Last month, this column examined skin assessment in the elderly. This month, we present the second part of the series on physical assessment in the elderly: the assessment of the respiratory system. Techniques, landmarks, and current information about normal age-related changes are included.
To begin, ask clients questions that will give you important clues about the status of the respiratory system. A history of smoking puts clients at considerable risk for respiratory disease; therefore, be sure to find out if your clients have smoked or are currently smoking. Ask how many years they have smoked and how many packs of cigarettes are used each day. Current research indicates that exposure to passive smoke from living with a smoker or working in a smoke-filled environment should also be considered. Ask about occupational hazards, such as working with chemicals, asbestos, or dust.
Other helpful information will be gathered by asking about frequent colds, pneumonia, emphysema, or asthma. Tuberculosis is on the rise in the United States, so ask if night sweats, weight loss, fatigue (especially later in the day), indigestion, or expectoration of blood or blood-streaked sputum have been occurring. Ask about current symptoms such as a cough, a change in voice or hoarseness, dyspnea, or wheezing. In addition, it is helpful to find out the approximate date and result of the last chest x-ray or intracutaneous tuberculin skin tests.
A complete respiratory assessment can include the use of all four physical assessment techniques: inspection, palpation, percussion, and auscultation. In practice, most nurses mainly use inspection and auscultation. Palpation and percussion will be discussed because these techniques give us more information. Be systematic and, when possible, use the same approach each visit to save time and eliminate the possibility of omissions.
Most practitioners begin their respiratory assessment on the posterior chest. The best position is to have clients sit in an upright position with their head bent forward and arms crossed in front. This is difficult for some elderly clients, so you may have to raise the head of the bed and give them a support such as an overthe-bed table to lean on. When you listen to the lateral chest, ask if your clients can sit up straighter with their arms overhead. For the anterior chest, ask clients to sit as erect as possible with their arms at their sides. Clothing is a real barrier for a thorough respiratory assessment. Be sure the room is warm enough to ask clients to remove all clothing to the waist. You can keep a bath blanket available as a drape if needed.
Look at your client's color, posture, and whether or not accessory neck, shoulder, abdominal, or intercostal muscles are used for breathing. Inspect the skin, nails, and lips for cyanosis or pallor. Notice the shape and symmetry of the chest. For respiratory assessment, compare the diameter of the chest from anterior/ posterior (AP) with the diameter from side to side (lateral). In younger clients, the AP to lateral ratio is normally 1 :2. Elderly clients can have a larger AP diameter as a normal finding. Those with chronic emphysema will have a barrel chest in which the diameter from front to back could equal that from side to side. It is important to note this and would be recorded as AP diameter = lateral, or 1:1 ratio. A barrel chest does not by itself impair function, but it should be recorded. If your client has a barrel chest, you may hear decreased breath sounds on auscultation. Many clients, especially women, experience an accentuated dorsal curve of the thoracic spine, or kyphosis, with age. As a result of kyphosis and other age changes, chest expansion is decreased, thus making it more difficult for the elderly client to breathe deeply.
Count your client's respiratory rate. The normal respiratory rate in the elderly is 12 to 24 respirations per minute. If the respiratory rate is above 28 breaths /minute (tachypnea), there usually will be other signs of labored breathing, such as the use of accessory muscles, supraclavicular retractions, or nasal flaring. If the respiratory rate is lower than 12 breaths/ minute (bradypnea), there will probably be overt signs of decreased levels of oxygen and consciousness, such as confusion or lethargy. Observe the respiratory rhythm. The pattern of breathing should be even, neither too shallow nor too deep. If clients are emphysemic or asthmatic, expect that their expirations will be prolonged. It is essential to count the respiratory rate and observe the rhythm and quality without the client's knowledge, because the client may have a misleading self-conscious response. Most nurses have worked out their own method to assess rhythm, such as holding the client's arm as if taking the radial pulse while counting respirations.
Auscultation of the Lungs
Auscultation is one of the most important parts of the respiratory assessment. Without a stethoscope, normal breathing is quiet. If wheezes or gurgling are present, you can often hear them merely by standing near the client. Using a stethoscope, however, is necessary to discover other pathology.
There are several things to keep in mind when auscultating lungs. Use a good stethoscope. The most commonly used is an acoustic stethoscope. The stethoscope should have ear pieces that fit snugly and comfortably to block outside sound. Be sure to point the ear pieces toward your nose so sound is projected toward the tympanic membrane. Make sure the diaphragm and bell are heavy enough to lie firmly on the surface of the body. The stethoscope should have a 1-inch bell and a 1½-inch diaphragm. Remember that the diaphragm is for high-pitched sounds and the bell is for low-pitched sounds. A way to remember this is the mnemomics HID (high use the diaphragm) and LOB (low use the bell). The diaphragm is used for auscultaing lung sounds. The length of the tubing should be between 12 inches and 18 inches to minimize distortion.
The second important factor is to visualize the anatomy of the chest as you auscultate. Thoracic landmarks have been established that help locate the underlying respiratory structures and enable the use of consistent language when describing the location of abnormal findings (Figures 1 through 3). The apices of the right and left upper lobes of the lung extend just above the clavicles anteriorly and above T-I vertebra posteriorly. The lower borders of the lungs descend on deep inspiration to about T-1 2 and rise on forced expiration to about T-9. Because the right lung has three lobes, note that the horizontal fissure between the upper right and middle lobes is located at the fourth rib on the midclavicular line (MCL). The lower right and left lobes begin at the sixth rib, also on the MCL. You can also observe that the trachea divides into the right and left main bronchi at about the level of the T-4 or T-5 vertebra and just below the manubriusternal junction (Angle of Louis).
The usual place to begin auscultation is at the apex of the lungs (Figure 2). The best place, however, to start auscultating in elderly clients is at the base on the posterior chest, proceeding up the back while comparing side to side. Then listen on both sides and in the front. Many pathologic conditions occur at the bases of the lungs; therefore, it is best to begin there before elderly clients become too tired. Ask clients to take slow, deep breaths and listen throughout inspiration and expiration. As mentioned earlier, older adults have more difficulty taking deep breaths due to decreased chest expansion or general muscle weakness. Compliant elderly clients can easily become dizzy from hyperventilating and may faint. You might not detect this immediately if you are absorbed in listening to breath sounds. If you are unfamiliar with normal breath sounds, practice on your family or friends. If you work in a hospital, take advantage of patient rounds with doctors or respiratory nurse clinicians.
Normal breath sounds are labeled as vesicular, bronchovesicular, and bronchial. Knowing how to recognize these sounds and where they are normally found is essential. Document the type and location of the sound. Normally, vesicular sounds are heard over most of the lung fields; bronchovesicular and bronchial sounds are heard over the larger airways.
Vesicular breath sounds are low-pitched, low-intensity sounds that are described as soft and breezy. Inspiration lasts longer than expiration. Bronchovesicular sounds should be heard anteriorly near the mainstem bronchi and posteriorly between the scapulae; they are more moderate in pitch and intensity. Another way to distinguish these sounds is to note that expiration equals inspiration. Bronchial breath sounds are loud, high-pitched, and hollow sounding, as if blowing through a pipe or tunnel. One nurse aptly described them as the sounds made by Darth Vader in the movie Star Wars. The expiratory phase of bronchial sounds is greater than their inspiratory phase.
Normally, bronchial sounds will be heard only over the trachea. If they are heard in an area other than the trachea, it often means consolidated lung tissue, such as that found in pneumonia, pleural effusion, tumor, or atelectasis. This is because consolidated lung tissue transmits sounds better then air, making them louder. This is also why you can evaluate the lung fields by listening to clients speak words or numbers as you listen to their chest with your stethoscope. As we speak, we transmit sounds through our lung fields. These sounds are normally muffled and are best heard medially. If the sounds are clear or loud, they are abnormal and are defined as bronchophony. The terms "whispered pectoriloquy" are used if you can hear even a whisper very clearly.
As you auscultate, also listen for abnormal (adventitious) breath sounds. These are superimposed on normal breath sounds and come from air passing through either moisture (crackles), through very narrowed airways (wheezes), or from an inflammation between the membranes lining the chest cavity and the lungs (pleural friction rubs). It is now recommended that the word "crackles" be substituted for the older term "rales," and "wheezes" for the word "rhonchi." These words are more descriptive of the actual sounds that can be heard.
Crackles are heard on inspiration and sound like rubbing hair next to your ear. They can be highpitched sounds heard at the base of the lungs near the end of inspiration (fine crackles); lower pitched sounds heard during the middle or latter part of inspiration (medium crackles); or loud, bubbling, gurgling sounds heard both on inspiration and expiration (coarse crackles). Coarse crackles are not cleared by coughing. Crackles will be heard in clients with pulmonary edema or congestive heart failure.
Wheezes are rumbling, musical sounds heard mainly during expiration. They occur in larger diameter airways and sound like a snore. Narrowing of the airway produces the wheeze and can be due to bronchospasm or swelling. If you hear these wheezes on only one side, the pathology may be a tumor or foreign body obstruction.
Pleural friction rubs sound like rubbing leather on leather and are heard in both expiration and inspiration. They are the result of inflamed pleural surfaces. While listening for adventitious sounds, keep in mind that older adults may have increased retention of mucus due to age-related decreased pulmonary function. This requires vigilance in noting if you hear any increase in the amount of secretions for each client.
Palpation is used if clients complain of pain in the thoracic area and you are looking for point tenderness or to see if the thorax expands symmetrically. Use your fingertips and palpate lightly. When palpating for thoracic expansion, stand behind your client and place your thumbs at the level of the 10th rib along the spinal processes with your palms lying lightly on the client's back and fingers pointing anteriorly. Ask your client to take a deep breath and see if your thumbs diverge symmetrically. A loss of symmetry in the movement of the thumbs can mean a problem on one or both sides.
If time allows, palpation can also be used to evaluate the quality of tactile fremitus, which is a vibration felt on the chest wall when clients speak. Ask clients to repeat a few numbers (for example "99") while you systematically palpate the chest using the palmar surfaces of your fingers. You will not feel fremitus over the scapulae. Decreased fremitus is caused by excess air in the lungs and may indicate a condition such as emphysema. On the other hand, increased fremitus occurs when there is lung consolidation or the presence of fluids within the lungs.
Indirect percussion (the act of striking while listening) can reveal additional information about your client's respiratory status. This technique involves using the tip of your middle finger of your dominant hand as a hammer and the distal phalanx of your middle finger of your other hand as the striking surface. By snapping the wrist of your dominant hand and sharply tapping the interphalangeal joint of the finger that is on the body surface, you can listen for percussion tones as you systematically move along the anterior and posterior chest wall. Resonance, or a loud, low-pitched sound, should be heard over all areas of the lungs. Hyperresonance, or a very loud, very low, booming sound, represents air trapping and should not be heard over the lungs in elderly adults. This is usually caused by obstructive lung diseases. A third sound, dullness, is a sound of medium intensity and medium to high pitch that is heard if there is atelectasis, pleural effusion, or lung consolidation.
Knowing the normal age-related changes of the respiratory system and how to look, listen, and feel for abnormalities will make you a better practitioner. Admittedly, motivation and some practice is needed so you can differentiate normal agerelated changes from findings that could indicate disease. Timely intervention for acute and chronic lung conditions will make your efforts worthwhile.
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