Nursing Respiratory [Lung Sound] Assessment of Breathing

Respiratory assessment is a crucial part of nursing care, and knowledge about it can make a huge difference in patient outcomes. A comprehensive respiratory evaluation includes physical, psychological, and physiological assessment components which provide insight into the health status of the patient’s lungs. 

Knowing how to properly assess the respiratory system is critical for nurses who are responsible for monitoring their patients’ respiration, detecting illnesses or changes in condition early on so that appropriate interventions can be implemented quickly before they get worse. 

In this blog post, we will cover some fundamental concepts related to assessing a person’s respiratory status, including common measurements taken during an evaluation, information on interpreting test results, and tips on best practices when conducting assessments.

Nursing Respiratory Assessment: Introduction & Main Components

In order to assess the respiratory system, it is important to understand the anatomy and physiology of respiration. The lung tissue consists of a network of airways (bronchi), alveoli (tiny sacs which allow for gas exchange) and blood vessels. Air travels through the nose or mouth into the larynx, where it is directed into either one lung or both lungs via bronchi.

At this point, the alveoli absorb oxygen, and carbon dioxide is exhaled back out again when breathing takes place. During inhalation, air passes through deeper passages in the lungs called bronchioles allowing more oxygen to enter while also trapping pollutants like dust particles and other irritants so that they can be expelled during exhalation.

The ability to carry out and document a full respiratory or lung assessment is essential for all nurses.

Resp Assessment Nursing Elements 

• An initial assessment
• history taking
• inspection
• palpation
• percussion
• auscultation
• and further investigations.

A prompt initial assessment allows immediate evaluation of the severity of illness, and appropriate treatment measures may warrant instigation at this point.

An Initial Assessment

The initial assessment includes a range of observations and questions about the patient’s respiratory status. This includes an evaluation of their breathing pattern, oxygen saturation levels, use of accessory muscles during respiration, chest wall integrity and airway patency. The nurse will also assess for signs and symptoms of respiratory illness, including cough, sputum production, shortness of breath, or wheezing.

Assess and Note respiratory rate and depth at least every 4 hours.

An adult typically breathes 10-20 times per minute. Taking notice of any changes in your breathing pattern is important as it can be an indication of possible damage to the respiratory system. It’s best to take action at the earliest sign of such a change.

Assess ABG levels according to facility policy.

This monitors oxygenation and ventilation status. See our Tic-Tac-Toe guide on analyzing ABG

Observe Breathing Patterns

Unusual patterns in breathing can be indicative of an underlying medical issue or disorder. Cheyne-Stokes respiration is a sign of damage to areas of the brain, such as the deep cerebral regions or diencephalon, and is usually caused by traumatic brain injury or metabolic disruption. Apneusis and ataxic breathing are both symptoms of failure in the respiratory centers of the pons and medulla.

Rates and depths of breathing patterns include:

• Apnea: A temporary cessation of breathing, especially during sleep.
• Apneusis: A deep gasp with a pause at full inspiration, followed by a brief and insufficient release.
• Ataxic patterns: An irregularity of respiration where pauses become progressively longer and more frequent.
• Biot’s respiration: Quick, shallow breaths separated by intervals of apnea (10-60 seconds).
• Bradypnea: Respirations dropping below 12 breaths per minute depending on the patient’s age.
• Cheyne-Stokes respiration: A pattern of gradually deeper and faster breathing, followed by a decrease that results in apnea; cycles usually last 30 seconds to 2 minutes.
• Eupnea: Normal, good and unlabored ventilation (also known as “quiet breathing” or “resting respiratory rate”).
• Hyperventilation: An increase in rate and depth of breathing.
• Kussmaul’s respirations: A pattern of deep respiration at a fast, normal, or slow rate associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) and kidney failure.
• Tachypnea: Rapid, shallow breathing with more than 24 breaths per minute.

Gather Information on Chief Complaints or Symptoms.

Gathering health information about the patient’s chief complaints and symptoms will help narrow the diagnosis of the respiratory condition. Below are some areas of assessment that focus on symptoms.

• Respiratory Rate: This is how many breaths the patient takes per minute and can indicate if there is an increase or decrease in the rate.
• Oxygen Saturation: This measures the amount of oxygen circulating in a person’s blood and can indicate if there is hypoxemia.
• Cough: A cough may be either dry and non-productive or productive with sputum.
• Chest Congestion: Chest congestion may be present with a thick mucus production, and this can indicate an infection such as pneumonia or bronchitis.
• Wheezing: Wheezing is a high-pitched sound that indicates airway constriction and can be caused by asthma or COPD.
• Hemoptysis: Hemoptysis is the coughing up of blood and can indicate a more severe respiratory condition.
• Shortness of Breath: This can be an indication of airway obstruction or increased work of breathing due to a decrease in lung function.
• Fever: A fever may be present with a bacterial infection such as pneumonia, bronchitis, or tuberculosis.
• Pain: Pain in the chest can be an indication of a pleural effusion or inflammation in the lungs.

History Taking

Once the initial assessment is complete, the nurse should ask additional questions to gain further information about the patient’s condition. These include asking about smoking history, any allergy or asthma triggers they may have been exposed to recently, as well as any other medical conditions they may have that could be affecting their breathing.

Ask the following questions to gather more information about the past medical history

1.  Have you had any type of thoracic surgery?
2. Any surgeries to any part of your chest?
3. Do you have any known allergies?
4. Do you take any medications that could affect your breathing?
5. Are you currently smoking, or have you ever smoked in the past?
6. Do you have any family medical history of asthma or other respiratory problems?
7. Do you experience any shortness of breath or difficulty breathing during activity?
8. Do you experience difficulty breathing when lying flat or reclined?
9. Are there any respiratory problems that are recurring?
10. How have you managed the recurring respiratory problem?
11. Have you ever had a respiratory infection?
12. When were you last diagnosed with a respiratory infection?
13. Has the infection recurred?
14. What treatment did you receive for the respiratory infection?
15. Was the treatment helpful?

Inspection

During the inspection, the nurse looks for any changes in the respiratory pattern or respiration rate, which could indicate a possible illness. Additionally, they also assess for chest wall expansion and symmetry, noting any areas of asymmetry which could point to an underlying problem. Other observations during the inspection include looking for signs of infection, such as discoloration of skin or mucous membranes, as well as any secretions that might be present.

Know the Landmarks of the Thorax Anteriorly and Posteriorly

The nurse should be aware of the landmarks of the thorax anteriorly and posteriorly. This includes being able to identify the sternum, ribs, spine, clavicles, and scapulae. Being able to locate these landmarks and observe any changes or abnormalities is key in determining if there are any issues with a patient’s respiratory system.

Inspection of the Anterior and Posterior Thorax

During the inspection of the thorax, the nurse should observe for any asymmetries or abnormalities. Asymmetries may indicate a structural change in the chest wall, such as an abnormality in rib development or fractures. Additionally, as previously discussed, signs of infection can also be observed during this portion of the physical exam. The nurse should assess both anteriorly and posteriorly for any areas of discoloration, swelling, or secretions.

Palpation

Palpation involves feeling for tenderness or abnormal masses, which may be present in the chest area, particularly around the rib cage. The nurse will also observe the patient’s breathing movements while palpating to get a better understanding of their condition.

Palpation of the Anterior and Posterior Thorax:

Assessing the anterior and posterior thorax through palpation can provide valuable information for healthcare professionals. It involves using touch to feel for abnormalities, tenderness, or changes in tissue texture and can help identify potential sources of pain or discomfort. Furthermore, incorporating neurological checks into the process can also help assess the function of the nerves and muscles in the area. Palpation is an important part of a thorough physical assessment and can help healthcare professionals make informed decisions about patient care.

Percussion

Percussion is another technique used to assess the respiratory system. During percussion, the nurse will use their fingers to tap on the patient’s chest wall and listen for any changes in sound or resonance. Abnormalities such as dullness or flatness indicate a fluid collection which can be indicative of pneumonia or pleural effusion.

Percuss the Anterior and Posterior Thorax

As healthcare professionals, we are constantly utilizing various techniques to assess and diagnose our patients. One such technique, percussing the anterior and posterior thorax, serves as a valuable tool in the evaluation of respiratory conditions. By tapping on specific areas of the chest with varying levels of force, we can determine the presence of normal or abnormal lung sounds. This process involves listening closely for changes in sound and can enable us to identify underlying issues such as fluid accumulation or airway obstruction.

To that end, here are some key percussion notes: flatness, dullness, resonance, hyper resonance, and tympany.

• Flatness: Flatness produces a high-pitched sound with a soft quality that can be heard when there is no air over dense tissue.
• Dullness: A medium-pitched dullness indicates a combination of solid and fluid-filled areas.
• Resonance: Resonance has a low pitch and occurs over normal lungs, whereas lower-pitched hyper resonance sounds indicate hyperinflated lungs.
• Tympany: Tympanic breath sounds, which sound like a drum, can be caused by either gas-filled areas or pneumothorax.

Auscultation (Nursing Lung Sounds Assessment):

The final step in assessing a patient’s respiratory condition is auscultation, where the nurse listens to breath sounds using a stethoscope. Auscultation involves analyzing for abnormal breath sounds such as crackles, wheezes, and rhonchi, which could be indicative of underlying issues like pneumonia or COPD.

 Auscultate breath chimes at least every 4 hours.

This is to detect decreased or adventitious breath sounds. Abnormal breath sounds may include:

• Bronchospasm: Labored breathing with rhonchi and wheezing, best managed with a bronchodilator.
• Expiratory grunt: Associated with nasal flaring, intercostal retractions, and increased work of breathing.
• Rales: Clicking, rattling, or crackling sounds are heard during inhalation and exhalation.
• Rhonchi: Coarse, wet crackle, which may require suctioning.Stridor: High-pitched, musical noise caused by a blockage in the larynx.Wheeze: 
• Wheeze: Whistling sound when air passes through narrowed breathing tubes in the lungs, most notably seen with asthma and congestive heart failure (CHF).

Further Investigations

After assessing the patient through inspection, palpation, and auscultation, further investigations may be required to confirm any suspected diagnosis. This could involve diagnostic tests such as chest X-rays or CT scans, which will give a more detailed image of the chest area and allow healthcare professionals to make an accurate diagnosis. Other forms of testing may include blood tests, pulmonary function tests (PFTs), and spirometry which measure the volume of air a person can inhale and exhale.

What Type Questions to ask the Patient Upon Assessment?

When assessing a patient with respiratory ailments, it is important to ask the right questions in order to get a better understanding of their condition. Some key questions to ask are:

• Do you smoke? How much do you smoke?
• Do you have any respiratory problems such as asthma or COPD?
• Are there any medications that you are currently taking for your respiratory condition?
• Have you had any recent changes in your breathing pattern?
• Have you had any episodes of shortness of breath, chest pain, or difficulty breathing recently?
• Do you experience fatigue when performing physical activity?
• Do you have any chronic illnesses such as diabetes or heart disease?
• Do you feel that your chest is tight or heavy when taking a deep breath?
• Are there any particular activities that make your symptoms worse?
• Do you experience coughing, wheezing, or other abnormal sounds when breathing?

These questions provide an opportunity to gain insight into the patient’s medical history and current state of health, which can help healthcare professionals decide on the best course of action for treatment.

Final Words

The respiratory assessment is a systematic approach to evaluating a patient’s breathing pattern and lung function. It involves gathering subjective information through direct questioning, as well as objective data through inspection, palpation, and auscultation. Further investigations, such as pulmonary function tests, X-rays, and CT scans, may be required to make an accurate diagnosis. By understanding the components of a respiratory assessment, healthcare professionals can gain insights into their patient’s condition and provide appropriate care. This ensures that patients receive the best possible treatment for their specific condition.

References:

• https://www.ncbi.nlm.nih.gov/books/NBK459253/#:~:text=The%20physical%20examination%20of%20the,from%20a%20complete%20lung%20examination.
• https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/286911/13_CIN_Respiratory_Assessment_notes.pdf
• https://pubmed.ncbi.nlm.nih.gov/16723920/#:~:text=The%20elements%20included%20are%3A%20an,warrant%20instigation%20at%20this%20point.