COVID-19 is an acute, sometimes severe, respiratory illness caused by a novel coronavirus SARS-CoV2. Person-to-person spread occurs through contact with infected secretions, mainly via contact with large respiratory droplets, but can also occur via contact with a surface contaminated by respiratory droplets. Nursing facilities face higher risk of transmission due to high population density creating difficulty in maintaining avoidance precautions. Significantly, residents of nursing homes are at high risk for more severe disease because of age and underlying medical disorders.

Clinical Presentation

People with COVID-19 may have few to no symptoms, although some become severely ill and die. Symptoms can include fever, cough, and shortness of breath. The exact incubation time is not certain with estimates ranging from 1 to 14 days. The risk of serious disease and death in COVID-19 cases increases with age. COVID-19 can cause Pneumonia and ARDS (Acute Respiratory Distress Syndrome), Severe Acute Respiratory Syndrome (SARS), Acute Respiratory Failure and several other conditions.

Respiratory Assessment

If COVID-19 disease is suspected as part of the screening process, a  thorough respiratory assessment is essential, including careful auscultation to identify residents with a risk of significant lower respiratory illness.


Tips for a Respiratory Assessment:

  • Collect and document a detailed Pulmonary History
      • Is the resident a smoker?
      • Nonsmoker?
      • Is there underlying Pulmonary disease; Emphysema, COPD, Lung CA, etc.?
  • Assess Respiratory Patterns
      • Is the pattern regular?
      • Increased?
      • Is Dyspnea present on exertion; irregular pattern?
      • Is there use of accessory muscles; prolonged expiration
      • Shortness of breath?
  • Listen to breath sounds
      • Are they clear to auscultation?
      • Decreased unilaterally?
      • Decreased bilaterally?
      • Rales in bases?
      • Wheezing, Rhonchi, Crackles, Rubs?
      • Location of abnormal breath sounds?
      • Pain with breathing?
  • Listen for coughing
      • Is it strong; spontaneous; nonproductive?
      • Strong; productive; color_________?
      • Weak; nonproductive
      • Weak; productive; color_________?
      • Congestion present?
      • No cough?
  • Use of Equipment
      • Is Oxygen being used?
      • How many Liters/Minute?
      • What type of oxygen?
      • Nasal Cannula
      • Mask
      • Nonrebreather
      • Bipap/CPap
      • Ventilator
  • Look for Signs/Symptoms
      • Runny nose
      • Sore throat
      • Appearance of Nail Beds, lips, mucous membranes, skin
      • Restlessness, irritability, confusion
      • Level of Consciousness
      • Fatigue, Malaise
      • Nausea, vomiting, diarrhea
  • Active Medications/Treatments
      • Medications; Antivirals, Antibiotics, Breathing treatments, Inhalers
      • Spirometer use
      • Is resident being suctioned?
      • Tracheostomy Care?
      • Droplet precautions: mask, respirator, eye protection gowns, gloves?


Understanding Differences in Lung Sounds:

  • Wheezes-High frequency whistling noise, very specific to airway narrowing. Focal or unilateral wheezes typically indicate focal pneumonia.  Diffuse or bilateral wheezes could mean upper airway bronchospastic disease or diffuse multifocal pneumonia
  • Crackles-Crackles, or rales, are a scratch sound quality evident when fluid fills up in the alveolar and interstitial spaces. These sounds can be focal and coarse in localized areas of pulmonary edema or consolidation in pneumonia.  Diffuse and fine crackles are more typical of pulmonary fibrosis, but can also be present in atypical types of pneumonia
  • Egophony-Provoked auscultation finding. Have the resident say “E” and auscultate to see if it becomes “A”.  Pneumonia can consolidate focal parts of the lungs into dense tissue that filters out lower frequencies, allowing for higher frequencies to pass through.


Communicate abnormal findings to the physician and clinical team as part of the ongoing process for  COVID-19 investigation and management.




Blog by Sherry Roberts, RN, Clinical Consultant, Proactive Medical Review