Problem 6 - Clinical Nursing Skills and Techniques

Question

A patient is hospitalized with respiratory failure caused by exacerbation of severe emphysema and bronchiectasis. Chest \(x\) -ray film examination revealed good lung expansion except for left lower lobe collapse. In which position should you place the patient for the ordered chest physiotherapy? 1 Right side-lying Trendelenburg's 2 Left side-lying Trendelenburg's 3 Right side-lying flat 4 Right side-lying Trendelenburg's with one-quarter turn back onto a pillow

Step-by-Step Solution

Answer

Place the patient in Right side-lying Trendelenburg's position.

Step 1: Understanding the Condition

The patient has respiratory failure due to severe emphysema and bronchiectasis with left lower lobe collapse. In such cases, chest physiotherapy is aimed at facilitating drainage and improving lung function.

Step 2: Identifying the Affected Area

The left lower lobe of the lung is collapsed. Therefore, the position chosen should help in expanding this lobe by allowing gravity to assist in draining any secretions and promoting re-expansion.

Step 3: Trendelenburg's Position Benefits

Trendelenburg's position (where the feet are higher than the head) can aid in the drainage of lungs, particularly helpful in cases of lower lobe collapse.

Step 4: Choosing the Lying Position

Placing the patient on the right side will help in draining the left lower lobe due to gravity, as secretions can more effectively be moved towards the large airways for clearance. This is beneficial especially in Trendelenburg's position.

Step 5: Finalizing the Position

To best facilitate drainage from the left lower lobe, the patient should be positioned in the Right side-lying Trendelenburg's position, as it uses gravity to target the collapsed left lower lobe.

Key Concepts

Respiratory Failure

Respiratory failure occurs when the lungs cannot exchange oxygen and carbon dioxide efficiently. This can lead to low levels of oxygen in the blood or high levels of carbon dioxide. Respiratory failure can be acute, occurring suddenly, or chronic, developing over time.
There are two main types:

• Type 1: Low oxygen levels (hypoxemic), often due to issues like pneumonia or pulmonary embolism.
• Type 2: Low oxygen levels combined with high carbon dioxide levels (hypercapnic), which may result from chronic lung diseases like COPD.

Symptoms include difficulty breathing, rapid breathing, and confusion. Treatment focuses on improving the oxygen supply, possibly with supplemental oxygen or mechanical ventilation. Identifying and addressing the underlying cause is essential for managing respiratory failure.

Emphysema

Emphysema is a lung condition that causes shortness of breath. In people with emphysema, the air sacs in the lungs (alveoli) are damaged. Over time, the inner walls of the air sacs weaken and rupture, creating larger air spaces instead of many small ones.
This reduces the surface area of the lungs and therefore, the amount of oxygen that reaches the bloodstream. Common risk factors include smoking and long-term exposure to air pollutants.
Emphysema is part of a group of lung diseases called chronic obstructive pulmonary disease (COPD). Signs and symptoms may not appear until irreversible damage has occurred. The main symptoms include:

• Persistent cough
• Wheezing
• Shortness of breath, especially during physical activities

While there is no cure, treatments can help relieve symptoms and slow the progression of the disease. These include inhalers, pulmonary rehabilitation, and in some cases, surgery.

Bronchiectasis

Bronchiectasis is a condition where the bronchial tubes of your lungs are permanently damaged, widened, and thickened. This condition is a result of chronic inflammation and infection-bearing mucus build-up. Patients with bronchiectasis often experience frequent infections.
It's important to clear mucus from the lungs to prevent these infections and maintain lung function. This condition can result from a prior infection like pneumonia or chronic diseases like cystic fibrosis. Symptoms include a chronic cough, coughing up blood or mucus, and recurring lung infections.
Treatment for bronchiectasis aims at controlling infections, removing mucus, and preventing complications. This might involve chest physiotherapy, which consists of techniques to help clear the respiratory tract. Preventative measures such as vaccinations are also crucial to avoid respiratory infections that can worsen the condition.

Trendelenburg's Position

Trendelenburg's position involves laying a patient flat on their back with the feet elevated higher than the head. This position is often used in medical settings to improve venous return and has applications in lung conditions, specifically for helping with drainage in chest physiotherapy.
When a patient has a collapsed lung segment, like in the case of the left lower lobe collapse mentioned earlier, using Trendelenburg's position can aid in draining secretions through gravity. This facilitates re-expansion of the collapsed section. It is crucial in cases of bronchiectasis for effectively clearing mucus.
However, care must be taken to ensure that the position is appropriate for the patient's overall condition. Trendelenburg's position is contraindicated in patients with head injuries or those at risk of increased intracranial pressure. By using this position, healthcare providers can enhance the effectiveness of treatments aimed at promoting better lung function and patient comfort.