1 Islamic University of Gaza Faculty of Nursing Chapter 8 Assessment of respiratory system

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Islamic University of GazaIslamic University of GazaFaculty of NursingFaculty of Nursing

Chapter 8Chapter 8

Assessment of respiratory systemAssessment of respiratory system

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Anatomy of Respiratory SystemAnatomy of Respiratory System

•NasopharynxNasopharynx•LarynxLarynx•TracheaTrachea•BronchiBronchi•BronchiolesBronchioles•AlveoliAlveoli

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AnatomyAnatomy

Respiratory tract extends from mouth/nose to alveoli:

Upper airway filters airborne particles, humidifies and warms inspired gases

Lower airway serves for gas exchange

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Assessment of respiratory system Assessment of respiratory system

Subjective data:* You must ask about: • Coughing (productive, non productive). • Sputum (type & amount).• Allergies, dyspnea or SOB (at rest or on exertion).• Chest pain, history of asthma, bronchitis,

emphysema, tuberculosis.• Cyanosis, pallor.• Exposure to environmental inhalants (chemicals,

fumes).• History of smoking (amount and length of time)

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Technique for Respiratory ExamTechnique for Respiratory Exam

• Before beginning, if possible:Before beginning, if possible:– Quiet environment– Proper positioning (patient sitting for posterior

thorax exam, supine for anterior thorax exam) – Expose skin for auscultation– Patient comfort, warm hands and diaphragm of

stethoscope, be considerate of women (drape sheet to cover chest)

• InspectionInspection• PalpationPalpation• PercussionPercussion• AuscultationAuscultation

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Initial Respiratory SurveyInitial Respiratory Survey

• Observe the patient’s breathing patternObserve the patient’s breathing pattern– Rate (normal vs. increased/decreased) Rate (normal vs. increased/decreased) – Depth (shallow vs. deep)Depth (shallow vs. deep)– Effort (any sign of accessory muscle use, Effort (any sign of accessory muscle use,

inspect neck)inspect neck)

• Assess the patient’s color (ex. Assess the patient’s color (ex. cyanosis)cyanosis)

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Normal Respiratory RatesNormal Respiratory Rates

– Infant 30-60Infant 30-60

– Toddler 24-40Toddler 24-40

– Preschooler 22-34Preschooler 22-34

– School-age child 18-30School-age child 18-30

– Adolescent 12-16Adolescent 12-16

– Adult 16-20Adult 16-20

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*Inspection for measurement and assessment of respiration patterns.

• Assess the skin and overall symmetry and integrity of the thorax.

• Assess thoracic configuration. -Client must be uncovered to the waist, and in sitting

position without support. -Observation of skin may give you knowledge about,

nutritional status of the client. -Anterior-posterior diameter of thorax in normal

person less than the transverse diameter = (1 – 2).

-Assess for abnormality of configuration, e.g. pigeon chest (a deformity of the chest characterized by a protrusion of the sternum and ribs), funnel chest (Several ribs and the sternum grow abnormally and produce a caved-in or sunken appearance of the chest), spinal deformities (Kyphosis, scoliosis, lordosis).

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Pigeon chestPigeon chest10

Funnel chestFunnel chest11

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• Assess ribs and inter-spaces on respiration – may give you information about obstruction in air flow e.g. bulging of inter-spaces on expiration may be from obstruction to air out flow “tumor, aneurysm, cardiac enlargement”

*Assess pattern of respiration: • Normally: men and children – breathe diaphragmatically

and Women breathe thoracically or costally. • Tachypnea: respiratory rate over than 20/m. • Bradypnea: respiratory rate less than 10/m.-Palpate areas of chest especially areas of abnormalities.If a client complains: all chest areas must be palpated

carefully for tenderness, bulges, or abnormal movements

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*Assess thoracic expansion: • Anterior – put your hands over anterior-lateral

chest and thumbs extended along costal margin pointing to xiphoid process.

• Posterior—thumbs placed at level of 10th rib with palms placed on posterior-lateral chest.-By the two ways, you feel amount of thoracic expansion during quiet and deep breathing, and symmetry of respiration between left and right hemi thoraces.

• * Assessment of fremitus: which is vibration perceptible on palpation".

• * In subcutaneous emphysema: you must palpate the tissue, audible cracking sounds are heard – these sounds are termed “Crepitation”.

Anterior assessment14

Posterior assessment15

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• Percussion of chest: to determine relative amounts of air, liquid, or solid material in the underlying lung, and to determine positions and boundaries of organs.

• * Percussion done for posterior and anterior and lateral aspects of chest with all directions, and with about “5”cms intervals.

*Auscultation: To obtain information about the function of respiratory system & to detect any obstruction in the passages.

• Instruct the client to breathe through the mouth more deeply and slowly than in usual respiration before beginning

• Auscultate all areas of chest for at least one complete respiration

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Auscultation cont..

• 12 anterior locations12 anterior locations

• 14 posterior locations14 posterior locations

• Auscultate symmetricallyAuscultate symmetrically

• Should listen to at least 6 locations anteriorly Should listen to at least 6 locations anteriorly and posteriorly and posteriorly

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• Breathe sounds: are analyzed according to pitch, intensity, quality, and relative duration of inspiratory and expiratory phases.

• * Bronchial breathe sounds: are normally heard

over the trachea, if heard over lung tissue – indicate pathologic condition, these sounds “high- pitched, loud sounds with decrease inspiratory and lengthened increase expiratory phases.

*Absent or decreased breath sounds can occur in: -Foreign body – in pleural space. -Bronchial obstruction. -Shallow breathing. -Emphysema

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Normal Breath SoundsNormal Breath Sounds

• TrachealTracheal– Very loud, high pitched soundVery loud, high pitched sound– Inspiratory = Expiratory sound durationInspiratory = Expiratory sound duration– Heard over tracheaHeard over trachea

• BronchialBronchial– Loud, high pitched soundLoud, high pitched sound– Expiratory sounds > Inspiratory soundsExpiratory sounds > Inspiratory sounds– Heard over manubrium of sternumHeard over manubrium of sternum– If heard in any other location suggestive of If heard in any other location suggestive of

consolidationconsolidation

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• Rale: is short, discrete, interrupted, crackling or bubbling sound that most commonly heard during inspiration “similar to sounds, produced by hairs being rolled between the fingers close to ear.”

* Important points when Auscultate rales: • Low pitched, coarse rales, occurring early in

inspiration means bronchitis “originate from bronchi”

• Medium pitched rales in mid-inspiration means disease in small bronchi e.g. bronchiectasis.

• High pitched, fine rales means disease affecting bronchioles and alveoli this occurs in late inspiration

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* Rhonchi: are continuous sounds produced by movements of air through narrowed passages in the tracheal- bronchial tree "musical sounds heard in expiration".

• Low pitched rhonchi “Sonorous rhonchi usually heard in early expiration originate in larger bronchi”

• High pitched: “Sibilant rhonchi or wheezes” – in late expiration, this originates in small bronchioles.

• Stridor– Inspiratory musical wheeze– Loudest over trachea– Suggests obstructed trachea or larynx– Medical emergency requiring immediate attention– Associated condition inhaled foreign body

• * Pleural friction rub: is aloud dry, cracking or grating sound indicating of pleural irritation, heard over lateral and anterior lung in sitting position &not clear with coughing )

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Causes of decreased or absent breath soundsCauses of decreased or absent breath sounds

• AsthmaAsthma

• COPDCOPD

• Pleural EffusionPleural Effusion

• PneumothoraxPneumothorax

• AtelectasisAtelectasis

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• Pneumonia: Pneumonia: Community-acquired pneumoniaCommunity-acquired pneumonia• Hospital-acquired pneumonia Hospital-acquired pneumonia • BacteriaBacteria• Viruses Viruses • Mycoplasma Mycoplasma • Fungi Fungi • Chemical Chemical

Common Respiratory Common Respiratory DisordersDisorders

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• Pleural EffusionPleural EffusionAccumulation of pleural fluid Accumulation of pleural fluid secondary to increased fluid formation secondary to increased fluid formation – Increased capillary permeability Increased capillary permeability – Deceased colloid osmotic pressure of the blood Deceased colloid osmotic pressure of the blood – Increased intrapleural negative pressure Increased intrapleural negative pressure – Impaired lymphatic drainage Impaired lymphatic drainage – Increased pressure in the capillaries or lymphaticsIncreased pressure in the capillaries or lymphatics

Common Respiratory Disorders cont..Common Respiratory Disorders cont..

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• Pneumothorax: Pneumothorax: Sudden onset of pleuritic chest Sudden onset of pleuritic chest painpain– Dyspnea, shortness of breath, increased work of Dyspnea, shortness of breath, increased work of

breathing breathing • Diagnostic testDiagnostic test

– CXR CXR • ManagementManagement

– Oxygen Oxygen – Possible placement of chest tubePossible placement of chest tube

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• Pulmonary Embolism Pulmonary Embolism Part of a deep vein Part of a deep vein thrombosis that has traveled and lodged in thrombosis that has traveled and lodged in the pulmonary arteriesthe pulmonary arteries

• Severity depends on the extent of occlusionSeverity depends on the extent of occlusion

• Mismatch of ventilation and perfusion Mismatch of ventilation and perfusion

• Testing Testing ( pulmonary angiogram)( pulmonary angiogram)

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• COPD COPD History History – Exposure to risk factors, co-morbidities, Exposure to risk factors, co-morbidities,

current medical treatment (beta blockers)current medical treatment (beta blockers)• Tests Tests

– Spirometry, ABGsSpirometry, ABGs• Management Management

– Oxygen, education, drug therapy, Oxygen, education, drug therapy, nutrition, exercise, surgical interventionnutrition, exercise, surgical intervention


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• AsthmaAsthma A chronic inflammatory disease of the airwaysA chronic inflammatory disease of the airways• Airway hyper responsivenessAirway hyper responsiveness• Variable airway obstruction Variable airway obstruction • Resolves spontaneously or after using a bronchodilatorResolves spontaneously or after using a bronchodilator• Testing :Testing :

– Spirometry Spirometry – Pulmonary function testingPulmonary function testing

• ManagementManagement– Education, prevent exacerbation, optimize Education, prevent exacerbation, optimize

pharmacotherapypharmacotherapy


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• Acute Respiratory FailureAcute Respiratory Failure A sudden and life–threatening A sudden and life–threatening deterioration in gas exchangedeterioration in gas exchange

• Type I – Acute hypoxemic respiratory failure Type I – Acute hypoxemic respiratory failure • Type II - Acute hypercapnic respiratory failureType II - Acute hypercapnic respiratory failure• Type III – Combined hypoxemic and hypercapnic failure Type III – Combined hypoxemic and hypercapnic failure • *Hypercapnia: is a condition where there is too

much carbon dioxide (CO2) in the blood. • TestsTests

– ABGs, CXR, CT, thoracentesisABGs, CXR, CT, thoracentesis• ManagementManagement

– Correction of gases, oxygen therapy Correction of gases, oxygen therapy – Reversal of any narcoticsReversal of any narcotics– Possible mechanical ventilationPossible mechanical ventilation


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1 Islamic University of Gaza Faculty of Nursing Chapter 8 Assessment of respiratory system