A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis.
Which of the following actions should the nurse take?
A.
Cover the area of percussion with a towel.
B.
Schedule postural drainage after meals.
C.
Instruct the client to exhale quickly during vibration.
D.
Perform percussion over the lower back.
The Correct Answer and Explanation is:
The correct answer is A. Cover the area of percussion with a towel.
Explanation:
Cystic fibrosis (CF) is a genetic disorder that affects the respiratory and digestive systems by producing thick, sticky mucus that can clog the airways and lead to infections. One of the key treatments for managing respiratory symptoms in CF is postural drainage combined with percussion and vibration. These techniques help to mobilize and clear mucus from the lungs, improving oxygenation and reducing the risk of infection.
Option A: Cover the area of percussion with a towel.
When performing percussion, the nurse should cover the area with a towel or lightweight cloth to prevent skin irritation and to soften the impact of the percussion on the client’s chest. Percussion involves rhythmically striking the chest wall with cupped hands to loosen mucus from the walls of the airways. Using a towel helps protect the skin and also makes the procedure more comfortable for the client, which is especially important because CF clients often undergo this procedure multiple times a day.
Option B: Schedule postural drainage after meals.
This option is incorrect because postural drainage should be done before meals or at least 1-2 hours after eating to avoid the risk of aspiration or vomiting. Postural drainage involves placing the client in positions that help drain mucus from different parts of the lungs, and lying in certain positions immediately after meals can lead to regurgitation.
Option C: Instruct the client to exhale quickly during vibration.
This is incorrect because during vibration, the client should be instructed to exhale slowly and deeply, not quickly. Vibration is applied at the end of exhalation to help move mucus towards the larger airways, making it easier to cough out.
Option D: Perform percussion over the lower back.
This is incorrect because percussion should be performed over the lungs, not the lower back, to effectively mobilize mucus in the airways.
By following the correct techniques, including covering the area of percussion with a towel, nurses can help CF clients effectively clear their airways and manage symptoms.