Physical Assessment of the
Respiratory System
Day 2A
History
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Physical problems
Function problems
Life style
Smoking
Family Hx
Occupation hx
Allergens / environment
Recreational exposure
Anxiety
S&S
• The nurse is teaching a group of prenatal clients
about the effects of cigarette smoke on fetal
development. Which characteristic is associated with
babies born to mothers who smoked during
pregnancy?
A. Low birth weight
B. Large for gestational age
C. Preterm birth, but appropriate size for gestation
D. Growth retardation in weight and length
Inspection
• Normal chest
– Slight retraction of
intercostal spaces
– 2x as wide as deep
– Anterior/posterior
diameter
• 1:2
Inspection
• Barrel chest
– D/t over inflation of
lungs
– anterior-posterior
diameter
• 2:2
Inspection
• Funnel chest
– Depression of the
lower portion of the
sternum
– Complications
• Heart damage
• i Cardiac output
– Nrs management
• Murmurs
Inspection
• Pigeon chest
– Sternum protrudes
outward
– anterior-posterior
diameter
• h
Inspection
• Scoliosis
– Lateral curvature of
thoracic spine
– Assessment
• Shoulders elevated?
– Complications
• Lung & heart damage
• Back problems
• Body image
Quiz?
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A.
B.
C.
D.
How many hours a day should a child wear a
brace for treating scoliosis?
8 hr
12 hr
23 hr
24 hr
Inspection
• Kyphosis
– AKA
• Hunchback
– Abnormal curvature of
the thoracic spine
Inspection
• Lordosis
– AKA
• Sway-back
– Abnormal curvature of
the lumbar spine
Inspection
• Uniform expansion of
the chest
– Pneumonia
– Pleural effusion
– Pneumothorax
• Bulging intercostal
spaces
– Obstruction
– Emphysema
Inspection
• Marked retraction of
intercostal spaces
– Blockage
• Shoulder rise
• Accessory muscles
• Posture
Inspection: Breathing patterns
Rate
• Eupnea
– Normal
– 12-20 / min
• Tachypnea
– h rate
– Pnuemonia, pulm edema, acidosis, septicemia, pain
• Bradypnea
– i rate
– h ICP, drug OD
Inspection: Breathing patterns
Depth
• Hyperpnea
– h depth
• Hyperventilation
– h depth & rate
• Hypoventilation
– i depth & rate
Inspection: Breathing patterns
Depth
• Kussmaul's
– h rate & depth
– Assoc. with sever acidosis
• Apneustic
– Prolonged gasping I following by short
Inspection: Breathing patterns
Rhythm
• Apnea
– Not breathing
• Cheyne-stokes
– Varying depth f/b apnea
– Death rattles
– Death rales
Inspection: Breathing patterns
Rhythm
• Biot’s
– h rate & depth w/ abrupt pauses
– Assoc w/ h ICP
Inspection:
• Trachea
– ? Deviation
• Pleural effusion
• Tension pneumothorax
• Atelectasis
• Color
• LOC
• Emotional state
Palpation
• TML
– Tenderness (T)
– Masses (M)
– Lesions (L)
• Sinuses
– Palpate below eyebrow &
Cheekbone
• Crepitus
– Subcutaneous emphysema
– Air leaks into the sub-q tissue
Percussion
Rational
• To determine if underlying
tissue is filled with air or
solid material
Procedure
• Pt sitting
• Tap starting at shoulder
• compare rt to lf
Percussion: results
• Resonance – drum like
– Normal
• Hyper-resonance
– Too much air
– Emphysema
• Flatness / dull
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Fluid or solid
Pleural effusion
Pneumonia
Tumor
Auscultation
Purpose
• Asses air flow through
bronchial tree
Procedure
• Diaphragm of
stethoscope
• Superior  inferior
• Compare rt to lf
Auscultation: Results
Normal
• Vesicular
– Lung field
– Soft and low
• Bronchial
– Trachea & bronchi
– Hollow
• Bronchovesicular
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Mixed
Between scapulae
Side of sternum
1st & 2nd intercostal space
Auscultation: Results
Adventitious
• Crackles
– Rales
– air  bronchi with
secretions
• Fine crackles
– Air  suddenly
reinflated
• Course Crackles
– Moist
Auscultation: Results
• Wheezes
– Sonorous wheezes
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Deep low pitched
Snoring
>E
Caused by air 
narrowed passages
• D/t h secretions
– Sibilant Wheezes
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High pitched
Whistle-like
I&E
Caused by air 
narrowed passages
• D/t constriction
– Asthma
Auscultation: Results
• Pleural friction rub
– D/t inflammation of
pleural membranes
– Grating, creaking
– I&E
– Best heard
• Anterior, Lower, lateral
area
Auscultation: Results
• Stridor
– Crowing
– Partial obstruction of
the larynx or trachea
Quiz?
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A.
B.
C.
D.
A child with difficulty breathing and a
“barking” cough id displaying signs
associated with which condition?
Asthma
Croup
Cystic fibrosis
Epiglottitis
Quiz?
•
A.
B.
C.
D.
E.
When assessing the lung sounds of a child
with asthma, which sound are you most
likely to hear?
Murmurs
Sonorous Wheezing
Sibilant Wheezing
Crackles
Pleural friction rub
Early & late signs of hypoxia
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Anxiety
Bradycardia
Cyanosis
Depressed respirations
Diaphoresis
Disorientation
Dyspnea
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Restlessness
Headache
Agitation
Poor judgment
Retraction
Tachycardia
Tachypnea
The nurse recognizes which of the following
as an early sign of hypoxia?
A.
B.
C.
D.
Restlessness, yawning & tachycardia
Dyspnea, confusion & bradycardia
Bradycardia, hypotension dyspnea
Dyspnea, restlessness, hypotension
Dyspnea
• Definition
– SOB
– SOB, flat affect, BS x 4
Dyspnea
• Significance
– Common with cardiac & resp. disease
– Sudden onset – healthy person 
• Pneumothorax
– Sudden onset ill, post-op or injury 
• Pulmonary emboli
Dyspnea
• Orthopnea
– Sit up to breath
• COPD
• CHF
Dyspnea
• Right ventricle
– If chronic airway resistance 
– h pressure 
– Rt ventricle h work 
– Rt. Vent damage
Dyspnea
• Nrs Management
– Find cause
– Give O2
– HOB h
– Communication
• KISS
Cough
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Definition
– To expel air from the lungs suddenly
– Irritation of mucous membrane
Cough
• Significance
– Infection
– Irritants
– Protective mechanism
– Dry, irritating
• URT
– Cough + chest pain
• Pleural or musculoskeletal
Cough
• Nrs management
– Assess
– Describe
– Directed
– Pain control
• Splinting
– Infection control
– Suppressants / Anti-tussives
Sputum Production
Definition
• Matter discharged
from resp. track that
contains mucus and
pus, blood, fibrin, or
bacteria
Sputum Production
Significance
• Purulent
– Thick, yellow/green
– Bacteria
• Rusty
– Strep or staph
• Thin, mucous
– Viral
Sputum Production
• Pink-tinged
– Lung CA
– TB
• Pink tinged, profuse,
frothy
– Pulmonary edema
• Malodorous
– Lung abscess
Sputum Production
Nrs Management
• Thick
– Hydrate
• h water
• Nebulizer
• Humidifier
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TCDB
No smoking
Oral care
h Appetite
Do You Know?????
What breath sound would you expect to hear on
a patient with increased sputum
production?
A. Vesicular
B. Crackles
C. Sonorous wheezes
D. Sibilant wheezes
Obtaining a sputum specimen
• Explain
– From lungs
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Sterile cup
Deep breath x 3 
Cough deeply
Expectorate
Best time for
specimen collection?
– AM
A nurse is to collect a sputum specimen for acid-fast
bacillus (AFB) from a client. Which
action should the nurse take first?
A. Ask client to cough sputum into container
B. Have the client take several deep breaths
C. Provide a appropriate specimen container
D. Assist with oral hygiene
Chest pain
Definition
• Cardiac or pulmonary
Chest pain
Significance
• CA (late stage)
• Pneumonia
• Pulmonary embolism
• Pleurisy
Chest pain
• Pleurisy
– Inflammation of pleura
– Sharp with breath
– i breath sounds
What?????
What breath sound would you expect to hear on
a patient suffering from pleurisy?
A. Crackles
B. Sonorous wheezes
C. Sibilant wheezes
D. Pleural Friction Rub
Chest pain
Nrs Management
• Assess
• Analgesics OK, but…
• Position for pain
– Affected side
– Splint
Clubbed fingers
Definition
• Sponginess of the nail
bed
• Loss of the nail bed
angle
• Finger tip is round and
bulbous
Clubbed Finger
Significance
• chronic hypoxia
Nrs Management
• Marker
Mr. Caveman:
Mr. Caveman enters the ER unconscious following an
Automobile accident. The paramedics report that his
O2 sats are 86%. You note that Mr. Caveman has
clubbed fingers. What does this tell you?
Hemoptysis
Definition
• Expectoration of
blood from the
respiratory tract
Hemoptysis
Significance
• Pulm or cardiac
• Common causes
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Pulm infection
CA of lungs
Pulm. Emboli
Pulm. Infarction
TB
Hemoptysis
• Hemoptysis
– Definition?
• Coughed up blood
– From?
• Pulm hemorrhage
– Description
• Pink, red, mixed with
sputum
– Blood pH
• Alkaline blood
• Hematemesis
– Definition?
• Vomited blood
– From?
• Stomach / GI
– Description
• “Coffee ground”
– Blood ph
• Acidic blood
Hemoptysis
Nrs Management
• Determine source
• Serious
Cyanosis
Definition
• Bluish coloring of skin
Cyanosis
Significance
• Very late indicator of
hypoxia
• Appears when O2 sats
< 85%
• NOT a reliable sign of
hypoxia
– Esp. with anemia
Cyanosis
• O2 sat definition
– % of hemoglobin
carrying oxygen
compared to total # of
hemoglobin
Cyanosis
• Normal
Breath 100 O2 molecules  98 cross into blood
Blood: 100 Hgb
• O2 SATS
– 98%
– No cyanosis
Cyanosis
• Hypoxia
Breath 100 O2 molecules  75 cross into blood
Blood: 100 Hgb
• O2 SATS
– 75%
– Cyanosis
Cyanosis
• Anemic and hypoxic
Breath 100 O2 molecules  75 cross into blood
Blood: 75 Hgb
• O2 SATS
– 100%
– No Cyanosis
Cyanosis
Nrs. Management
• Know color of Pt. skin
• Assess color of tongue &
lips
• Fingernail polish
• African-American
• Vasoconstriction (cold
weather)  peripheral
cyanosis