Chapter objectives: At the end of this chapter, the learner will:

  1. Conduct a health history pertaining to the respiratory system.
  2. Identify anatomic landmarks in identifying underlying structures and the location of physical findings.
  3. Inspect the thorax for pattern of respiration, skin, symmetry, and use of accessory muscles.
  4. Auscultate the anterior and posterior thorax for normal breath sounds and adventitious sounds.
  5. Describe the findings using correct terminology.
  6. Document the findings of the respiratory exam.

I. Overview of the Respiratory System

The assessment of the respiratory system includes assessing the thorax, lungs, ventilatory function and oxygenation of the body.  Focused assessment techniques will be applied intensively in this system: inspect level of consciousness, agitation, skin color, clubbing fingers, shortness of breath, use of accessory muscles, position and alignment of the spine ; auscultate breathing sounds; palpate position of the trachea,  subcutaneous emphysema; percuss to assess the underlying structure of the chest.  

 

II. Anatomy and Physiology

Identifying thoracic landmarks is essential to the systematic examination of the respiratory system. Click the link below to review anatomy and physiology of the respiratory system. You will need to apply your knowledge in the assessment process.

III. Medical Terminology

Important terms to know and understand:

Adventitious sounds abnormal breath sounds
Atelectasis incomplete expansion or collapse of a part of the lungs
Bradypnea slow rate of breathing
Cheyen-Stokes Respirations gradual increase and then gradual decrease in depth of respiration followed a period of apnea
Crackles crackling sounds made as air moves through wet secretions in the lungs
Crepitus a grating sound or sensation under the skin around the lungs, or in the joints
Cyanosis bluish coloring of the skin
Dyspnea difficult or labored breathing
Hemoptysis sputum containing blood
Hyperventilation condition in which there is more than the normal amount of air entering and leaving lungs
Hypoventilation decreased rate or depth of air movement into the lungs
Hypoxia inadequate amount of oxygen available to the cells
Nasal Flaring nostrils widen while breathing indicates difficulty in breathing
Pneumothorax air in the pleural space
Stridor harsh, high-pitched sound usually heard on inspiration when upper airway become narrowed
Tachypnea rapid rate of breathing
Wheezes high-pitched, musical noise that sounds like a squeak

IV. Step by Step Assessment

Safety considerations:
  • Perform hand hygiene.
  • Check room for¬†contact precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient‚Äôs privacy and dignity.
  • Apply principles of¬†asepsis and safety.
  • Check¬†vital signs.
Steps Additional Information
1. Conduct a focused interview related to history of respiratory disease, smoking, and environmental exposures. Ask relevant questions related to dyspnea, cough/sputum, fever, chills, chest pain with breathing, previous history, treatment, medications, etc.
2. Inspect:

  • For use of accessory muscles and work of breathing
  • Shape and symmetry of the chest, anteroposterior to lateral diameter
  • Respirations for rate (1¬†minute), depth, rhythm pattern
  • Skin color of lips, face, hands (clubbing fingers), feet
  • O2 saturation with a pulse oximeter
Patients in respiratory distress may have an anxious expression, pursed lips, and/or nasal flaring.

The anteroposterior (AP) diameter of the thorax should be approximately 1/2 of the lateral diameter.

Asymmetrical chest expansion may indicate conditions such as pneumothorax, rib fracture, severe pneumonia, or atelectasis.

With hypoxemia, cyanosis of the extremities or around the mouth may be noted.

3. Auscultate (anterior, posterior and lateral) lungs for breath sounds and adventitious sounds.

Fine crackles (rales) may indicate asthma and chronic obstructive pulmonary disease (COPD).

Coarse crackles may indicate pulmonary edema.

Wheezing may indicate asthma, bronchitis, or emphysema.

Low-pitched wheezing (rhonchi) may indicate pneumonia.

Pleural friction rub (creaking) may indicate pleurisy.

4. Report and document assessment findings and related health problems according to agency policy. Accurate and timely documentation and reporting promote patient safety.

 

V. Documentation of Assessment Findings

A sample narrative documentation:

A & O x 4, denies shortness of breath or chest pain, RR18, without use of accessory muscles, symmetrical chest wall movement, clear breath sounds in all lung fields, O2 98% in room air.

 

VI. Related Laboratory Values and Diagnostic Findings

A spirometry test (pulmonary function test), have the patient inhale and exhale through a device to check the  lung capacity. It can be used to diagnose asthma and chronic obstructive pulmonary disease. A chest X-ray is used to view the structure inside of the chest and is a useful test to diagnose pneumonia. A computerized tomography (CT) scan may also be used to identify respiratory problems that an X-ray cannot detect.  Bronchoscopy is an invasive procedure that a fiberscope is inserted into the patient’s airway to examine bronchi. It can be used to retrieve tissues in the airway (biopsy) to diagnose lung cancer or to treat airway blockage or obstruction due to foreign objects.

VII. Learning Exercises

A patient came to emergency department (ED) complained of wheezing and difficulty in breathing.  The patient has been sick for the past 5 days with symptoms of cough with white and thick sputum. The patient denies history of asthma but has seasonal allergy.  As an ED nurse, what is your next action of care for this patient?

VIII. Attributions and References

Desai, R. & Khan, S. https://www.khanacademy.org/science/high-school-biology/hs-human-body-systems/hs-the-circulatory-and-respiratory-systems/v/meet-the-lungs

Step by Step Checklist adapted from https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/ by authors Glynda Rees Doyle and Jodie Anita McCutcheon

Wikipedia contributors. (2019, July 30). Respiratory sounds. In Wikipedia, The Free Encyclopedia. Retrieved 23:46, August 29, 2019, from https://en.wikipedia.org/w/index.php?title=Respiratory_sounds&oldid=908541418

Barrel Chest picture adapted from https://commons.wikimedia.org/wiki/File:%CE%92%CF%85%CF%84%CE%B9%CE%BF%CE%B5%CE%B9%CE%B4%CE%AE%CF%82_%CE%B8%CF%8E%CF%81%CE%B1%CE%BA%CE%B1%CF%82_(barrel_chest).png

Reyes FM, Le JK. Lung Exam. [Updated 2019 Jun 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459253/

 

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Guide to Health Assessment for Nurses Copyright © by Raki Bertiz and Ching-Chuen Feng is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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