If I had to choose one focused assessment I’ve done more than any other, it would be respiratory (followed very closely by neurological assessments, which you can review here. Working in the MICU, so many of my patients were admitted with respiratory disorders. And now, working in the PACU, I am allllll about that airway.
In this article you’ll learn the basics of what goes into a respiratory assessment. Before you dive in, you might want to review Oxygenation Concepts for Nursing Students first. Ok, ready? Let’s do this!
Listen to the below information on conducting a respiratory assessment in episode 237 of the Straight A Nursing podcast wherever you get your podcasts or straight from the website here.
Nursing Respiratory Assessment Overview
A general respiratory assessment is going to be heavily reliant on what you see and hear. Your assessment will also be guided by any underlying respiratory disorders and what is currently going on with the patient’s physiology and plan of care. For example, a patient with a chest tube will have assessments specific to that, and a patient with asthma is going to be assessed differently than a patient with congestive heart failure. So let’s go through a basic adult respiratory assessment step-by-step. Want to learn more about pediatric respiratory assessment? Here you go!
Respiratory Assessment – Observation
The first thing I do when I assess my patient’s respiratory status is observe. This lets you know immediately if the patient is having trouble so you can quickly intervene.
- Do they look like they’ve having any respiratory distress or compromise? This could look like increased work of breathing, tachypnea, air hunger, pursed lip breathing, agonal breathing, etc…
- Increased work of breathing is present when accessory muscles are being utilized to facilitate breathing, so you may also hear this called “accessory muscle use.” The most obvious muscles to watch are the scalenes and sternocleidomastoid, but you also want to observe the pectoralis major, trapezius and external intercostals. If it appears the patient is using any accessory muscles to facilitate breathing, they are in trouble and require prompt intervention.
- What is the respiratory rate? A normal respiratory rate is 10-20 breaths per minute. Anything below 10 is bradypnea and a rate above 20 is tachypnea.
- What is the patient’s position? For example, a patient who is sitting up and leaning forward with hands on knees is in the tripod position, which helps facilitate lung expansion. This is common in patients experiencing respiratory compromise due to emphysema, asthma, COPD and even intense exercise.
- What is the patient’s level of consciousness? A patient who is restless or agitated may be exhibiting signs of hypoxia. Conversely, a patient who is somnolent or obtunded may be in respiratory acidosis, which is common in COPD exacerbations. Decreased level of consciousness could also be due to respiratory failure, which often occurs after a period of intense respiratory effort as the body tries to compensate.
- Is the patient drooling? Drooling can be associated with airway obstruction or even epiglottitis which makes swallowing difficult and painful. Though more common in children, epiglottitis can occur in adults.
- Is the chest rising and falling equally on both sides? Trauma victims can have fractured ribs that contribute to destabilization of the chest wall (called a “flail chest”). Another common cause of asymmetrical chest wall expansion is pneumothorax.
- Do the breaths appear shallow, deep or “normal?” Shallow breathing could indicate the patient is over sedated or has too many opioids on board. Very deep and fast breathing is a sign of metabolic acidosis, often seen in diabetic ketoacidosis.
- Is the respiratory pattern regular or irregular? An irregular breathing pattern, such as Cheyne-Stokes respirations, is an indicator of neurological impairment.
- Is the patient moving air? You can hold a hand in front of their nose/mouth or watch for their breath to fog up a simple oxygen mask if using.
- What are the skin signs? In light or fair-skinned individuals, low oxygen levels cause cyanosis, which is a bluish discoloration of the skin, nail beds or lips. In darker skinned individuals, assess for pallor on the inside of the lower lip, the conjunctiva and palms. In individuals with yellow skin tones, cyanosis presents as a grayish-greenish discoloration.
- Is clubbing present? Clubbing of the nails is a swelling of the soft tissue that flattens the nail bed and is often present in lung cancer, interstitial lung disease and COPD.
- Is the patient coughing? If the patient has a productive cough, assess the sputum for amount, color, odor and consistency.
- Amount – scant, small, moderate or large
- Color – typically white or clear in viral illness; yellow/green in bacterial illness. Black in the sputum likely indicates smoke inhalation and blood-tinged or rust colored could be present in tuberculosis and some types of pneumonia.
- Odor – a foul odor is often associated with bacterial pneumonia and lung cancer.
- Consistency – thick or thin (thick sputum is more difficult to clear, so always be thinking of airway protection and patency!).
- If the patient is able to communicate, can they speak full sentences without pausing for breath? If not, this is a sign of shortness of breath.
Respiratory Assessment – Auscultation
The next step in the respiratory assessment is to listen.
- Using the diaphragm of the stethoscope, you’ll listen to your patient’s lungs in a Z pattern both posterior and anterior. You do a Z pattern to compare right to left at each area of the lungs.
- The three types of lung sounds are bronchial, bronchovesicular and vesicular. When assessing these lung sounds, you’re essentially confirming they are audible in the location they’re expected to be. When they’re heard outside of that expected location, this is an abnormal finding.
- Bronchial sounds are high pitched and loud. You’ll hear them over the trachea and larynx, and will sometimes see them referred to as “tracheal” breath sounds. When bronchial breath sounds are heard in other areas of the lung this could be an indication of disease such as pneumonia.
- Bronchovesicular sounds are moderate in pitch and amplitude. You can hear bronchovesicular sounds at the mid sternum and between the scapula.
- Vesicular sounds are auscultated in the peripheral lung fields and make up the majority of the sounds you will hear. They are lower in pitch and volume than the other sounds.
- Abnormal breath sounds can be diminished, absent or adventitious. Diminished and absent lung sounds are a sign of decreased airflow and decreased lung expansion. This can be due to a variety of factors such as pleural effusion, hypoventilation secondary to sedation, airway obstruction or pneumothorax.
- Adventitious sounds are audible abnormal sounds. These include crackles, rhonchi, wheezes, stridor and pleural friction rub.
- Crackles (also known as “rales”) can be fine or coarse. Fine crackles are often caused by atelectasis. Typically more coarse crackles are caused by things like aspiration and pulmonary edema. You may hear the lung sounds of someone with pulmonary edema or ARDS referred to as “wet,” as in “I’m concerned about Mr. Reynolds. His lungs sounds are wet and his urine output has decreased.”
- Rhonchi are low-pitched breath sounds that are often compared to a snoring sound. Rhonchi can be heard on both inspiration and expiration, and are most likely to be heard in the large airways. A common cause of rhonchi is airway obstruction due to the thick mucus that is present in cystic fibrosis.
- Wheezes are high-pitched sounds often associated with asthma and COPD. Wheezes can be inspiratory or expiratory, and it’s important to note that a lack of wheezing in someone experiencing an asthma exacerbation could indicate the airways are too constricted and little to no air is moving. This patient needs intervention STAT!
- Stridor occurs when the upper airway is obstructed. It’s a harsh, high-pitched sound heard during inspiration.
- Pleural friction rub (sometimes simply called a pleural rub) is a grating sound that can occur with inspiration and expiration. It is due to inflamed pleural surfaces rubbing against one another and can occur in conditions such as pleurisy or pleural effusion.
Assessment of voice sounds
Another way to assess pulmonary status is by listening to voice sounds. In healthy lungs, the organs are filled with air which does not transmit sound effectively. So, if you listen to your patient’s lungs and have them speak, it should be muffled. But when a substance is present that transmits sound more effectively (such as fluid or a solid mass), you’ll be able to hear the words more clearly. We assess for three types of voice sounds:
- Bronchophony: Listen to the lung fields as the patient says the words “ninety-nine.” A normal finding is that the words will be indistinct. If you can hear the words clearly, this is positive for bronchophony.
- Egophony: Listen to the lung fields while the patient says “ee-ee-ee.” A normal finding is that you will hear the “ee” sound as in “feet.” When consolidation is present, you’ll instead hear an “ay” sound as in “hay.”
- Whispered pectoriloquy: Listen to the lung fields while the patient whispers “one-two-three.” In healthy lungs you’ll hear very faint sounds or perhaps none at all. If you can hear the words clearly, this indicates an abnormality of the lung tissue such as consolidation or a mass.
Assessing with palpation
The two key assessments you’ll conduct with your hands are for tactile fremitus and crepitus. Tactile fremitus (also called vocal fremitus) is pronounced vibration over areas of lung consolidation and diminished vibration in cases of hyperinflation or when fluid is present. To assess for tactile fremitus, place either your palms or ulnar sides of the hands on the posterior chest and ask the patient to say “ninety-nine” or “one-two-three.” Move the hands to the areas where you would normally place your stethoscope and compare the amount of vibration you feel from side-to-side. PROTIP: Ask the patient to cross his arms in front of his chest to displace the scapula for easier palpation.
To assess for crepitus (also known as subcutaneous emphysema), you’ll simply palpate the chest wall. Crepitus feels like bubble wrap under the skin and is caused by air getting into the subcutaneous tissue. It’s common with chest tubes, chest trauma, pneumothorax, mechanical ventilation (barotrauma), pulmonary blebs, and tears in the airway. A key part of your chest tube assessment will be to determine if crepitus is present and if it is worsening or resolving.
Something you’ll learn in the skills lab is to assess for symmetrical chest expansion by using your hands. Place your hands around the chest wall with thumbs at T9 or T10 and ask the patient to take a deep breath. Your hands should move symmetrically.
What questions to ask the patient
While the questions you ask your patient will be guided by their unique symptoms or disease pathology, some key questions to ask are:
- Do you smoke? If yes, how many packs per day and for how many years? This will enable you to calculate the “pack-year history.”
- If the patient has a cough, ask how long they’ve had it and if it occurs more in the morning versus throughout the day/night. A morning cough in someone who smokes is generally considered “a smoker’s cough.” Morning coughing is also common in individuals with COPD, bronchitis, and those with postnasal drip and/or seasonal allergies (though, of course, coughing can occur at any time). A cough that lasts more than eight weeks is considered “chronic” and may be due to medication (such as ACE inhibitors), GERD, asthma, tuberculosis, cancer, asthma and COPD. A sudden-onset acute cough could be due to allergies or an infection, though it is important to note the cough from an infection (such as pneumonia or bronchitis) could linger for several weeks.
- Ask about shortness of breath by saying, “Do you have any difficulty breathing?”. Though dyspnea can be noticed through observation, patients will often feel it before it becomes outwardly evident. This can be scored with a numeric rating scale, much like we use with pain assessment.
- To assess for paroxysmal nocturnal dyspnea ask the patient “Do you ever wake up suddenly feeling out of breath that resolves when you sit upright?”
- To assess for orthopnea, ask the patient “How many pillows do you sleep on at night?”
I hope this helps you conduct a basic respiratory assessment. Please note that detailed assessments can vary based on each unique situation so always use your best judgment and clinical resources as guides.
Want to learn more about the respiratory system? These articles should help!
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