Open Resources for Nursing (Open RN)
With an understanding of the basic structures and primary functions of the respiratory system, the nurse collects subjective and objective data to perform a focused respiratory assessment.
Collect data using interview questions, paying particular attention to what the patient is reporting. The interview should include questions regarding any current and past history of respiratory health conditions or illnesses, medications, and reported symptoms. Consider the patient’s age, gender, family history, race, culture, environmental factors, and current health practices when gathering subjective data. The information discovered during the interview process guides the physical exam and subsequent patient education. See Table 10.3a for sample interview questions to use during a focused respiratory assessment.
Table 10.3a Interview Questions for Subjective Assessment of the Respiratory System
Life Span Considerations
Depending on the age and capability of the child, subjective data may also need to be retrieved from a parent and/or legal guardian.
A focused respiratory objective assessment includes interpretation of vital signs; inspection of the patient’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope. For more information regarding interpreting vital signs, see the “General Survey” chapter. The nurse must have an understanding of what is expected for the patient’s age, gender, development, race, culture, environmental factors, and current health condition to determine the meaning of the data that is being collected.
Evaluate Vital Signs
The vital signs may be taken by the nurse or delegated to unlicensed assistive personnel such as a nursing assistant or medical assistant. Evaluate the respiratory rate and pulse oximetry readings to verify the patient is stable before proceeding with the physical exam. The normal range of a respiratory rate for an adult is 12-20 breaths per minute at rest, and the normal range for oxygen saturation of the blood is 94–98% (SpO₂) is less than 12 breaths per minute, and is greater than 20 breaths per minute.
As a general rule of thumb, respiratory rates outside the normal range or oxygen saturation levels less than 95% indicate respiration or ventilation is compromised and requires follow-up. There are disease processes, such as chronic obstructive pulmonary disease (COPD), where patients consistently exhibit below normal oxygen saturations; therefore, trends and deviations from the patient’s baseline normal values should be identified. A change in respiratory rate is an early sign of deterioration in a patient, and failing to recognize such a change can result in poor outcomes. For more information on obtaining and interpreting vital signs, see the “General Survey” chapter.
Inspection during a focused respiratory assessment includes observation of level of consciousness, breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion.
Figure 10.2 Landmarks of the Anterior, Posterior, and Lateral Thorax
Figure 10.3 Comparison of Chest with Normal Anterior/Posterior Diameter (A) to a Barrel Chest(B)
Figure 10.4 Clubbing of the Fingers
Using the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration. Instruct the patient to take deep breaths through their mouth. Listen through the entire respiratory cycle because different sounds may be heard on inspiration and expiration. As you move across the different lung fields, the sounds produced by airflow vary depending on the area you are auscultating because the size of the airways change.
Listen to normal breath sounds on inspiration and expiration.
Correct placement of the stethoscope during auscultation of lung sounds is important to obtain a quality assessment. The stethoscope should not be performed over clothes or hair because these may create inaccurate sounds from friction. The best position to listen to lung sounds is with the patient sitting upright; however, if the patient is acutely ill or unable to sit upright, turn them side to side in a lying position. Avoid listening over bones, such as the scapulae or clavicles or over the female breasts to ensure you are hearing adequate sound transmission. Listen to sounds from side to side rather than down one side and then down the other side. This side-to-side pattern allows you to compare sounds in symmetrical lung fields. See Figures 10.5 and 10.6 for landmarks of stethoscope placement over the anterior and posterior chest wall.
Figure 10.5 Anterior Auscultation Areas
Figure 10.6 Posterior Auscultation Areas
Expected Breath Sounds
It is important upon auscultation to have awareness of expected breath sounds in various anatomical locations.
Adventitious Lung Sounds
Adventitious lung sounds are sounds heard in addition to normal breath sounds. They most often indicate an airway problem or disease, such as accumulation of mucus or fluids in the airways, obstruction, inflammation, or infection. These sounds include rales/crackles, rhonchi/wheezes, stridor, and pleural rub:
Life Span Considerations
There are various respiratory assessment considerations that should be noted with assessment of children.
As the adult person ages, the cartilage and muscle support of the thorax becomes weakened and less flexible, resulting in a decrease in chest expansion. Older adults may also have weakened respiratory muscles, and breathing may become more shallow. The anteroposterior-transverse ratio may be 1:1 if there is significant curvature of the spine (kyphosis).
Percussion is an advanced respiratory assessment technique that is used by advanced practice nurses and other health care providers to gather additional data in the underlying lung tissue. By striking the fingers of one hand over the fingers of the other hand, a sound is produced over the lung fields that helps determine if fluid is present. Dull sounds are heard with high-density areas, such as pneumonia or , whereas clear, low-pitched, hollow sounds are heard in normal lung tissue.
Expected Versus Unexpected Findings
See Table 10.3b for a comparison of expected versus unexpected findings when assessing the respiratory system.
Table 10.3b Expected Versus Unexpected Respiratory Assessment Findings
A feeling of shortness of breath.
Blood-tinged mucus secretions from the lungs.
Decreased respiratory rate or slow breathing less than 10 breaths/minute for an adult or as it pertains to the normal rate lifespan considerations.
Rapid breathing greater than 20 breaths per minute in and adult or outside the range expected for lifespan considerations, and often shallow.
Decreased levels of oxygen in the blood.
Increased carbon dioxide levels in the blood.
muscles other than the diaphragm and intercostal muscles that may be used for labored breathing.
The “pulling in” of muscles between the ribs or in the neck when breathing, indicating difficulty breathing or respiratory distress.
A feeling of shortness of breath when lying flat.
A bluish discoloration of the skin, lips, and nail beds. It is an indication of decreased perfusion and oxygenation.
A reduced amount of oxyhemoglobin the skin or mucous membranes. Skin and mucous membranes present with a pale skin color.
An equal AP-to-transverse diameter that often occurs in patients with COPD due to hyperinflation of the lungs.
Outward curvature of the back; often described as “hunchback”.
A change in the configuration where the tips of the nails curve around the fingertips, usually caused by chronic low levels of oxygen in the blood.
Air trapped under a subcutaneous layer of the skin; creates a popping or crackling sensation as the area is palpated.
High-pitched hollow sounds heard over trachea and the larynx.
Mixture of low- and high-pitched sounds heard over major bronchi.
Low-pitched soft sounds like “rustling leaves” heard over alveoli and small bronchial airways.
Also referred to as “rales”; sound like popping or crackling noises during inspiration. Associated with inflammation and fluid accumulation in the alveoli.
Another term used for crackles.
High-pitched sounds heard on expiration or inspiration associated with bronchoconstriction or bronchospasm.
High-pitched crowing sounds heard over the upper airway and larynx indicating obstruction.
Alveoli or an entire lung is collapsed, allowing no air movement.