Beyond the Stethoscope: Respiratory Assessment of the Older Adult LINDA G

peak technique

Beyond the stethoscope: Respiratory assessment of the older adult LINDA G. COLLETON, RN,BC, MSN Senior Clinical Practice Educator • Welch Healthcare and Retirement Group • Norwell, Mass.

RESPIRATORY ASSESSMENT of an older or currant jellylike sputum may indicate Check out patient requires you to have clinical knowl- pneumonia. these tricks edge, skills, and competence in the age- This is also a good time to find out if your of the trade. related changes found in this population. patient has been vaccinated against influen- Normal aging may result in structural za and pneumonia, and to provide education changes to the chest wall or thoracic spine on the benefits of vaccination for older that can limit chest expansion, decreased adults. Remember that the influenza vacci- respiratory muscle strength that may inter- nation should be given annually, while the fere with effective airway clearance by pneumococcal vaccine should be given just coughing, and increased physiologic de- once to adults over age 65. If your patient mand, such as in pneumonia or heart fail- was vaccinated before age 65, he’ll need to ure, that may lead to a poor compensatory be vaccinated again 5 years after the initial response to hypoxia. vaccination. In this article, I’ll help you expand your assessment techniques beyond the stetho- Inspect and observe scope and differentiate between normal and Begin your physical assessment by ob- abnormal respiratory findings in the older serving your patient’s respiratory rate, ef- adult. fort, and function. Count his respiratory rate; expect 12 to 24 breaths/minute. History collector Look for signs of increased respiratory A comprehensive respiratory assessment in- effort, such as mouth breathing or acces- cludes gathering a medical history that may sory muscle use, and measure his oxygen impact or explain physical assessment find- saturation level. Observe the shape and ings. The older adult has a long history that symmetry of his chest. The normal adult may include smoking or exposure to sec- thorax is wider (transverse diameter) than ondhand smoke, environmental exposures it’s deep (anterior to posterior diameter). An to asbestos or other pollutants, and illnesses older adult may have developed a barrel such as chronic obstructive pulmonary dis- chest due to COPD or kyphosis (curvature ease (COPD), congestive heart failure of the upper spine) due to bone degenera- (CHF), or pneumonia. Ask your patient tion, which may reduce chest expansion. about his energy level, functional abilities, Observe for shortness of breath with and and independence, and inquire about without exertion and orthopnea (the need symptoms such as coughing and sputum to be in an upright or forward leaning posi- production because the timing of a cough tion to get an adequate breath), which is of- and the characteristics of sputum may indi- ten seen in patients with COPD. Check his cate specific problems. A nocturnal cough mucous membranes, skin color, and mental may be a sign of pulmonary edema associ- status as indicators of effective oxygenation. ated with CHF, which sometimes produces If your patient has an increased respirato- pink-tinged or frothy sputum; rust-colored ry rate, dyspnea, accessory muscle use, or an

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oxygen saturation him to say “ninety- level of less than nine.” You’ll feel a 90%, initiate oxygen very slight vibration therapy and notify each time your the health care patient speaks; how- provider of your ever, if there’s an assessment findings. area of consolida- Keep him comfort- tion, the vibration able by allowing will feel more in- him to sit upright, tense because fluid administer medica- transmits sounds tions or breathing and vibrations better treatments as than air-filled lungs. ordered, and pro- Notify the health vide emotional sup- care provider if you port to reduce anxi- suspect lung consoli- ety associated with dation or pneumo- dyspnea. Educate thorax. him about breathing and relaxation tech- To evaluate your patient’s thorax, place niques and energy conservation. your palm (or palms) lightly over the thorax The next steps in your physical assess- and palpate for tenderness, alignment, ment include palpation, percussion, and aus- bulging, and retractions of the chest and cultation. Let’s take a closer look. intercostal spaces. Repeat this procedure on his back. Then use the pads of your fingers Hands on First, palpate your patient’s back at the level of the tenth rib with your thumbs on each side of the spine and your fingers spread laterally. Ask him to take deep breaths as you as- sess the adequacy and equality of lung expansion by watch- ing your hands move up and apart during each breath. A patient with an area of consolida- tion, as seen with conditions such as pneumonia and tu- mors, may have reduced lung expansion on the affected side resulting in minimal or ab- sent movement of your hand. Reduced lung expansion may also be a sign of pneumo- thorax. Then ask your patient to fold his arms across his chest while you place your open palms on both sides of his back without touching his back with your fingers. Ask

12 Nursing made Incredibly Easy! September/October 2008 to palpate the front and back of the thorax. pitched sound as heard over the stomach; Pass your fingers over his ribs and any scars, indicates a hyperinflated lung as in emphy- lumps, lesions, or ulcerations. Note the tem- sema or pneumothorax memory perature, turgor, and moisture. Muscles • tympanic—a loud, high-pitched, drum- should feel firm and smooth. like sound as heard over a puffed-out jogger cheek; indicates excess air as in a large While inspecting Percussion please pneumothorax. his chest, look for these characteris- Next, perform percussion by tapping on tics that may put a your patient’s chest wall. Begin by using the Listen up! CRAMP in your middle finger of your nondominant hand Last, auscultate your patient’s back, chest, patient’s respirato- and placing it on his chest or back. Don’t and sides to listen for the presence of nor- ry system. make contact on his skin with your other mal and adventitious (abnormal) breath Chest-wall asym- fingers or the palm of your hand because sounds. For the chest auscultation sequence, metry this diminishes the vibrations you’re trying see “Every breath you take: Making sense Respiratory rate to create. Strike your finger briskly with the of breath sounds” from our January/Febru- and pattern (abnor- index or middle finger of your dominant ary 2007 issue. Normal breath sounds in- mal) clude: Accessory muscle • tracheal—high-pitched, harsh tubular use Masses or scars sounds heard over the trachea and throat Paradoxical move- • bronchial—high-pitched tubular sounds ment (less harsh than tracheal sounds) heard over the large airways of the chest • bronchovesicular—tubular sounds (not as loud as bronchial sounds) best heard poste- riorly between the scapulae • vesicular—low-pitched, soft blowing sounds heard throughout the lung fields that occur throughout inspiration and fade one-third of the way through expiration. If you hear bronchial or bronchovesicular sounds over the lung periphery where these sounds aren’t typically heard, suspect pneu- monia or tissue consolidation. Adventitious breath sounds include: • crackles (course or fine)—discontinuous popping or bubbling sounds that occur hand in the intercostal spaces on each side when air is forced through fluid-filled air- of his chest or back. ways, causing the airway to suddenly open; Listen for sounds with these characteris- if you hear crackles, suspect pulmonary tics: edema, chronic CHF, or pneumonia • flat—a short, soft, high-pitched, and ex- • wheezes (sonorous or sibilant)—musical tremely dull sound as heard over bone or sounds that occur when air moves quickly muscle; indicates consolidation, such as in through mucus-filled, narrowed airways, atelectasis or extensive pleural effusion heard on inspiration or expiration; if you • dull—a thudlike sound as heard over hear wheezes, suspect pulmonary disease, solid organs such as the liver; may replace such as asthma, COPD, or an acute allergic resonance in the lungs when fluid is present reaction as in pneumonia • pleural friction rub—a creaking or grating • resonant—a long, loud, low-pitched, and sound caused by the inflamed pleural sur- slightly hollow sound as heard over the faces rubbing together; sometimes heard in lungs or abdomen; indicates bronchitis the presence of pneumonia. • hyperresonant—a very loud, lower- For more information about abnormal

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The sounds we Auscultation findings for common disorders make can help you determine Disorder Auscultation findings what’s wrong Asbestosis • Bronchial sounds in both lung bases with us. • High-pitched crackles heard at the end of inspiration • Pleural friction rub Asthma • Diminished breath sounds • Musical, high-pitched expiratory polyphonic wheezes • With status asthmaticus, loud and continuous random monophonic wheezes, along with prolonged expiration and possible silent chest if severe Atelectasis • High-pitched, hollow, tubular bronchial breath sounds, crackles, and wheezes • Fine, high-pitched, late inspiratory crackles • Bronchophony, egophony, and whispered pectoriloquy when right upper lobe is affected Bronchiectasis • Profuse, low-pitched crackles heard during mid-inspiration Chronic obstructive • Diminished, low-pitched breath sounds pulmonary disease • Sonorous or sibilant wheezes • Inaudible bronchophony, egophony, and whispered pectoriloquy • Prolonged expiration • Fine inspiratory crackles Pleural effusion • Absent or diminished low-pitched breath sounds • Occasionally loud bronchial breath sounds • Normal breath sounds on contralateral side • Bronchophony, egophony, and whispered pectoriloquy at the upper border of pleural effusion Pneumonia • High-pitched, tubular bronchial breath sounds over the affected area during inspiration and expiration • Bronchophony, egophony, and whispered pectoriloquy • Late inspiratory crackles not affected by coughing or position changes Pneumothorax • Absent or diminished low-pitched breath sounds • Inaudible bronchophony, egophony, and whispered pectoriloquy • Normal breath sounds on contralateral side Upper-airway • Stridor obstruction • Decreased or absent breath sounds • Wheezing

breath sounds, see Auscultation findings for cal assessment data beyond the stetho- common disorders. scope, incorporating knowledge of changes An older adult with pneumonia or con- that may affect him to determine the most solidation may also have abnormal voice appropriate interventions in his care. I sounds such as bronchophony. Assess this by having your patient say “ninety-nine” as Learn more about it you auscultate his lungs. In air-filled lungs Barakzai MD, Fraser D. Assessment of infection in older the words will sound muffled and indistin- adults: Signs and symptoms in four body systems. Journal guishable. When auscultating over an area of of Gerontological Nursing. 34(1):7-12, January 2008. fluid or consolidation, the words will sound Goroll AH, Mulley AG. Primary Care Medicine: Office Eval- unusually loud. Suspect pneumonia if bron- uation and Management of the Adult, 5th edition. Philadel- phia, Pa., Lippincott Williams & Wilkins, 2006:314-329. chophony is present. Health Assessment Made Incredibly Visual! Philadelphia, Pa., Lippincott Williams & Wilkins, 2007:70-85. Go beyond Sharma G, Goodwin J. Effect of aging on respiratory sys- When caring for an older patient, you tem physiology and immunology. Clinical Interventions in must be able to gather and interpret physi- Aging. 1(3):253-260, 2006.

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