The nurse should perform which assessments for a patient complaining of a cough

No matter what kind of nurse you are – triage, paediatric, emergency, ICU or even mental health – the skills to perform a thorough patient assessment are a vital component of good nursing practice.

And essential to this assessment is to effectively evaluate a patient’s breathing. Signs of respiratory failure are a key indicator for escalation of care. As a nurse you need to know optimum respiratory function and be able to recognise signs of deterioration to care for your patient safely.

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A respiratory assessment is the first step towards identifying if, and how soon, you need a doctor to review your patient, or if you need to make a MET call.

"The respiratory assessment is a key component to nursing skill and care," says Registered Nurse and academic, Jessica Stokes-Parish.

"It is fundamental to a good nursing assessment and should be a part of your suite of skills. It takes time to develop, and should be a priority area of skill development.

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The A-G patient assessment method

The A-G method is becoming a commonly used tool in primary and secondary care settings. It integrates the procedure mandated for resuscitation and emergency situations. However, it is also useful for systematic baseline patient assessment and can improve patient mortality in hospital.

A-G covers: airway, breathing, circulation, disability, exposure, further information (including family and friends) and goals. Its systematic approach has been proven effective in identifying deteriorating patients or those at risk of deterioration. A respiratory assessment forms a key part of the A-G method.

What is a respiratory assessment?

A respiratory assessment forms part of the A-G model and is a way to assess the respiratory system function. It comprises the 'A' and 'B' of a physical assessment - airway and breathing.

Airway assessment:

The aim of airway assessment is to ensure that any obstruction of the anatomy of the airway is identified.

The main causes of airway obstruction are:

• Foreign body, aspiration
• Laryngotracheal trauma
• Vocal cord paralysis
• Allergic reaction
• Laryngeal oedema
• Haematoma
• Abscess

Signs of partial airway obstruction include:

• Breathing sounds (gurgling, stridor, bubbling, expirtory wheeze)
• Gasping for air
• Laboured breathing
• Unable to speak full sentences
• Coughing
• Reduced level of consciousness
• Signs of complete airway obstruction include:
• Agitation
• Unable to speak
• No air entry at auscultation (no chest movement)
• Choking
• Panic
• High pitched breathing noises
• Unconsciousness
• Stridor

Breathing assessment:

In a healthy patient, breathing should be:

• Effortless;
• Equal bilateral chest expansion;
• At a rate of 12-20 breaths per minute (respiratory rate);
• Noise-free; that is, no wheezing, stridor (a harsh vibrating noise) or rattling;
• The airway should be free of sputum.

During the breathing component of assessment, nurses must use the ‘Look, Listen and Feel’ technique. Looking for any respiratory distress signs, assessing the depth and pattern of the respiratory cycle for 15 seconds and counting the respiratory rate for a full minute is recommended.

The acceptable oxygen saturation is >96% for patients without hypercapnic respiratory failure or chronic obstructive pulmonary disease (COPD) and 88-92% for patients with those conditions or at risk of worsening hypercapnia. The patient’s ability to talk in full sentences is a good indicator of their breathing status.

"A thorough respiratory assessment involves checking the respiratory rate, the symmetry, depth and sound (auscultation) of breathing, observes for accessory muscle use and tracheal deviation," says Ms Stokes-Parish.

In addition to this, the assessor will check oxygen saturations (SpO2) and observe the colour of the skin.

"Look at the way the chest rises and falls - how fast, is it equal, how deep, listen to the sound of the lungs - can you hear an audible sound, is air entry equal, are there any unusual sounds, and feel - place your hand on the chest, feel the depth of breathing, the symmetry."

When is a MET (Medical Emergency Team) call required?

Each hospital has their own policy and criteria for calling a Medical Emergency Team - in some states this is called a Rapid Response Team.

"You should call a MET team if your patient has a respiratory rate outside of normal range, appears blue in the face or has a stridor - loud, noisy breathing caused by an obstruction to the throat.

"If the patient fits all the normal criteria but you are still worried, you should call a MET anyway.

"Another consideration is to compare the data you have collected to the previous set of observations, has it changed dramatically? If yes, it might be time for a MET.”

MET call criteria:

• A threatened or obstructed airway.
• Respiratory rate <8 breaths/min or >36 breaths/min.
• Pulse oximetry saturation <90% despite oxygen administration.
• If you are seriously concerned about the patient.

Back to Basics

If the patient can’t talk, or if you are waiting for the MET team to arrive, it's time to run through the basic life support algorithm: ABCDE. Here are some measures you can take before the MET team arrives.

• Airways – is this patent? Check and clear any blockages in the mouth via suction. Nurse the patient onto their side (unless contraindicated) and help to open the airway with a chin lift or jaw thrust.
   
• Breathing – if the patient has low SpO2, give high flow oxygen through a mask to aim for SpO2 >94%.
   
• Circulation – insert 2 large IV cannula and take blood. Give a fluid bolus if the patient’s blood pressure is low. Perform a 12-lead ECG if the patient has chest pain.
   
• Disability – do a finger-prick test to assess blood glucose level.
   
• Exposure – help expose the patient’s body for examination. Remove unnecessary clothes/layers, but keep a blanket on to maintain body warmth and respect the dignity of the patient.

Whilst doing the above, ideally another nurse on the ward should ensure that both the patient’s inpatient folder and medication/observations folder are by the bedside, ready for easy access by the doctors.

Less Urgent Cases

If your patient can talk, begin by taking a background:

• Family history: Atopy, COPD, cancer.
• Occupation: Occupational exposure to asbestos and certain mining/farming areas may predispose patients to certain diseases.
• Sick contacts: Are any of your friends/family members sick? Have you travelled anywhere (especially overseas) recently?
• Smoking: Risk factor for lung cancer and COPD. Quantify smoking by the number of “pack-years” (1 pack-year = 20 cigarettes/day for 1 year).
• Past ICU admissions.
• Patient’s medications (amiodarone, beta-blockers and ACE-inhibitors for example can have respiratory side effects).
• Look up any of your patients’ past discharge summaries to check their past medical history and medications.

Questions to ask your patient about their current symptoms:

• Cough: Duration, character, any sputum production (and colour).
   
• Are you coughing up any blood/is there any blood mixed with your sputum? Coughing up blood (aka haemoptysis) needs to be brought to a doctor’s attention as it may suggest trauma, bleeding in a lung cavity or pulmonary embolism.
   
• Dyspnoea and change in exercise tolerance: Particularly important in patients with heart failure and COPD.
   
• Wheezing (especially in patients with asthma or COPD).
   
• Night sweats, weight loss: May indicate tuberculosis or cancer.
   
• Chest pain: May indicate a more serious cause of the patient’s respiratory distress such as a heart attack or pulmonary embolism. Perform an ECG if the patient complains of chest pain or palpitations and have it reviewed by a doctor immediately.

The Paediatric Patient

The ranges of acceptable respiratory rates are different in children - you should check the reference ranges prior to doing an assessment in a child.

"Children are also more likely to occlude their airway due to the size of their tongue, and are more susceptible to airway obstruction," says Ms Stokes-Parish.

"Additional signs of respiratory distress in children include nasal flaring and sternocleidomastoid contraction.

"Pay particular attention to whether they have an obstructed airway, and call for help early."

There are certain crucial things you’ll need to ask parents/guardians when they bring in a sick child/baby.

Red flag signs of a sick child:

• Character of the cough (e.g. barking may indicate croup, whooping may be a sign of whooping cough)
• Stridor/the possibility that the child may have swallowed a foreign body
• Substernal retraction/nasal flaring/tracheal tug – visual signs that a baby/child is struggling to breathe properly
• Drowsiness/lethargy
• Decreased intake of milk/food and decreased number of wet nappies
• A child that is not up to date with vaccinations

Things to look for on examination

Basic Management

• Give them oxygen if they require it, to meet the saturation range the doctor has recommended (usually above 94%).
• Ensure they have easy access to Ventolin puffers if they have asthma or COPD.
• Give them reassurance – it will help if the patient can try to relax.
• Call a MET call and apply ABCDE in an emergency.

Sources:

• ARC Advanced Life Support Level 1: Immediate Life Support. Third Edition. Australian Edition. Australian Resuscitation Council 2011.
• Oxford Handbook of Clinical Medicine (9 ed.) by Murray Longmore, Ian Wilkinson, Andrew Baldwin, and Elizabeth Wallin.

Which assessment finding of the respiratory system is considered normal?

Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem?

Which assessment findings would the nurse expect in a patient in acute respiratory distress?

In which client should the nurse prioritize assessments for respiratory depression?