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Physical examination of the adult patient with chronic respiratory disease.

Chronic obstructive pulmonary disease (COPD) refers to a large group of deteriorating, progressive respiratory diseases that interfere with breathing due to airway obstruction (American Lung Association, 2013). COPD is an increasingly prevalent public health concern, with over 24 million adults currently diagnosed; it is the third leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2013). COPD frequently results in hospitalization or emergency department visits (CDC, 2014). Nurses play a critical role in the diagnosis and management of COPD, as well as early detection of disease exacerbations. While nurses conduct respiratory assessments as part of routine nursing care, the assessment of a patient with COPD presents unique challenges. The components of a basic respiratory assessment will be reviewed, including specific considerations for the patient with COPD.

Pathophysiology of COPD

COPD is associated with impaired pulmonary gas exchange and trapping following inflammatory injury to the intrathoracic airways, lung parenchyma, and pulmonary vasculature. Repeated exposure to noxious stimuli (smoking, chemicals, airway irritants) perpetuates an inflammatory response in the airway walls and lumen (Tamimi, Serdarevic, & Hanania, 2012). COPD can be classified by different phenotypes, including infrequent exacerbators with chronic bronchitis or emphysema, asthma-COPD overlap, and frequent exacerbators either with emphysema or chronic bronchitis predominant (Miravitlles et al., 2013). For the purpose of this article, the term COPD will include each of these sub-classifications.

Breathing perception occurs as a two-stage process in the brain, with recognition of breathing disruption occurring first, followed by the affective evaluation, or how the individual feels about his or her breathing (Davenport & Vovk, 2009). Alterations in this cognitive process contribute to the high rates of anxiety and depression associated with chronic respiratory disease (Miller & Davenport, 2015). Dyspnea (the subjective sensation of difficult breathing) is an incapacitating symptom that accompanies COPD and is a better predictor of mortality than forced expiratory volume in liters (Laviolette & Laveneziana, 2014). Consequently, dyspnea should be evaluated during every respiratory assessment for its predictive value and negative effect on quality of life.

Nursing Assessment of COPD

A thorough respiratory assessment is needed to quantify and qualify oxygen status and respiratory function. A general respiratory assessment includes inspection, palpation, percussion, and auscultation (Goolsby & Grubbs, 2011; Jarvis, 2012). To assess the full impact of the disease on the patient's life, the nurse also should evaluate subjective sensations, such as dyspnea and breathlessness (Dains, Baumann, & Scheibel, 2012). Dyspnea and breathlessness can be quantified using the classic Medical Research Council Dyspnea scale (see Table 1) (DePew, Garofoli, Novotny, & Benzo, 2013; Fletcher, Elmes, Fairbairn, & Wood, 1959). This scale first was published in the 1950s, and the modified version remains to describe succinctly the range of respiratory disability from none (Grade 1) to almost completely incapacitated (Grade 5). A nurse can use this scale to produce a quantitative dyspnea score in a few seconds. Due to the aversive effects of dyspnea and strong risk of development of psychological co-morbidities, initial screening for anxiety and depressions also should be included in standard clinical assessment of all patients with COPD (Miller & Davenport, 2015).

Inspection

Initial inspection allows the nurse to observe physical signs of respiratory dynamics during the clinical examination. The first step in general assessment is a thorough inspection of the upper airway, including the mouth, nasal cavities, throat, chest wall, and abdomen. The patient may be in the supine position for inspection of the anterior thorax, and seated or standing for inspection of the posterior thorax. When the nurse inspects the upper airway, nasal flaring (outward movement of the nares upon inspiration), pursed-lip breathing (tightened lips and contracted cheek muscles upon expiration), and obvious growths or obstructions in the nares, mouth, and throat should be noted (Jarvis, 2012). Patients with COPD often alter their breathing position to allow use of accessory muscles to breathe. They may contract the muscles of their shoulders, neck, abdomen, or dorsum, and use pursed-lip breathing (Kim et al., 2012).

To characterize abnormalities in structure or movement of the rib wall, the nurse should visualize each area and compare it to the opposing side (anterior to posterior, right to left). Thoracic malformations, many of which are congenital, can be noted during inspection. During advanced stages of COPD, increases in anteroposterior diameter may lead to the classic barrel-chested appearance. Kyphosis often accompanies this deformation as the ribs lose their angling and become more horizontal (Weaver, Schoell, & Stitzel, 2014). Chronic atelectasis or pleural fibrosis can lead to spinal curvature. Respiratory dynamics, including respiratory rate and pattern, are evaluated during inspection. The normal respiratory rate is 12-20 breaths per minute in an adult patient.

Cyanosis due to impaired arterial blood oxygenation is assessed best in the mucous membranes. The membranes typically have a pinkish or red hue. However, blood lacking in oxygen is dark bluish-red, which contributes to a bluish color best seen in the mucous membranes (Kraft, 2011). Prolonged low oxygen in the blood may lead to painless enlargement of connective tissue, or clubbing, which can be noted in the dorsal terminal phalanges. The fingers may appear large or bulging, with nails curved downward in an upside-down spoon shape (Murray & Schraufnagel, 2010).

Palpation

Palpation of the thorax confirms any suspected abnormalities by touch, including enlarged lymph nodes, intercostal masses or separations, and thoracic malformations. Using the fingertips and flat of the hand, the nurse should palpate in an orderly method the neck, thorax, and abdomen using firm but gentle pressure. Size, shape, and movement of the thorax during inspiration and expiration should be noted. The nurse should palpate the intercostal spaces for any bulging, retractions, or paradoxical movement. By placing the thumbs on each side of the spine, with fingers spread laterally, at the level of the tenth rib and asking the patient to take a deep breath, the nurse can assess the adequacy of lung expansion and symmetry as he or she watches the fingers move up and apart. Tracheal position can be evaluated by lightly placing the index finger in the suprasternal notch and moving it slightly upward until the tracheal cartilage is felt (Jarvis, 2012).

Percussion

Percussion is a key component of respiratory assessment to assist in differential diagnosis. Percussion produces audible sounds and vibrations that help determine if underlying lung tissue is filled with air, fluid, or solid material. Pneumonia, pleural effusions, tumors, emphysema, or pneumothorax can alter the characteristics of percussed sounds and assist with diagnosis. Hyper-resonance might be heard with air trapping in emphysema or pneumothorax. Dullness will be percussed when fluid or solid tissue replaces air or invades the pleural space as with pneumonia, pleura effusion, or tumor. Percussion is used to determine tone of the percussed sounds and respiratory excursion (Weber & Kelley, 2013).

When the nurse percusses for tone of the posterior chest wall, the patient should be sitting upright if possible, with his or her arms folded across the chest. Percussing of the anterior chest wall is accomplished best while the patient is supine. Correct technique requires practice and is essential to obtain accurate findings. The nurse should place one hand over the area to be percussed, extending the middle finger with fingers slightly separated. The middle finger of the opposite hand should be used to strike the middle finger quickly, using a loose swinging movement from the wrist. Percussion should be performed in a sequence over both sides of the chest while avoiding the scapulae and ribs, which will dampen sounds (Jarvis, 2012).

Percussion over normal lung tissue should produce resonance, a low-pitched, drum-like sound the examiner will learn to identify with experience in performing percussion on patients with normal lung function. Hyper-resonance is a low-pitched, hollow sound that can be heard over areas where air is trapped or more abundant than normal, such as in emphysema or pneumothorax; it is described as the sound of percussing over a puffed cheek. Dullness is percussed when fluid or solid tissue is present in lung tissue, as with pneumonia, pleural effusion, atelectasis, or tumor, and is a medium-pitched firm sound. Percussion thus is an important assessment for the patient with COPD (Jarvis, 2012; Weber & Kelley, 2013).

Auscultation

Auscultation is a key component of respiratory assessment of the lungs and pleural space leading to identification of COPD-related conditions. Auscultation includes three components: listening to sounds created by air during normal quiet breathing, listening for additional or adventitious sounds, and listening to how the spoken or whispered voice is transmitted through the chest wall. Auscultation of the anterior and posterior chest wall is accomplished by placing the stethoscope directly over the patient's skin and asking the patient to breathe deeply through the mouth. Consideration of the patient's comfort should be made throughout the auscultation sequence, and unnecessary deep breathing should be avoided to prevent the patient from becoming lightheaded. The examiner should listen to the intensity, pitch, and duration of the sounds through a full inspiratory and expiratory cycle, with comparisons made between right and left lung fields (Weber & Kelley, 2013). Intensity is considered the loudness or volume of the sound, pitch involves how high or low the sound is, and duration indicates how long the sound lasts. The examiner also should note the timing of any abnormal breath sound or when the sound occurs in the respiratory cycle.

Three types of breath sounds can be auscultated (see Table 2). Bronchial breath sounds are harsh, loud, and high-pitched, and are heard over the trachea and thorax. Bronchovesicular sounds, of moderate pitch and amplitude, are heard over the major bronchi. Vesicular sounds are heard in peripheral lung fields; they are low pitched and soft. Breath sounds heard in other areas are considered abnormal due to lung disease. For example, pulmonary edema can lead to bronchial breath sounds in peripheral lung fields. Diminished or decreased breath sounds might be heard in patients with emphysema or asthma when obstructed airflow or fluid-filled tissue is present (Goolsby & Grubbs, 2011).

Adventitious sounds are extra sounds that are superimposed over normal breath sounds and heard during auscultation. Crackles (fine and coarse) and wheezes are examples of adventitious sounds. Inspiratory and expiratory wheezes often are auscultated in patients with asthma and chronic emphysema. Low-pitched coarse crackles and high-pitched fine crackles often are heard in bronchitis, asthma, and emphysema. Voice transmission is assessed only if abnormal bronchial or bronchovesicular breath sounds are heard. Bronchophony is assessed by asking the patient to repeat the phrase "ninety-nine" while the nurse auscultates the chest wall. Egophony is assessed by asking the patient to repeat the letter "e," while whispered pectoriloquy is assessed by asking the patient to whisper the phrase "12-3" while the nurse auscultates the chest wall. If areas of consolidation are present due to pneumonia or atelectasis, abnormal voice transmission might be noted (Goolsby & Grubbs, 2011; Jarvis, 2012; Weber & Kelley, 2013). While assessment of voice transmission is not part of a routine respiratory assessment, the nurse should be prepared to conduct these assessments when abnormal lung sounds are auscultated in the patient with COPD.

Nursing Implications

Nurses' close, frequent monitoring of their patients means they are often the first to recognize early changes in physiological status (Clarke, 2004; Clarke & Aiken, 2003). Changes in respiratory function can be indicative of an impending adverse event or worsening COPD. Inspection, palpation, percussion, and auscultation (including bronchophony, egophony, and whispered pectoriloquy) are steps in a thorough, in-depth assessment. While these strategies are taught in the assessment lab, their performance may not be practical or merited in most situations. An effective assessment can be obtained using inspection and auscultation of adventitious lung sounds as previously described. However, when abnormalities related to COPD are present, palpation and percussion should be utilized to provide comprehensive information to guide nursing care.

Conclusion

A thorough respiratory assessment offers valuable insight into disease progression, promotes positive patient outcomes, and improves patient care (Duff, Gardiner, & Barnes, 2007). Evaluation and quantification of dyspnea should be included in initial examination as a baseline and reassessed periodically because deviations from baseline may signify a deleterious change in function. Anxiety and depression also should be assessed periodically due to their frequent occurrence in persons with COPD. In conclusion, nurses who care for patients with COPD should recognize a thorough respiratory assessment is a critical component of quality nursing care.

REFERENCES

American Lung Association. (2013). Trends in COPD (chronic bronchitis and emphysema): Morbidity and mortality. Retrieved from http://www.lung.org/finding-cures/our-research/trend-reports/copdtrend-report.pdf

Centers for Disease Control and Prevention (CDC). (2013). Chronic obstructive pulmonary disease among adults--United States 2011, 67(46), 938-943.

Centers for Disease Control and Prevention (CDC). (2014). Fastats. Chronic obstructive pulmonary disease (COPD) Includes: Chronic bronchitis and emphysema. Retrieved from http://www.cdc. gov/nchs/fastats/copd.htm

Clarke, S.P. (2004). Failure to rescue: Lessons from missed opportunities in care. Nursing Inquiry, 11(2), 67-71.

Clarke, S.P, & Aiken, L.H. (2003). Failure to rescue. American Journal Nursing, 103(1), 42-47.

Dains, J.E., Baumann, L.C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Mosby Elsevier.

Davenport, P.W., & Vovk, A. (2009). Cortical and subcortical central neural pathways in respiratory sensations. Respiratory and Physiological Neurobiology, 167(1), 72-86.

DePew Z.S., Garofoli, A.C., Novotny, P.J., & Benzo, R.P. (2013). Screening for severe physical inactivity in chronic obstructive pulmonary disease: The value of simple measures and the validation of two physical activity questionnaires. Chronic Respiratory Disease, 10(1), 19-27.

Duff, B., Gardiner, G., & Barnes, M. (2007). The impact of surgical ward nurses practising respiratory assessment on positive patient outcomes. Australian Journal of Advanced Nursing 24(4), 52-55.

Fletcher, C.M., Elmes, P.C., Fairbairn, M.B., & Wood, C.H. (1959). The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal, 2, 57-266.

Goolsby, M.J., & Grubbs, L. (2011). Advanced assessment: Interpreting findings and formulating differential diagnoses (2nd ed.). Philadelphia, PA: F.A. Davis.

Jarvis, C. (2012). Physical examination and health assessment ANZ adaptation. St. Louis, MO: Saunders Elsevier.

Kim, K., Byun, M., Lee, W., Cynn, H, Kwon, O., & Yi, C. (2012). Effects of breathing maneuver and sitting posture on muscle activity in inspiratory accessory muscles in patients with chronic obstructive pulmonary disease. Multidisciplinary Respiratory Medicine, 7(1), 9.

Kraft, M. (2011). Approach to the patient with respiratory disease. In L. Goldman & A. I. Schafer (Eds.), Goldman's cecil medicine (pp. 512-516). Philadelphia, PA: Elsevier Saunders.

Laviolette, L, & Laveneziana, P. (2014) Dyspnoea: A multidimensional and multidisciplinary approach. European Respiratory Journal, 43(6) 1750-1762.

Miller, S., & Davenport, P.W. (2015). Subjective ratings of prolonged inspiratory resistive loaded breathing in males and females. Psychophysiology, 52(1), 90-97.

Miravitlles, M., Soler-Cataluna, J.J., Calle, M., Molina, J., Almagro, R, Quintano, J., ... Soriano, J. (2013). A new approach to grading and treating COPD based on clinical phenotypes: Summary of the Spanish COPD guidelines (GesEPOC). Primary Care Respiratory Journal, 22(1), 117-121.

Murray, J.F., & Schraufnagel, D.E. (2010). History and physical examinations. In R.J. Mason, V.C. Broaddus, & T.R. Martin (Eds.), Murray & Nadel's textbook of respiratory medicine (pp. 360-361) Philadelphia, PA: Saunders Elsevier.

Tamimi, A., Serdarevic, D., & Hanania, N. (2012). The effects of cigarette smoke on airway inflammation in asthma and COPD: Therapeutic implications. Respiratory Medicine, 106(3), 319-328.

Weaver, A., Schoell, S., & Stitzel, J. (2014). Morphometric analysis of variation in the ribs with age and sex. Journal of Anatomy, 225(2), 246261.

Weber, J., & Kelley, J. (2013). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Sarah Miller, PhD, RN, is Assistant Professor, Loewenberg School of Nursing, University of Memphis, Memphis, TN.

Laura Owens, PhD, RN, is Assistant Professor, Loewenberg School of Nursing, University of Memphis, Memphis, TN.

Erin Silverman, PhD, CCC/SLP, is Research Assistant, University of Florida, Gainesville, FL.
TABLE 1.

Dyspnea Rating Scale

* Grade 1: Breathless only on strenuous exertion

* Grade 2: Breathless when walking up a slight hill

* Grade 3: More breathless than contemporaries when
walking on level ground

* Grade 4: Breathless on walking 100 meters

* Grade 5: Breathless on dressing or undressing

Sources: DePew et al., 2013; Fletcher et al., 1959

TABLE 2.
Breath Sounds

Type           Amplitude  Pitch     Quality    Duration     Location

Bronchial      Loud       High      Harsh    Short         Trachea
                                             during        and
                                             Inspiration;  thorax
                                             long
                                             during
                                             expiration

Bronchovesi-   Moderate   Moderate  Mixed    Equal         Over
cular                                        during        the
                                             inspiration   major
                                             and           bronchi
                                             expiration

Vesicular      Soft       Low       Breezy   Long          Peripheral
                                             during        lung
                                             inspiration   fields
                                             and
                                             short
                                             during
                                             expiration

Sources: Jarvis, 2012; Weber & Kelley, 2013
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Title Annotation:Clinical 'How To'
Author:Miller, Sarah; Owens, Laura; Silverman, Erin
Publication:MedSurg Nursing
Date:May 1, 2015
Words:2726
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