Respiratory Assessment and Treatments Presented by ATOP clinical staff

Learning Objectives

• Ability to perform a respiratory assessment

• Appropriate documentation of respiratory assessment – Pulse oximetry

– Rate, rhythm and effort

– Inspect, observe and listen

• Define and identify signs and symptoms of asthma, pneumonia and COPD

• Understand treatments and devices used in respiratory care

• Perform pulmonary care and toileting

Respiratory Assessment

• A respiratory assessment is an external assessment of ventilation that includes observations of the rate, depth and pattern of respirations.

• An accurate assessment of respiration depends on recognizing normal thoracic and abdominal movements.

• On inspiration, the diaphragm contracts, causing abdominal organs to move downward and forward, increasing the vertical space of the chest cavity.

• At the same time, the ribs lift upward and outward, and the sternum lifts outward to aid the transverse expansion of the lungs.

• On expiration, the diaphragm relaxes upward, the ribs and sternum return to their relaxed position, and the abdominal organs return to their original position.

Respiratory Assessment Cont.

Assess the resident for signs and symptoms of respiratory changes:

• Complaints of shortness of breath (dyspnea)

• Bluish or cyanotic appearance of the nail beds, lips, mucous membranes and skin

• Restlessness, irritability, confusion, decreased level of consciousness

• Pain during inspiration and expiration

• Labored or difficult breathing

• Orthopnea

• Use of accessory muscles

• Abnormal breath sounds such as wheezes, rhonchi or rales

• Inability to breathe spontaneously

• Thick, frothy, blood-tinged or copious sputum production

• Paradoxical chest wall movement

Respiratory Assessment Cont.

• Assess the resident for factors that influence the character of respirations:

– Activity

– Anxiety

– Acute pain

– Gastric distention

– Medications

– Body position

– Presence of abdominal incisions or dressings

– Fever

Respiratory Assessment and the Older Adult

Normal aging may result in structural changes in the chest wall or thoracic spine that can limit chest expansion, decrease respiratory muscle strength and interfere with effective airway clearance. This may lead to a poor compensatory response to hypoxia during states of increased physiologic demand, such as in pneumonia or heart failure.

Respiratory Assessment and the Older Adult Cont.

• Perform ongoing assessments of the resident’s respirations for rate, depth and breathing pattern with pulse oximetry reading every 30 minutes if the resident’s oxygen saturation is unstable.

• Compare respirations with resident’s previous baseline and typical rate, depth and breathing pattern. (Comparison helps detect a change in the resident’s condition and the presence of a cardiac alteration. Notify the physician if a change has occurred.)

• Assess patients who have difficulty breathing (e.g. those with heart failure or abdominal ascites) while they are in the position of greatest comfort. Repositioning may increase the work of breathing, which increases the respiratory rate.

• Irregular respiratory patterns and periods of apnea (cessation of respiration for several seconds) are symptoms of an underlying disease in the adult and should be reported to the practitioner. Further assessment and immediate intervention may be necessary.

• Kyphosis and scoliosis may also restrict chest expansion.

• Depth of respirations tends to decrease with aging. The change in lung function with aging results in respiratory rate that is generally higher with a range of 12 to 24 breaths/min. Some older adults depend more on accessory abdominal muscles during respiration than weakened thoracic muscles, which may result in altered respiratory patterns related to positioning and increased abdominal pressure.

• Older patients, even when healthy, may tire more easily during assessment; therefore, the pace and demands of the assessment should be considered. Review INTERACT Care Pathways for both symptoms of shortness of breath (SOB) and symptoms of lower respiratory infection.

Rate, Rhythm and Effort

Pulse Oximetry

Oximeter sensor attached to a finger

Inspect and Observe

• Keep resident comfortable by allowing them to sit upright

• Provide emotional support to reduce anxiety associated with dyspnea

• Observe the shape and symmetry of the chest (a normal adult’s thorax is wider in transverse diameter than its anterior to posterior diameter)

• Older adults may have developed a barrel chest due to COPD which may reduce chest expansion

• Observe for shortness of breath with and without exertion and orthopnea (the need to be in a upright or forward-leaning position to get an adequate breath) seen in residents with COPD

Inspect and Observe: Back

• Palpate your resident’s back at the level of the 10th rib with your thumbs on each side of the spine and your fingers spread laterally

• Ask resident to take deep breaths as you assess the adequacy and equality of breath

• Resident with an area of consolidation, as seen in conditions such as pneumonia and lung tumors, may have reduced expansion of the affected side resulting in a minimal or absent movement of your hand

• Reduced lung expansion may be also a sign of a pneumothorax

Inspect and Observe: Thorax

• Place your palm (or palms) lightly over the thorax and palpate for tenderness, alignment, bulging, and retractions of the chest and intercostal spaces

• Use the pads of your fingers to palpate the front and back of the thorax

• Pass your fingers over the resident’s ribs and any scars, lumps, lesions or ulcerations

• Note the temperature, turgor and moisture (muscles should feel firm and smooth)

Listen Up

Auscultate your resident’s back, chest and sides to listen for the presence of normal and abnormal breath sounds.

– Vesicular – low-pitched, soft blowing sounds heard throughout the lungs fields that occur throughout inspiration and fade one-third of the way through expiration

Abnormal sounds: – Tracheal – high-pitched, harsh tubular sounds heard over the trachea and throat

– Bronchial – high-pitched tubular sounds over the large airways of the chest

– Bronchovesicular – tubular sounds , best heard posteriorly between the scapulae

– Crackles –(course or fine) popping or bubbling sounds that occur when air is forced through fluid-filled airways, suspect pulmonary edema, chronic CHF, or pneumonia

– Plural-friction rub – a creaking or grating sound caused by the moves quickly through mucus-filled, narrowed airways, such as asthma or COPD

Patterns of Respirations

Asthma

• Asthma is a chronic inflammatory disease that affects the airways and is characterized by reversible airway obstruction, airway inflammation and increased airway responsiveness to a variety of stimuli.

• During an exacerbation, there is an early-phase bronchoconstriction and a late-phase airway inflammation, and the bronchoconstriction, bronchospasm and the airway inflammation must be treated.

• If the patient is experiencing an asthma exacerbation, rescue relief medications should be progressively administered to relieve symptoms and the patient should be monitored closely.

Resident and Family Education

• Assure the resident and family that asthma symptoms can be controlled when managed properly

• Proper self-management helps keep the asthma under control

Documentation for Asthma

• Frequency of daytime symptoms

• Frequency of nighttime symptoms

• Frequency of short-acting beta2 agonist use

• Current asthma severity

• Revisions or updates to the asthma action plan

• Unexpected outcomes and related interventions

• Patient and family education

• Peak flow rate results

Pneumonia

Pneumonia is an infection of the lungs that is caused by bacteria, viruses, fungi or parasites

Pneumonia may cause the following signs and symptoms: • Inflammation of the alveoli in the lungs

(alveoli are microscopic sacs in the lungs that absorb oxygen)

• Chest-ray shows new pulmonary infiltrate

• Abnormal temperature >100.4 (oral)

• Blood oxygen saturation level <90 percent on room air or on usual oxygen setting in residents with chronic oxygen requirements

• Respiratory rate above 30 breaths per minute

• Productive cough

• Increase functional decline

• Abnormal leukocyte

• Lungs fill with fluid and make breathing difficult

Pneumonia Cont.

• In the U.S., pneumonia is the most common cause of hospital admissions other than women giving birth.

• About 1 million adults in the U.S. are hospitalized with pneumonia every year, and about 50,000 die from this disease.

• Older people have a higher risk of getting pneumonia, and are most likely to die from it if they do. For U.S. seniors, hospitalization for pneumonia has a greater risk of death compared to any of the other top 10 reasons for hospitalization.

• Pneumonia is the most common cause of sepsis and septic shock, causing 50 percent of all episodes.

American Thoracic Society Pneumonia Facts 2015

Prevention Measures

• Influenza vaccination annually helps prevent pneumonia as it is often a secondary infection after a bout of influenza

• Pneumococcal vaccination • Helps prevent 23 different strains of bacterial

pneumonia (although there are many more strains of bacterial pneumonia)

• Is effective for a shorter amount of time in older adults • Should be administered every five years.

Prevention Measures Cont.

• Positive Infection Control Program (healthcare-associated infections)

• Dental/oral hygiene causes for aspiration pneumonia – Dependent feeding (dysphagia residents)

– Dependent oral hygiene

– Missing teeth (infected teeth)

– Tube feeding

– Multiple medications

Documentation

• Respiratory rate, depth and breathing pattern

• Type and amount of supplemental oxygen therapy or respiratory support

• Spirometer readings pre- and post-breathing treatments

• IV and/or oral medication given

• Unexpected outcomes and related nursing interventions

• Patient and family education

• Pain assessment and management

Chronic Obstructive Pulmonary Disease (COPD)

• COPD, which includes chronic bronchitis and emphysema, is a chronic lung disease that makes it hard to breathe, also known as dyspnea.

• Damage to the airways in the resident’s lungs leads to shortness of breath, impacting their ability to work, exercise, sleep and perform everyday activities.

• This disease is increasingly common, affecting millions of Americans, and is the third leading cause of death in the U.S., per the American Lung Association.

Positioning

Resident Positioning: Dyspnea

COPD Care

• Administer oxygen and medications as indicated and prescribed.

• Ensure that oropharyngeal suction and emergency airway equipment is readily available.

• Monitor respiratory status. If the patient’s condition deteriorates, anticipate the need for more aggressive measures.

• Assess, treat and reassess pain.

• Closely monitor older adults in the orthopnea position because they may tire quickly and require additional support or repositioning.

Documentation

• Frequency of symptoms observed and reported

• Care provided

• Position that offers patient the most relief

• Unexpected outcomes and related interventions

• Patient and family education

Metered-Dose Inhaler

• Patient opens lips • Places inhaler mouthpiece in

mouth with opening toward back of throat

• Inhale slowly and deeply through the mouth for 3 to 5 seconds and depress the medication canister fully while breathing in slowly

• Remove MDI from mouth (closed-mouth technique) before exhaling

• Wait 30 to 60 seconds between puffs

Older Residents with MDI

• Patients with arthritis may not be able to actuate an MDI.

• Older adult patients may not be able to sufficiently coordinate MDI actuation and initiation of inspiration, so a spacer device may be needed.

• Older adult patients may not be able to create an adequate inspiratory flow to inhale medication from a dry powder inhaler.

• If the patient is unable to actuate an MDI, coordinate inspiration to the MDI actuation, or inhale rapidly from a dry powder inhaler, then the medication should be delivered by a small-volume nebulizer.

Peak Flow Meter

• Determine the severity of a resident’s asthma.

• Evaluate the effectiveness of current treatments.

• Determine when to add or stop certain medicines.

• Recognize an asthma attack before signs or symptoms appear.

• Decide when to seek emergency care.

How to Use a Peak Flow Meter

• Stand up or sit up straight.

• Make sure the indicator is at the bottom of the meter (zero).

• Take a deep breath in, filling the lungs completely.

• Place the mouthpiece in your mouth; lightly bite with your teeth and close your lips on it. Be sure your tongue is away from the mouthpiece.

• Blast the air out as hard and as fast as possible in a single blow.

• Remove the meter from your mouth.

• Record the number that appears on the meter pre-breathing treatment.

• Repeat steps post breathing treatment and record number.

Nebulizer Treatment

• Nebulizers provide medications in an aerosolized form that a patient inhales into the tracheobronchial tree and that may enter the bloodstream through the alveoli.

• Adding moisture to the respiratory system through nebulization improves clearance of pulmonary secretions.

Incentive Spirometer

• Incentive spirometry is an inexpensive and effective tool for encouraging patients to breathe deeply and achieve normal inspiratory capacity. Incentive spirometry is designed to mimic natural sighing or yawning, which increases lung expansion and gas exchange.

• It is also useful in detecting declining pulmonary status.

Incentive Spirometry

Pulmonary Care

• Chest physiotherapy (CPT) includes chest percussion, postural drainage (PD), vibration and rib shaking, and is used for patients who have difficulty clearing their own secretions.

• Pulmonary hygiene consists of hydration, deep breathing exercises and coughing techniques. Older patients are prone to dehydration and therefore are at risk for airway plugging.

Payment Reform Pneumonia

Pneumonia • Qualifying Diagnosis:

• Chest X-ray confirmation of a new pulmonary infiltrate

• OR TWO or more of the following:

• Fever >100.4 (oral) or two degrees above baseline

• Blood oxygen saturation level < 92 percent on room air or on usual O2 settings in patients with chronic oxygen requirements

• Respiratory rate above 24 breaths per minute

• Evidence of focal pulmonary consolidation on exam, including rales, rhonchi, decreased breath sounds, or dullness to percussion

• Symptomatic Guidance: Productive cough, increased functional decline, increased dependence in ADLS, reduced oral intake, or increased lethargy, altered mental status, dyspnea

• Treatment: Antibiotic therapy (oral or parenteral), hydration (oral, sc or IV), oxygen therapy and/or bronchodilator treatments; additional nursing supervision for symptom assessment and management (vital sign monitoring, lab/diagnostic test coordination and reporting)

• Maximum Benefit Period: Seven days

Payment Reform Asthma/COPD

COPD/Asthma

• Qualifying Diagnosis: • Known diagnosis of COPD/asthma or CXR (Chest x-ray) showing COPD with hyper-

inflated lungs and no infiltrates

• AND TWO or more of the following: • Symptoms of wheezing, shortness of breath or increased sputum production

• Blood oxygen saturation level below 92 percent on room air or on usual O2 settings in patients with chronic oxygen requirements

• Acute reduction in Peak Flow or FEV1 on spirometry

• Respiratory rate > 24 breaths per minute

• Treatment: Increased bronchodilator therapy, usually with a nebulizer, IV or oral steroids, oxygen and sometimes antibiotics

• Maximum Benefit Period: Seven days

References

• Barakzai MD, Fraser D. Assessment of infection in older adults: Signs and symptoms in four body systems. Journal of Gerontological Nursing. 34(1): 7-12, January 2008

• Goroll AH, Mulley AG, Primary Care Medicine: Office Evaluation and Management of the Adult, 5th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2006: 314-329.

• Health Assessment Made Incredibly Visual! Philadelphia, Pa., Lippincott Williams & Wilkins, 2007: 70-85.

• Sharma G, Goodwin J. Effect of aging on respiratory system physiology and immunology. Clinical Interventions in Aging. 1(3): 253-260, 2006

• Colleton, Linda G, Beyond the stethoscope: Respiratory assessment of the older adult. Nursing Made Incredibly Easy. Vol 6 – Issue 5 – pages 11-14 October 2008

References Cont.

• Centers for Disease Control and Prevention. (2014). Pneumonia

• Arnold, F. W., et. Al. (209). Improving outcomes in elderly patients with community-acquired pneumonia by adhering to national guidelines. Arch Intern Med, 169, 1515-1524.

• Thiem, U., Heppner, H., & Pientka, L. (2011). Elderly patients with community-acquired pneumonia. Drugs Aging, 28 (7), 519-537.

The project described was supported by Funding Opportunity Number 1E1CMS331084-04-00-15 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the HHS or any of its agencies.