Introduction
Assessment of respiratory system is a vital nursing skill that helps detect early signs of respiratory distress, monitor chronic conditions, and guide treatment decisions.
Respiration is a process of taking in of oxygen and releasing carbon dioxide while breathing. An excellent knowledge of the anatomy and physiology of the respiratory system is necessary to conduct an effective assessment of the respiratory system. An assessment of the respiratory system should be done in an organized and systematic manner to obtain accurate findings.
Components of Respiratory Assessment
- History taking.
- Physical examination: Inspection, palpation, auscultation, percussion.
Articles
- Gloves (optional).
- Drapes.
- Gown for patient.
- 4. Stethoscope.
- 5. Pen and paper to record.
General Instructions
- Wash hand thoroughly before touching the patient.
- Warm hands by rubbing hands together before examining patient.
- Ensure privacy, dignity and comfort of the patient.
- Expose only the necessary area that needs to be exposed for the examination.
- When assessing for the first time, ensure that a comprehensive examination is done.
- Explain procedure to patient and how long the procedure may take. Obtain verbal consent.
- Ensure that assessment is conducted in a well-lit area that ensures privacy.
- Obtain a set of vital signs including pulses, blood pressure and oxygen saturations.
- Proceed in a systematic and organized manner.
Procedure
History Taking
Assessment begins with a focused history taking of the patient.
Chief Complaint
Common symptoms pertaining to the respiratory system include:
- Shortness of breath
- Cough (productive or nonproductive, duration, precipitating factors)
- Sputum (characteristics, color, tenacity)
- Dyspnea (precipitating factors like activity and rest, severity of symptoms)
- Wheezing (causes precipitating factors)
- Paroxysmal nocturnal dyspnea
- Orthopnea
- Use of accessory muscles of breathing
- Cyanosis
All these symptoms may indicate underlying respiratory pathology. When collecting data on these symptoms, information must be obtained regarding the nature of symptom, characteristics, severity, the time of onset, precipitating factors and relieving factors. On many occasions, it is important to collect general symptoms related to other physiological systems as they may be a result of an underlying respiratory pathology. For example, altered mental status, anxiety or confusion may be the result of hypoxia.
Past medical history
When taking the medical history pertaining to respiratory system. The common diseases are as follows but not limited to:
- Chronic obstructive pulmonary diseases
- Bronchial asthma
- Emphysema
- Chronic bronchitis
- Tuberculosis
- HIV- related pulmonary conditions
- Pulmonary fibrosis
- Pneumonia
- Pulmonary infections and inflammations
- Underlying cardiac conditions.
The clinician should also include personal history such as allergies, smoking history (number of packs/ day number of years of smoking= number of pack years), exposure to chemicals and occupational exposure. The nurse should take a comprehensive history about current medications, and surgeries that the patient may have had. Include all surgeries in your history, as even abdominal surgeries can lead to pulmonary complications.
Diagnostic Findings
The nurse should include recent diagnostic tests pertaining to the pulmonary system including chest X-rays, Computerized Tomographic scans and Magnetic Resonance Imaging studies. Pulmonary function tests also give valuable information regarding lung volumes when taking an in-depth history of the pulmonary system.
Physical Examination
| Steps of physical examination | Rationale |
| Inspection Assess using all your senses and observe for the size, morphology, appearance of the skin, appearance of any skin lesions, symmetry, and color of the skin, appearance of landmarks, sounds and odors. Observe the patient for nasal flaring, pursed lip breathing, retraction of intercostal space, diaphoresis and clamminess. Observe the patient’s speech patterns.Assess respiratory patterns-rate, regularity and symmetry. Assess for inspiratory-expiratory (I: E) ratio. | Abnormal shape of the thorax will indicate the presence of underlying respiratory conditions. For example, a barrel chest can indicate that the patient has COPD. Abnormalities of the spine like scoliosis and kyphosis can lead to abnormal lung volumes. Patients with respiratory difficulties will have difficulty speaking normally. Patients having cyanosis of lips or nails may have underlying hypoxic conditions. Nasal flaring, pursed lip breathing, use of accessory muscles and retraction of intercostal muscles, will all indicate patient having difficulty taking abnormal breaths. The normal respiratory rate is 12-20 breaths per minute, equal and symmetrical bilaterally. Normal I:E ratio is 1:2. Patients with COPD will have prolonged expirations which can result in abnormal ratios. |
| Palpation Assist the patient to a sitting position facing away from you. Spread your hand on the patient’s back at the level of the 10 th rib with thumbs at the side of the spine and the fingers spread laterally. This helps in identifying adequate lung expansion.Palpate the thorax anteriorly and posteriorly to identify any masses, protrusions or crepitation. When palpating the chest wall, instruct the patient to repeat phrases like “99”to identify fremitus, which are palpable vibrations that are transmitted from the larynx to the bronchi and lung parenchyma. | Lung expansion may be compromised in restrictive lung diseases. Abnormal crepitations may be felt in case of subcutaneous emphysema that may result from air entering the subcutaneous tissue due to an injury in the chest wall. Decreased fremitus may be felt in conditions such as obstructive lung disease, pleural effusions, pneumothorax, emphysema, or in pulmonary fibrosis. |
| Percussion Percussion of the chest wall is done over healthy lung tissue. Resonance is the normal sound heard over healthy lung tissue. Hyperresonance is the low-pitched sound heard when percussing areas over increased air trapping. Dullness is the sound heard when percussing over dense tissue and solid masses. | Hyperresonance is heard in the case of pneumothorax or emphysema. Dullness is heard when percussing over tumors and flat sounds are heard when percussing over fluid fill area. |
| Auscultation Ensure quietness of the room and press the diaphragm/bell of the stethoscope to the skin of the chest anteriorly and posteriorly. The auscultation must be done in a systematic and organized manner while asking the patient to breathe in and out through the mouth in a regular manner. | Ensures obtaining accurate data. |
| Wash hands. | To prevent cross infection. |
| Document findings. | Ensure proper documentation of the data collected and procedure performed. |
Normal Breath Sounds
- Vesicular (heard over lung fields)
- Bronchial (heard over upper lobes)
- Bronchovesicular (heard over trachea and upper bronchi)
Common Abnormal Breath Sounds or Adventitious Breath Sound
- Crackles-High pitched sound heard on inspiration also known as rales or crepitations indicating fluid passing through secretions.
- Wheezes-Musical high-pitched sound heard upon expiration indicating air flowing through constricted airways.
- Stridor-Loud high-pitched sound heard in the upper airways due to an obstruction.
- Ronchi-A low pitched wheeze occurring when large amount of secretions filling the airway.
- Rubs-These are coarse grating sound heard caused by inflammation of the visceral and parietal pleura as the opposing surfaces rub together during inspiration and expiration
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
