Assessing pulmonary status: It's more than listening to breath sounds

Assessing a client's pulmonary status in the home really isn't much different from assessment in the hospital. It's an ongoing process that requires accurate and thorough interviewing, inspection, palpation, percussion, and auscultation. But as with most home assessments, you'll have to cope with a few twists. For one thing, you can't control the environment. Not every house has good lighting or is perfectly quiet. For another, you may not have complete information about the client-and he may be unable to adequately fill in the blanks. What's more, his condition may have changed since hospital discharge. So you need to be prepared for a challenge. Here, I'll give you some pointers to help you make the most of your assessment time. BEGIN WITH THE INTERVIEW Interviewing, the start of pulmonary assessment, lets you get the client's history as he knows it and assess his education level and how much he understands about his disease. You can also begin to establish rapport with both the client and caregiver. Start with questions about the client's history, including the following: What was life like for you before this illness? This will give you a lot of information without having to ask a lot of questions. Be sure, though, to follow up on anything that is unclear or concerns you. What kind of work did you do before you retired or couldn't work anymore? Knowing about the client's work conditions can reveal whether he was exposed to any respiratory irritants, such as asbestos, chemicals, or cigarette smoke. Do you have any allergies? If so, what's the allergic response? This will tell you two things: whether the client uses any allergy medications that could interact with new medications ordered by the physician and whether he's allergic to any medications. Do you have a personal or family history of asthma, tuberculosis (TB), lung cancer, cystic fibrosis, bronchitis, emphysema, or any other lung disease? You'll want to know if the client has had or is predisposed to any of these illnesses. If he's been exposed to TB by a family member, he may need a tuberculin skin test. Next, move on to these questions about the current illness: Are you having any difficulty breathing? This question will tell you his current status. Do you have any chest pain when you breathe? Chest pain could be cardiac, pulmonary, or musculoskeletal in origin. Pain that increases with deep breathing is most likely pulmonary, indicating pleuritic or lung mass involvement from infection. Although the lungs don't have pain-sensitive nerve endings, the thoracic muscles, parietal pleura, and tracheobronchial tree do. So pulmonary-related chest pain may be a late sign of lung disease. Do you have a cough? A cough, whether productive or nonproductive, could disrupt the client's activities of daily living or cause chest pain or acute respiratory distress. So if the answer to your question is yes, explore: -when it occurs. Coughing due to chronic airway inflammation from smoking or bronchitis generally occurs early in the morning, the result of changing position. A late-afternoon cough may indicate prolonged exposure to irritants, which could exacerbate bronchitis. Chronic postnasal drip, sinusitis, or gastric reflux with nocturnal aspiration could be the cause of an evening cough. -how it sounds. A client with a cold, pneumonia, or bronchitis could have a congested cough. If the cough is nonproductive, suspect a cardiac condition. Do you bring up any phlegm when you cough? If so, find out what it looks like. Normally, it'll be thin, clear to white, tasteless to the client, and odorless. Tracheobronchitis or asthma could cause mucoid sputum. If the sputum is yellow or green, suspect a bacterial infection. Rust-colored sputum could indicate pneumonia or TB. Pulmonary edema can cause pink, frothy sputum. Be sure to evaluate and describe the sputum in your documentation if you witness a productive cough. Are you ever short of breath? Dyspnea suggests that the client isn't receiving adequate oxygen to the lungs and alveoli, making him feel as if he isn't getting enough air. This is a compensatory mechanism of the pulmonary systemthe client breathes rapidly, then can't accomplish full lung capacity on inspiration and expiration. Does this shortness of breath occur at rest or on exertion? The answer will tell you how well the client tolerates activity. Dyspnea at rest, obviously, means zero tolerance. If the client reports dyspnea only on exertion, find out how difficult breathing during exertion is and how soon he feels comfortable again. Also, ask what type of activity precipitates exertional dyspnea. What relieves your shortness of breath? Does he use pillows to prop himself up? (The more pillows, the worse his dyspnea probably is.) Does he lean forward (which would let him exhale all of the air by putting pressure on his elevated diaphragm)? Does he use pursed-lip breathing to force trapped air out on exhalation? Is he using any medication to decrease inflammation and open his airways? Do you hear yourself wheezing when you get short of breath? This indicates narrowing airways, possibly caused by mucus trapped in the airways-the result of inflammation (bronchitis or emphysema) or bronchospasm (asthma). NEXT, INSPECT THE THOR/IX Inspection gives you information about the client's respiratory rate, rhythm, and depth and about symmetry of chest expansion. Prepare the client for inspection by encouraging him to relax. Explain what you're going to do, then remove his clothes from the waist up. Also observe his abdomenmany people with chronic obstructive pulmonary disease (COPD) use abdominal muscles to compensate for impaired pulmonary function. Have him sit in a chair, unless contraindicated by his condition, so you'll have access to his anterior, posterior, and lateral thorax. If he's lying down, he may have to change position throughout the assessment, which could tire him. But if he can't sit and you must reposition him during the assessment, be sure to assess his tolerance, noting any shortness of breath or color changes. (Color changes indicate poor ventilation and inadequate oxygen/carbon dioxide exchange in the tissues.) As you begin your assessment, remember these points: Inspect the thorax for any scars, wounds, incisional lines, and lesions. Also, assess for symmetry of chest wall movement, which could be affected by trauma, surgery, or skeletal deformities. Assess the duration of the inspiratory/expiratory cycle. Prolonged expiration, for example, suggests difficulty in getting the airflow out. This is common and profound in clients with emphysema or asthma. Assess the respiratory pattern (rate and rhythm). Count the respiratory rate for 1 minute (normal rate: 12 to 20 breaths/minute for an adult). Respirations shouldn't be audible. If they are, observe for any associated symptoms, such as use of accessory muscles, nasal flaring, and discoloration of the nail beds. Check for wheezing, and ask the client whether he feels short of breath. Document your findings and report them to the physician. Also assess for an abnormal respiratory pattern. For example, deep, rapid respirations (Kussmaul's respirations) indicate diabetic ketoacidosis. Be sure to assess and document any abnormalities and to intervene as needed. Assess for accessory or abdominal muscle use, intercostal retractions, nasal flaring, or pursed-lip breathing, all indications of airflow obstruction or poor ventilation. Measure the anterior-posterior diameter of the chest. This will help you assess for thoracic deformities, including pigeon chest, a diminished anterior-posterior diameter caused by depression of the lower sternum, and barrel chest, a frontal protrusion of the chest causing an increase in anterior-posterior diameter. Assess the client's posture. Someone with COPD, for example, will lean forward and use his arms to prop himself up to improve breathing. Posture changes may also be associated with thoracic deformities, such as scoliosis (lateral curve of spine) and kyphosis (exaggeration of normal curvature of the spine, also called humpback).

PALPATE TN#ST WALL Palpation is the first hands-on step in the assessment process. As you palpate the chest wall, note muscle mass, skin turgor, and any areas of tenderness. Palpate for symmetrical expansion of the chest wall. Standing behind the client, place your hands (fingers spread apart) beneath his arms, about 2 inches (5 cm) below the axilla. Your fingers should be pointing toward the anterior chest; your thumbs, toward the spine. This will let you feel the chest rising and falling on inspiration and expiration. As he breathes, assess chest expansion, noting the rise and fall of your hands on inspiration and expiration. A pause in movement on either inspiration or expiration could mean that he has a fractured rib or diseased lung. Also assess whether both sides of the chest expand and deflate equally. Asymmetrical expansion may indicate paralysis of the diaphragm, a tumor, or fluid or air in the pleural cavity. Palpate for tactile fremitus, a vibration felt when he speaks. Ask the client to say a specific word or phrase, such as "99" or "A, B, C," while you use just the palm of your hand to palpate the chest for vibrations or a purring sensation. Move your hand over his chest from the central airways to the lung periphery and back. Repeat this procedure on the posterior thorax. The vibrations should be equal in intensity on both sides of the chest. Vibration intensity varies with the thickness and structure of the client's chest wall and his voice intensity and pitch. Normally, fremitus occurs in the upper chest, close to the bronchi; it's strongest at the second intercostal space on either side of the sternum. Absence of tactile fremitus indicates bronchial obstruction in this area. You'll feel little or no fremitus in the lower chest. Tactile fremitus in any area other than the upper chest, close to the bronchi, indicates lung consolidation (as in pneumonia). Palpate and assess for crepitus or subcutaneous emphysema (a crackling sensation felt underneath the skin), especially around operative or wound sites. Crepitus can indicate rib fracture-you'll feel the two fractured edges of bone rubbing together. Palpate the spine for scoliosis or kyphosis. PERCUSS FOR AIR OR FLUID CONSOLIDATION Percussion is an essential step for detecting air-filled, fluid-filled, or solid areas of the lungs. It can also help you identivy the anatomic borders of the lungs and diaphragm. You'll percuss the anterior thorax, then the lateral thorax, and finally the posterior thorax to detect differences in pitch. Percuss over intercostal spaces, not over ribs, and be sure to compare sounds from one side with the other. Percussion should produce a low-pitched resonance from above the clavicle to the fifth intercostal space on the right and to the third intercostal space on the left. You'll start to hear dullness close to the liver on the right, near the heart on the left, and over the ribs. Percuss the lateral chest, which will give you information about the left and right upper and lower lobes and the right middle lobe. You should hear resonance to the sixth or eighth intercostal space. Percuss the posterior thorax according to the standard percussion sequence. Expect to hear resonance to the level of T10. Resonance, of course, is the normal percussion sound you want to hear. But abnormal sounds could be audible, including: -hyperresonance, a loud sound resulting from increased air over the lung area (in emphysema clients, for example) -dullness, a medium-pitched sound resulting from fluid, pneumonia, or abscess in the lungs (consolidation); pleural effusion can produce a profound dull or flat sound from a sac or pocket of fluid with minimal air -flatness, a high-pitched sound heard in areas without any air, such as the liver, right upper quadrant of the abdomen, and heart (left second, third, and fourth intercostal spaces) on the anterior thorax. THE ESSENTIALS OF AUSCULTATION Auscultation lets you assess symmetry of airflow bilaterally and note whether the client has normal or abnormal breath sounds. (See Normal Breath Sounds and Abnormal Breath Sounds.) Before beginning, ask the client to take a few deep breaths so you can evaluate him. If he's deep-breathing incorrectly and ineffectively, correct him. He should count to two as he inhales through his nose, then count to four as he exhales through his mouth. He may start to breathe faster every time he feels you move the stethoscope. Remind him that he needs to breathe slowly and deeply (and to do this consistently) so that you hear the airflow traveling through his airways. Breathing too rapidly or deeply can result in excess carbon dioxide loss, which could cause vertigo or syncope. Most airflow occurs in the anterior and posterior thorax, so that's where pulmonary defects will be most noticeable. Only a small portion of the lung can be accessed laterally (right middle lobe). But don't skip lateral auscultation-you can use it to compare airflow over the major lung fields. Start auscultation with the posterior thorax, above the scapulae. (Make sure that you warm the stethoscope's diaphragm before placing it on the client's skin.) You start here because the lung fields are closer to the wall of the posterior thorax and there's less interference from heart sounds than with the anterior chest. Auscultate a point on one side of the back, then the same point on the other side. Move downward in a stair-step fashion, comparing your findings from one side with those from the other side. Auscultate the anterior thorax, following the same pattern as anterior percussion. Compare findings from one side with those from the other. To assess the right middle lobe, place the stethoscope on the chest underneath the right breast. Auscultate at the level of the fourth to sixth intercostal spaces, following the lateral auscultation sequence (same as lateral percussion sequence). You may hear extra breath sounds, audible high in the bronchial tree, if the client has an upper respiratory infection. Usually caused by mucus in the upper airways, they're no different in quality than fine or coarse crackles. But they aren't considered abnormal unless they don't clear when the client coughs. TIME TO COMMUNICATE When you're done, you need to tie your assessment findings together. Use them to build a clear picture of the client and his disease process, identifying any new, different, or ongoing problems. Communicate any abnormal findings to the primary care provider as clearly and precisely as possible. Then you can collaborate on a plan of care and make appropriate referrals for further evaluation as needed. Make sure your documentation clearly reflects the existing problem and the plan of care. This is necessary for adequate reimbursement. As I said at the beginning of this article, pulmonary assessment is an ongoing process. It lets you continue monitoring the client's condition so you can detect any changes that may require modifications in the plan of care. And that's the best way to ensure that your interventions will be appropriate and effective. SELECTED REFERENCES