.
ASSESSMENT OF OUTCOME OF PDT CONT…
2. Change in breath sounds of lung fields being drained
• With effective therapy, breath sounds may 'worsen' following the therapy as
secretions move into the larger airways and increase rhonchi.
• An increase in adventitious breath sounds can be a marked improvement
over absent or diminished breath sounds.
• Note any effect that coughing may have on breath sounds. One of the
favorable effects of coughing is clearing of adventitious breath sounds.
ASSESSMENT OF OUTCOME OF PDT CONT…
3. Patient subjective response to therapy
• The caregiver should ask patient how he or she feels before, during, and
after therapy.
• Feelings of pain, discomfort, shortness of breath, dizziness, and nausea
should be considered in decisions to modify or stop therapy.
• Easier clearance of secretions and increased volume of secretions during and
after treatments support continuation.
ASSESSMENT OF OUTCOME OF PDT CONT…
4. Change in vital signs
• Moderate changes in respiratory rate and/or pulse rate are expected.
• Bradycardia, tachycardia, or an increase in irregularity of pulse, or fall or
dramatic increase in blood pressure are indications for stopping therapy.
5. Change in chest x-ray
• Resolution or improvement of atelectasis may be slow or dramatic.
6. Change in arterial blood gas values or oxygen saturation
• Oxygenation should improve as atelectasis resolves.
7. Change in ventilator variables
• Resolution of atelectasis and plugging reduces resistance and increases
compliance.
PDT MONITORING:
• The following should be chosen as appropriate for monitoring a patient's response
to PDT, before, during, and after therapy.
1. Subjective response--pain, discomfort, dyspnea, response to therapy
2. Pulse rate, dysrhythmia, and EKG if available
3. Breathing pattern and rate, symmetrical chest expansion, synchronous
thoracoabdom-inal movement, flail chest
4. Sputum production (quantity, color, consistency, odor) and cough effectiveness
5. Mental function
6. Skin color
7. Breath sounds
8. Blood pressure
9. Oxygen saturation by pulse oximetry (if hypoxemia is suspected)
10. Intracranial pressure (ICP)
FREQUENCY Postural Drainage Therapy

1. In critical care patients, including those on mechanical ventilation, PDT should be


performed from every 4 to every 6 hours as indicated.

• PDT order should be re-evaluated at least every 48 hours based on


assessments from individual treatments.

2. In spontaneously breathing pa-tients, frequency should be determined by


assessing patient response to therapy.

3. Acute care patient orders should be re-evaluated based on patient response to


therapy at least every 72 hours or with change of patient status.

4. Domiciliary patients should be re-evaluated every 3 months and with change of


status.
PDT INFECTION CONTROL:
1. Implement Universal Precautions
2. Observe all infection control guidelines posted for patient.
3. Disinfect all equipment used between patients.
COMPLICATIONS OF POSTURAL DRAINAGE
Hypoxemia
• Action To Be Taken/Possible Intervention:
• Administer higher oxygen concentrations during procedure if potential for or
observed hypoxemia exists
• If patient becomes hypoxemic during treatment,
• Administer 100% oxygen,
• Stop therapy immediately
• Return patient to original resting position, and consult physician
• Ensure adequate ventilation
• Hypoxemia during postural drainage may be avoided in unilateral lung
disease by placing the involved lung uppermost with patient on his or her
side
COMPLICATIONS OF POSTURAL DRAINAGE CONT…

Increased Intracranial Pressure


• Action To Be Taken/Possible Intervention:
• Stop therapy

• Return patient to original resting position, and consult physicians

Acute Hypotension during Procedure


• Action To Be Taken/Possible Intervention:
• Stop therapy, return patient to original resting position, and consult physician
COMPLICATIONS OF POSTURAL DRAINAGE CONT…

Pulmonary Hemorrhage
• Action To Be Taken/Possible Intervention:
• Stop therapy,

• Return patient to original resting position and call physician immediately

• Administer oxygen and maintain an airway until physician responds

Pain or Injury to Muscles, Ribs, or Spine


• Action To Be Taken/Possible Intervention:
• Stop therapy that appears directly associated with pain or problem,

• Exercise care in moving patient, and consult physician


COMPLICATIONS OF POSTURAL DRAINAGE CONT…
Vomiting and Aspiration
• Action To Be Taken/Possible Intervention:
• Stop therapy,
• Clear airway and suction as needed,
• Administer oxygen,
• Maintain airway
• Return patient to previous resting position, and contact physician immediately.
Bronchospasm
• Action To Be Taken/Possible Intervention:
• Stop therapy,
• Return patient to previous resting position,
• Administer or increase oxygen delivery while contacting physician.
• Administer physician-ordered bronchodilators.
COMPLICATIONS OF POSTURAL DRAINAGE CONT…

Dysrhythmias
• Action To Be Taken/Possible Intervention:
• Stop therapy
• Return patient to previous resting position
• Administer or increase oxygen delivery while contacting physician
LIMITATIONS OF POSTURAL DRAINAGE THERAPY

• Presumed effectiveness of PDT and its application may be based more on


tradition and anecdotal report than on scientific evidence

• The procedure has been used excessively and in patients in whom it is not
indicated

• Airway clearance may be less than optimal in patients with ineffective cough

• Optimal positioning is difficult in critically ill patients


Thank
you

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