Breathing is essential for life, a process we often take for granted until there’s an issue. As nurses and healthcare professionals, we must know respiratory assessment fundamentals to assess our patients and provide the best possible care expertly.
In this blog post, we will discuss key points of respiratory assessment nursing history taking, physical exam techniques, normal findings, and abnormal findings – all designed to help you acquire the knowledge to perform respiratory assessments on your future patients properly. Read on to start learning about assessing this vital bodily function.
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Nursing Respiratory Assessment: Complete Guidance
The respiratory assessment is a crucial component of the overall health assessment of any patient. To properly assess a patient’s respiratory system, it’s essential to understand the history-taking and physical exam techniques associated with this type of assessment.
Respiration Assessment History Taking
Nurses must take an in-depth history of a patient’s respiratory system. This includes questions such as:
• What symptoms does the patient have?
• Do they have asthma, COPD, or other chronic respiratory conditions?
• How often do they experience shortness of breath?
• Has the patient ever had pneumothorax, pleurisy, or pulmonary embolism?
In Infants and Newborns
• Is the infant’s breathing regular or episodic?
• Does the infant have difficulty sucking or swallowing?
• Is there any evidence of respiratory distress, such as grunting, nasal flaring, or retractions?
• Is there any history of premature birth, low birth weight, or congenital anomalies?
Physical Exam Techniques for Respiratory Assessment
Once the nurse has taken a comprehensive history of the patient’s respiratory system, they can perform a physical exam to gain further information. This includes:
• Observing and palpating the chest wall to assess symmetry, depth, and pattern of respirations.
• Auscultate breath sounds to assess abnormal sounds such as crackles, wheezes, and stridor.
• Palpate for lymphadenopathy in the cervical and axillary regions to assess for any enlargements.
• Percuss the chest wall to detect dullness or areas of hyper resonance.
• Use a peak flow meter or spirometer to measure lung function if necessary.
Physical Exam Techniques
Once the history taking is complete, physical exam techniques can be utilized to assess a patient’s respiratory system. These include:
• Listening for breath sounds with your stethoscope.
• Inspect the chest wall for symmetry, deformity, or signs of distress.
• Palpating the chest wall to assess for tenderness.
• Performing percussion on the chest to assess for hyper resonance.
When performing a resp assessment nursing, several normal findings may be observed. These include:
• Normal breath sounds (i.e., vesicular and bronchial).
• No pain or tenderness on palpation of the chest wall.
• Symmetrical chest wall movement upon inspiration and expiration.
• Good oxygen saturation levels as measured by pulse oximetry readings.
Respiratory assessments can also reveal abnormal findings, such as:
• Wheezing or crackles in the lungs.
• Tachycardia or bradycardia indicative of respiratory distress.
• Dyspnea (shortness of breath).
• Decreased oxygen saturation levels.
• Abnormal chest wall movement indicating respiratory distress.
What are the 4 Main Steps of the Respiratory Assessment?
The main four steps of the respiratory exam are
- Auscultation of respiratory sounds
Typically first carried out from the back of the chest.
The patient should be upright with their arms at the sides and chest area free of clothing for the four stages of examination. To get a better view of the lungs from behind, ask them to move their arms forward so that the shoulder blades don’t block out any part of the upper lung fields. These fields are designed to match up with the lung lobes and are inspected on the anterior and posterior parts of the chest.
The examiner then estimates the patient’s respiratory rate by observing their inhalations and exhalations over one minute. This assessment is often conducted while they are preoccupied with another exam to ensure that the patient does not change their breathing patterns due to conscious awareness of being watched. On average, adults will take 14-20 breaths per minute, while infants can reach a rate of up to 44 breaths per minute.
After getting the patient’s respiratory rate, the examiner notices any signs of respiratory distress, which may include:
- Cyanosis, a purplish discoloration of the skin and mucous membranes, often appears on the limbs (peripheral cyanosis) or tongue (central cyanosis).
- Pursed-lip breathing can also occur with accessory muscles such as scalene and intercostal muscles.
- Another sign is diaphragmatic breathing, in which the diaphragm moves outward during inhalation.
- Additionally, intercostal indrawing and decreased chest–chest movement on the affected side may be observed.
- An increased jugular venous pressure could point to possible right heart failure.
For any abnormalities, the anterior and posterior chest walls are also checked, which may include the following:
- Kyphosis is a condition causing an abnormal anterior-posterior curvature of the spine.
- Scoliosis refers to an abnormal lateral curvature of the vertebral column.
- A Barrel chest is characterized by bulging out of the chest wall, which is standard in children and typical for hyperinflation in chronic obstructive pulmonary disease (COPD).
- Pectus excavatum describes the sinking-in of the sternum into the chest.
- Pectus carinatum is characterized by a protrusion of the sternum from the chest.
In addition to gauging the patient’s respiratory rate, the examiner will observe the patient’s breathing pattern:
- A patient with metabolic acidosis typically shows a rapid breathing pattern called Kussmaul. This helps to reduce the drop in blood pH by expelling more carbon dioxide, which prevents further acid accumulation.
- Cheyne-Stokes respiration is an alternating pattern of fast and slow breaths that may be due to a brain stem injury or could be normal in newborns.
- Asthmatic patients may experience chest retractions, where the skin blends into the chest. This sign of respiratory distress can be seen as supra-sternal retractions, where the neck muscles contract to help with breathing, or intercostal retractions, where the skin between ribs sinks in as the intercostal muscles support respiration.
The physician then typically inspects the fingers for cyanosis and clubbing. The tracheal deviation is also examined.
Palpation is an examination technique that involves physical touch. The physician checks for tender areas, skin abnormalities, respiratory expansion, and fremitus during palpation.
- To assess areas of tenderness, feel for any pain, bruises, or lesions on both sides of the chest. Bruises could indicate a fractured rib; tenderness between the ribs may mean inflamed pleura.
- Palpate any masses or odd structures on either side of the chest — these might be associated with infections.
- To observe chest wall expansion on the back of the body, place hands with fingers parallel to ribs and thumbs at the 10th rib.
- Ask the patient to inhale and watch thumbs move from opposite directions.
- Repeat the process at the front of the chest to further observe expansion. Asymmetry in chest expansion may be caused by lung or pleura diseases.
- When testing for fremitus, hold the bony parts of palms around the patient’s scapulae while they say “ninety-nine” or “one one one.” Repeat on the front side and look for decreased fremitus, pointing to a soft voice, obstructed bronchus, COPD, pneumothorax, or other obstructive illnesses/injuries.
Palpation is a vital examination technique that helps diagnose pain-related abnormalities, skin irregularities, and respiratory function.
Percussion is a technique used to assess structures underneath the skin’s surface. It involves tapping the body with two fingers, one placed over the examined area, and another used to strike its last joint.
This activity is done systematically from the top of the chest to its lower ribs, taking note of any difference in resonance between the left and right sides of the chest when done from both front and back.
Generally, five different types of ‘notes’ can be heard depending on the tissue being tapped. This method often evaluates lung movement or other possible lung conditions.
Percussion over different body tissues results in five common “notes.”
- Resonance: Loud but low in pitch. A typical lung sound.
- Dullness: Medium-intensity and -pitch; commonly heard when fluid is present.
- Hyper-resonance: Excessively loud, low-pitched, and occupies a longer duration than usual. Abnormal resonance may result from asthma or emphysema.
- Tympany: High pitched and quite loud. It’s the classic percussion sound over gas-filled cavities such as pneumothoraxes.
- Flatness: Soft but high in pitch compared to other sounds. This type of sound can be indicative of certain medical conditions.
Auscultation (Nursing lung sounds assessment)
The lungs assessment can be auscultated using a stethoscope to listen for abnormal sounds within the lung fields. These consist of the posterior, lateral, and anterior regions at the back, under the axillae, and at the front. On the back is an area known as the triangle of auscultation, which contains. Thinner musculature and is often more audible. During auscultation, deep breaths are taken through the mouth to detect any irregularities in sound.
Abnormal sounds that may be heard include:
- Wheezes (a continuous musical sound during expiration or inspiration caused by narrowed airways)
- Rhonchi (low-pitched, musical bubbly noises heard on both inspiration and expiration due to fluid in the airways)
- Crackles or rales (intermittent non-musical sounds heard only during inspiration, caused by alveoli opening due to increased air pressure)
- Stridor (a high-pitched musical breath sound resulting from the turbulent airflow in the larynx)
- An appropriate ratio of inspiration to expiration time (which is usually longer in COPD).
- Bronchial or vesicular breath sounds may also be heard.
What Questions to Ask the Patient
While their unique symptoms or disease pathology will guide the questions you ask your patient, some key questions to ask are:
- Do you smoke? If so, please indicate the number of packs daily and how long you’ve smoked. This information will be used to calculate your “pack-year history.”
- If you have a cough, let us know how long it has lasted and whether it is more prevalent in the morning or throughout the day and night. Morning coughing is often associated with smokers (“smoker’s cough”) but can also occur in those with COPD, bronchitis, postnasal drip, or seasonal allergies. A cough that persists for more than eight weeks could be due to a range of conditions such as medication use (i.e., ACE inhibitors), GERD, asthma, tuberculosis, cancer, or COPD. An acute cough that appears suddenly could be caused by allergies or infection, although coughing associated with a disease (e.g., pneumonia or bronchitis) can persist for several weeks.
- To measure your shortness of breath, we will ask if you have “any difficulty breathing.” Although this symptom can sometimes be seen in physical observations, patients often feel it before it becomes outwardly evident. This phenomenon can be quantified and measured using a numerical rating scale similar to the one used for pain assessment.
- If you experience paroxysmal nocturnal dyspnea (PND), we will inquire if you ever wake up feeling out of breath without warning, which resolves when you sit up.
- To assess for orthopnea, we will ask how many pillows you use when sleeping at night.
The physical exam of the chest is a comprehensive set of skills for assessing the lungs and thoracic structures. Palpation can be used to detect tenderness, characteristics of the skin, as well as abnormalities along the rib cage. Percussion can help distinguish between different lung sounds and their underlying causes. Finally, auscultation is an essential tool for determining if there are any abnormal breath or airway sounds that may be indicative of disease.
These observations should be combined with patient history taking to provide a complete assessment and accurate diagnoses. Utilizing these exams together will ensure that healthcare professionals accurately understand the patient’s condition when treating respiratory ailments.
Mrs. Marie Brown has been a registered nurse for over 25 years. She began her nursing career at a Level I Trauma Center in downtown Chicago, Illinois. There she worked in the Emergency Department and on the Surgical Intensive Care Unit. After several years, she moved to the Midwest and continued her nursing career in a critical care setting. For the last 10 years of her nursing career, Mrs. Brown worked as a flight nurse with an air ambulance service. During this time, she cared for patients throughout the United States.