Faculty of Nursing-IUG

Chapter (7)Assessment of respiratory system

Anatomy of Respiratory System

The lung is a two cone-shaped, elastic structure suspended

within the thoracic cavity.

Lung are paired, they are not complete symmetric, the

right lung contain three lobe, whereas the left lung contain

only two lobes.

The apex of each lung extended slightly above the clavicle,

where the base is at the level of diaphragm

The thoracic cavity contains the nasopharynx, larynx,

trachea, bronchi, bronchioles, alveoli.

The thoracic cavity is lined by a thin, double- layered

serous membrane collectively called the pleural membrane2

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Assessment of respiratory system

Subjective data: the nurse must ask the client 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) 5

Technique for Respiratory Exam

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)

After that the nurse should apply the four

techniques; Inspection, Palpation, Percussion and

Auscultation6

Initial Respiratory Survey (Inspection)Observe the patient’s breathing pattern

Rate (normal vs. increased/decreased) Depth (shallow vs. deep)Effort (any sign of accessory muscle use, inspect

neck)Assess the patient’s color

Cyanosis Normal Respiratory Rates

Infant 30-60Toddler 24-40Preschooler 22-34School-age child 18-30Adolescent 12-16Adult 16-20 7

Inspection 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, funnel chest, spinal deformities. Assess ribs and inter spaces on respiration – may give

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 for adult.

Bradypnea: respiratory rate less than 10/m.

Palpation: palpate areas of chest especially areas of

abnormalities.

If clients complains: all chest areas must palpated

carefully for tenderness, bulges, or any 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 T 10 with palms placed on posterior-lateral chest.

By 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 Crepitation10

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Percussion of chest: Done 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 obtains 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 and then to hold the breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli.

Auscultate all areas of chest for at least one complete respiration: 12 anterior locations and 14 posterior locations

Auscultate symmetrically: Should listen to at least 6 locations anteriorly 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 manubrium of sternum

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. Bronchial obstruction. Shallow breathing. Emphysema

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Breath SoundsNormal breath sounds are distinguished by their

location over a specific area of the lung and are identified as tracheal, vesicular, bronchovesicular, and bronchial (tubular) breath sounds as the next:

1. TrachealVery loud, high pitched soundInspiratory = Expiratory sound durationHeard over trachea in the neck2. BronchialLoud, high pitched soundExpiratory sounds > Inspiratory soundsHeard over manubrium of sternumIf heard in any other location suggestive of

consolidation15

3. Bronchovesicular Intermediate intensity, intermediate pitchInspiratory = Expiratory sound durationHeard best 1st and 2nd ICS anteriorly, and

between scapula posteriorlyIf heard in any other location suggestive of

consolidation

4. VesicularSoft, low pitched soundInspiratory > Expiratory soundsMajor normal breath sound, heard over most of

lungs

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Adventitious Breath SoundsAn abnormal condition that affects the bronchial tree

and alveoli may produce adventitious (abnrmal= addtional) sounds. Adventitious sounds are divided into two categories: discrete, noncontinuous sounds (crackles) and continuous musical sounds (wheezes) as the next:

1. Crackles (Rales)Discontinuous, intermittent, nonmusical, brief

sounds. Heard more commonly with inspirationClassified as fine or coarse Its may associated with Prolonged recumbency Crackles caused by air moving through secretions

and collapsed alveoli and associated with the following conditions: pulmonary edema, early CHF, and pnumonia

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2. WheezeContinuous, high pitched, musical sound, longer than

cracklesWhistle quality, heard during expiration, however,

can be heard on inspirationProduced when air flows through narrowed airwaysAssociated conditions: asthma, chronic bronchitis,

and COPD

3. Rhonchi Similar to wheezes (subtype of wheeze)Low pitched, snoring quality, continuous, musical

soundsImplies obstruction of larger airways by secretionsAssociated condition: acute bronchitis

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4. Stridor Inspiratory musical wheezeLoudest over tracheaSuggests obstructed trachea or larynxMedical emergency requiring immediate attentionAssociated condition inhaled foreign body

5. Pleural Friction RubPleural friction rubs are specific examples of crackles.

Discontinuous or continuous brushing soundsIt is a loud dry, cracking or grating sound indicating of

pleural irritation, heard over lateral and anterior lung in sitting position that heard during both inspiratory and expiratory phases

Occurs when pleural surfaces are inflamed and rub against each other

Associated conditions as pleural effusion, Pneumonothorax

Medical conditions associated with decreased or absent of breath sounds

Asthma COPD Pleural Effusion: fluid accumulating within the

pleural spacePneumothorax: caused by accumulation of air or

gas in the pleural space. ARDS( adult respiratory distress syndrome)Atelectasis : is defined as a state in which the lung,

in whole or in part, is collapsed or without air entery

Five Main Symptoms of Respiratory DiseaseCough Sputum PainBreathlessness Wheeze