Respiratory assessment 1
MENNONITE COLLEGE OF NURSING
AT ILLINOIS STATE UNIVERSITY
Diagnostic Reasoning for Advanced Nursing Practice 431
Respiratory Assessment
Respiratory System - History
 First, assess for signs of acute respiratory distress:
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restlessness!
anxiety
inability to follow conversation
noisy or labored respirations
 If so, treat or obtain help.
 When breathing comfortably, proceed with full health history.
History
 Chief complaint
 SH (recent travel, work, home)
 HPI
 PMH
 FH
 ROS
Respiratory System - History
 Shortness of breath? (pattern, how relieved) ~ see Dains Chapter 13 Dyspnea
 Wheezing?
 Position, time, activity affecting breathing?
 How many stairs, block(s) before feels SOB?
 Cough? (OLDCART) ~ see Dains Chapter 10 Cough
 Sputum? (OLDCART)
 Chest pain? (OLDCART)
 Hx. of resp. illness/surgery/diagnostic studies?
 How many pillows to sleep on?
 Seasonal allergies? (cause, sx., tx.)
 Smoke tobacco? (how long, how much) How many pack years is 1 pack every 3 days for 10 years?
 Use OTC nasal sprays or inhalers?
 Use nebulizer or other breathing tx.?
 Use oxygen at home?
 Vaccinated against flu/pneumonia?
 Family hx: emphysema, asthma, allergies, TB?
 In last 1-2 months: fever, chills, fatigue, or night sweats?
Respiratory assessment 2
 Anemia? Polycythemia?
 Sinus problems?
History: Children Particulars
 Respiratory problems at birth? (treatment?)
 Frequent congestion, runny nose, colds?
 Does SOB interfere with taking bottle?
 Does cough/SOB interfere with child’s play or school activities?
 Cough at night? Does child awaken?
History: Elderly Elements
 Aware of any changes in breathing patterns?
 Easily fatigued when climbing stairs?
 Trouble breathing when lying flat?
 Seem to have more colds that last longer?
Health Promotion Questions
 Last CXR? Last TB test?
 Tobacco cessation?
 Immunizations?
 Home remedies used for resp. problems?
 Need assistance for activities? $ for meds?
 Any hobbies with respiratory irritants?
 3 large meals or several small meals?
 Does work/home stress affect breathing?
 Home: others-NH, pets, heating, dust, mold, where sleeping?
Examination of the Chest
 See CD with Bickley for demonstration of several techniques.
General Approach: Position
 Sitting upright
 Recumbent if too ill
 Good lighting
 Undressed to waist!
Proceed in orderly fashion
 Inspection, palpation, percussion, auscultation → in this order!
 Compare one side with other
 Work from above-down
Respiratory assessment 3
 Begin with posterior chest
 Try to visualize underlying tissue
Observation (Inspection)
 Posture – tripod position?
 THORACIC CAGE
 Shape
 deformities of thorax
 shape of ribs
What does AP:Lat. of 1:1 describe?
What’s the proper term for “pigeon chested”?
 Retraction of interspaces on inspiration
 Bulging interspaces
 Finger nails and skin
 RESPIRATORY MOVEMENT
 Rate/rhythm
 Depth
 Use of accessory muscles
 Symmetry and expansion
Palpation
 Areas of tenderness
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Check costochondral junctions
 Abnormalities such as masses
 Respiratory excursion (range, symmetry)
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What is tenderness at this location called?
thumbs at level of 10th ribs
grasp rib cage laterally; deep inhalation
 Check supra/infraclavicular nodes
 Crepitation: subcutaneous emphysema
Palpation: Tactile fremitus
 Definition: palpable vibrations transmitted to chest wall when patient speaks
 Use ball of hand (side of hand in child)
 “99” or “1, 2, 3”
 Can do both sides at once
 Increased Tactile Fremitus:
consolidation due to pneumonia - especially close to surface
large patent bronchus
 Decreased Tactile Fremitus:
 obstructed bronchus
 fluid in pleural space
 air in pleural space (pneumothorax)
 normal finding (dull over heart)
 COPD, fibrosis, tumor
 thick chest wall
 soft voice
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Respiratory assessment 4
Percussion: Sounds ~ it is an Art!
 Resonance - normal lung
 Hyperresonance - increased air volume
 Tympany - gastric air bubble
 Dullness - consolidation in lung; normal over liver and heart
 Flatness - large fluid mass, pleural effusion, normal over thigh
Percussion: Procedure
 Percuss symmetrical areas at 5 cm intervals (< 5 cm in child) down posterior chest and sides of chest
 Note: Anteriorly: dull at 5th right rib due to liver
Percussion: Diaphragmatic excursion
 Diaphragmatic excursion: note distance between levels on full expiration and full inspiration
 Normal = 5-7 cm. Difference
 Exhalation - 10th rib
 Inhalation - 12th rib
Auscultation
 Listen to lungs as patient breathes through his mouth, more deeply than normal
 Listen to one full breath at each location on posterior, lateral, and anterior chest. All 5 lobes!
Normal Breath Sounds
 Vesicular:
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Most of lungs
Inspiration > Expiration (I > E)
Low pitch, soft intensity
 Bronchovesicular:
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Near main bronchi
I = E, medium pitch and intensity
 Bronchial (tracheal):
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Over trachea
E > I, high pitch, low intensity
Adventitious (Additional) Sounds
 Discontinuous sounds:
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Crackles (rales)
Fine
Coarse
 Continuous sounds:
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Wheezes
Rhonchi
 Clearing of adventitious sounds by cough suggested secretions caused them (as in bronchitis or atelectasis)
Fine Crackles
 Fluid in alveoli
 End of inspiration
 Like rolling a strand of hair between fingers next to ear
Respiratory assessment 5
 Occurs with CHF, pneumonia, atelectasis, bronchitis, pulmonary fibrosis
Coarse Crackles
 Exudate in larger bronchi and smaller bronchioles
 Early to mid inspiration and expiration
 Loud - gurgling, bubbling
Wheezes
 Partial obstruction to airflow in smaller bronchi and bronchiole
 Frequently heard on expiration
 Wheezes may be on both inspiration and expiration due to narrowing of bronchioles by spasm or obstruction
 NO wheezes in asthmatic may mean complete obstruction!!!
Rhonchi
 Partial obstruction to airflow in large rhonchi and trachea - usually from mucous collection
 Prominent on expiration though may be heard in both
 Lower pitch than wheeze - Snoring
 Coughing may clear
Auscultation (resource – The Auscultation Assistant, http://www.wilkes.med.ucla.edu/lungintro.htm)
 If breath sounds are decreased, or you suspect but cannot hear signs of obstructive breathing, ask patient to
breath hard and fast
 If abnormality present, check spoken and whispered voice sounds
What physical findings would you expect
to find with COPD? Asthma?
Voice Sounds
 Normal voice transmission
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not loud or clear
syllables are not distinguishable
 Abnormal voice sounds
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often associated with consolidation
Abnormal Voice Sounds
 Bronchophony - loud only, cannot distinguish words/syllables
 Whispered pectoriloquy - whispered syllable; can distinguish what is whispered; occurs even when process too
small to produce bronchial breathing
 Egophony - letter “E” sounds like “A”
Stridor
 Upper airway obstruction
 Prominent on inspiration
 Crowing sound
What might these abnormal sounds represent?
Respiratory assessment 6
 Narrowing of trachea
 Example: acute glossitis
Pleural Friction Rub
 Pleural irritation without fluid
 Heard on inspiration and expiration but is frequently heard at the end of inspiration
 Grating, leathery quality, noncontinuous
 Auscultatory site: usually anterior lateral wall
 Found in pulmonary embolus, pleurisy, pneumonia
Sample Documentation
 Objective: Height 5’6”, Wt. 124#, T 99.2, HR 104/regular, BP 168/96, RR 36 labored with use of accessory
muscles, pursed lip breathing. Thin, barrel-chested male appearing older than stated age of 56. Complexion
with bluish cast. Chest expansion symmetrical/minimal movement. Crepitus over LLL. Hyperresonance over
all chest walls. Decreased breath sounds over LLL with prolonged expiration.
Other Objective Findings
To add to the “O” of the SOAP format
Diagnostic Testing
 ABGs
 CBC (esp. RBCs, Hgb)
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Compensatory polycythemia in COPD
 CXR
 V/Q scans
 Pulse oximetry
 Peak flow meter
Respiratory Case Study-group discussion in class