00:00
So on the screen,
you'll see that NCSBN,
Nursing Clinical
Judgement Model again,
I know it looks complex,
but remember what we're focusing on
is how you as a nurse should be
able to recognize and analyze cues
so that your form a hypothesis when
you're making a clinical judgement.
00:17
It's just a really long way to say,
how you should think like a nurse.
00:22
So in geriatric
pulmonary assessment,
these are the cues you
should be looking for.
00:27
Watch for decreased
pulmonary reserve.
00:28
So the patient will be less able
to respond to increased demand,
like the more you're moving
them and walking them,
they're not going to be
able to respond to that
as well as they could have
when they were younger.
00:39
Watch the respiratory rate.
00:41
These are cues that
you'll be assessing for,
should be about 12 to
24 breaths a minute.
00:46
And we would anticipate
that an elderly client
would have relatively shallow breathing
in comparison to a younger adult.
00:54
Now, their diaphragm is just not
going to work as well, right?
Those muscles are weakened,
they also may be kyphotic.
01:01
That's the shape
of their spine.
01:03
So they have a
reduced tidal volume.
01:06
Their cough may be decreased and
also their deep breathing capacity,
meaning they don't cough is strong,
and they can't take as deep a breath.
01:16
Well, this puts them at risk
because they can't clear mucus
or foreign matter from
their lungs as easily.
01:22
So it increases their risk if they do
aspirate something developing an infection
and also for bronchospasms.
01:29
Here's a geriatric pulmonary assessment
cue that you can see externally.
01:34
We call it barrel chest.
01:36
Now here's why.
01:37
On the left, you see that the person
you can see the diameter of their chest,
when you look at those arrow
lines from side to side
is going to be longer
than from front to back.
01:48
But when a patient
experiences an increase
in anteroposterior chest
diameter from skeletal changes,
that's simply just calling
a patient barrel chest.
01:59
Look at the second
picture, right?
Anteroposterior is now equal to
the length this way to this way,
and that's why they
look more like a barrel.
02:10
You can see it's much
easier to say barrel chest
than increase in anteroposterior
chest diameter from skeletal changes.
02:18
But that is the cause
of barrel chest.
02:21
Now, lung sounds.
02:21
You want to look at their breathing
rate, rhythm, depth and volume.
02:25
Is it regular?
Do they look like they're struggling?
Watch for decreased lung sounds
in the bases specifically.
02:33
My dad's pneumonia
got missed in a clinic
because his lungs
were so consolidated
that they didn't hear
lung sounds in the bases
but the clinician didn't
pick that up initially.
02:44
So be very thorough, listen to your
patients in the front and in the back.
02:49
And make sure you listen from top
to bottom all the way through.
02:53
So the mucosal membranes,
another thing you can take a look at,
they don't have the same
ciliary and macrophage activity,
so these membranes
can get kind of dry.
03:03
Now, I'm not talking about
older gentleman's nose hairs
that seemed to be
excessive in growth,
I'm talking about
the actual membranes.
03:11
They don't have the same level of
activity and they tend to be rather dry,
which defeats the purpose of
how your mucosal membranes
protect you from infection.
03:22
Now, the last pulmonary
assessment cue
we're going to talk about
is the cough reflex.
03:26
You already know that the geriatric client
is at risk for a diminished cough reflex.
03:31
So there's some very important
assessment questions you can ask a client
and learn a lot about what's going
on in the respiratory system.
03:39
So here are four questions I
would recommend regarding cough.
03:43
So ask your client.
03:44
"Mr. Jones,
how often do you experience a cough?"
The next questions kind of
gross but really important.
03:51
You ask him, "Is the cough
productive or nonproductive?"
Now, that's a really nursey
way to say something.
03:59
I found that when you're dealing with
clients that may not make sense to them.
04:03
So think about another way
that you could word that.
04:05
You may say something like,
"Mr. Jones, when you cough,
do you cough anything up?"
"Do you cough any sputum or
phlegm up when you cough?"
Versus asking them a question
like productive or nonproductive.
04:18
If the client tells you, "Yes,
I do cough something up."
You're gonna ask them
to describe it to you.
04:23
Now, this is not always a
comfortable situation for someone
because it's kind of gross
but it's really important.
04:31
Make sure you make eye
contact, you're kind,
you talk to them slowly and
act like it's no big deal.
04:37
Although phlegm is
not my favorite.
04:40
You always put
your nurse face on,
act like it's no big deal and just
ask them to describe it to you.
04:46
So you might want to ask them
some very specific questions.
04:49
We know that if the sputum is present and
there's blood in it, call that haemoptysis.
04:55
I'm not going to ask a patient
if they have haemoptysis.
04:59
I'm going to ask them,
"What color is it?"
"Have you noticed any streaks of color in
it, any red streaks?"
"Does it look yellow? Does it look green?
Does it look kind of white?"
What's the color?
So help your patients.
05:13
Sometimes we go through
an assessment so quickly,
because we're trying to check
all the boxes on our screen
because there are tons
of questions to ask.
05:21
But slowdown this area
because you can catch things
that may be missed by the team
unless you do a thorough assessment.
05:29
So number 1, ask them,
How often do you experience a cough?
2. Is it productive?
If they say yes,
here comes that third question.
05:38
What does it look like?
And the fourth or final question,
ask them when the cough happens.
05:45
So does your cough happen often
during eating or drinking,
then we know we have
a choking problem.
05:50
This may be a sign of possible
dysphasia or risk for aspiration.
05:56
Now just because they say,
"Yeah, it happens a lot."
When sometimes I've
had patients say,
"I eat rice or when I'm drinking
something warm or cold."
That doesn't mean you
automatically have dysphasia.
06:06
But that is a trigger.
06:08
It's a cue to you to
ask additional questions
to help you refine
that hypothesis.