Geriatric Pulmonary Assessment Cues (Nursing)

by Rhonda Lawes, PhD, RN

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    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.

    About the Lecture

    The lecture Geriatric Pulmonary Assessment Cues (Nursing) by Rhonda Lawes, PhD, RN is from the course Assessment of the Geriatric Patient: Respiratory System (Nursing).

    Included Quiz Questions

    1. Tidal volume decreases
    2. Diaphragm movement decreases
    3. Pulmonary reserve increases
    4. Breaths become deeper
    5. Cough reflex increases
    1. 12-24 breaths per minute
    2. 10-18 breaths per minute
    3. 8-16 breaths per minute
    4. 14-20 breaths per minute
    1. “When I listened to your lungs, I noticed decreased air entry to the bottom of your lungs, which is quite unusual for people your age.”
    2. “You mentioned that you have noticed that your breathing has become shallower over the past few years, which is normal and is a result of aging.”
    3. “When you cough, is it a dry cough, or do you cough up any mucus or phlegm?”
    4. “Can you describe what the phlegm you cough up looks like? What color is it?”

    Author of lecture Geriatric Pulmonary Assessment Cues (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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