ASSESSMENT OF THE RESPIRATORY SYSTEM

 Any client can develop a respiratory disorder.

 By using a systematic assessment, you’ll be able to detect

subtle or obvious respiratory changes.

 The depth of your assessment for depend on several factors,

including the client’s primary health problem and his risk of
developing respiratory complications.

 A physical examination of the respiratory systems follow four

steps: inspection, palpation, percussion and auscultation.

 Before you begin, make sure the room is well lit and warm

 General Appearance  A barrel chest presents as a rounded shape that is the same
diameter from anterior to posterior as it is transversely.
 Make a few observations about the client as soon as you Barrel chest is associated with chronic emphysema and
enter the room. asthma but may also be present in the normal, older adult
 Note how the client is seated, which will most likely be the
position most comfortable for him.

 Take note of his level awareness and general appearance.

 Does he appear relaxed? Uneasy? Uncomfortable? Is

having trouble breathing?

 You’ll include these observations in your final assessment.

1. Performed hand hygiene.

2. Introduce yourself and explain why you’re there.
3. Position client appropriately (Upright).
4. Remove gown from posterior chest.
 Keep front of the chest and legs covered.  Pectus excavatum, a congenital shape, is usually not
symptomatic but presents as a depression at the junction of
 Remove the gown from area being examined. the xiphoid with the sternum.
5. Explain all the steps. Encourage client to relax and breathe
normally
6. Examine the back of the chest first, using inspection, palpation,
percussion and auscultation.

 Always compare one side with the other.

 Then examine the front of the chest using the same

sequence.

 The client can lie back when you examine the front of the
chest if that’s more comfortable for him.

 INSPECTION

 Inspect for :

1. SHAPE

 Pectus carinatum presents as a forward protrusion of the

sternum. It is less common than pectus excavatum, and
minor conditions require no treatment.
2. DEFORMITIES - The thorax in the normal adult is
elliptical in shape and is narrower anterior to posterior than
it is across the transverse axis.

1
3. POSITION OF SPINE - when all 3 curves of the spine—
cervical (neck), thoracic (middle) and lumbar (lower)—are
present and in good alignment.
B. Intercostal retraction - Indrawing of the skin in between
each rib

C. Suprasternal retraction - Indrawing of the skin in the

middle of the neck above the sternum (breastbone).
 ABNORMAL

6. BULGING OF INTERCOSTAL SPACES

During Expiration- the visible expansion of the
soft tissues between the ribs that occurs when increased
expiratory effort is needed to exhale.

4. SLOPE OF RIBS - normally ribs are inserted into the 7. SYMMETRICAL EXPANSION
spine at a 45E angle and inserted into the costal angle at a
45E angle.  Chest expansion is symmetrical.
 Both sides take off at the same time and to the
same extent.
 Asymmetrical chest expansion is abnormal.
 The abnormal side expands less and delays behind
the normal side.
 Any form of unilateral lung or pleural disease can
cause asymmetry of chest expansion.
SYMMETRY

1) Note masses or scars that indicate trauma or surgery.

2) Look for chest wall symmetry.

3) Both side of chest should be equal at rest and expand equally

as the client inhales.

4) The diameter of the chest from front to back, should be about

5. RETRACTION OF INTERCOSTAL SPACES half the width of the chest.
DURING EXPIRATION 5) Look at the angle between the ribs and the sternum at the
point immediately above the xiphoid process.
 Abnormal Retraction of Interspaces During Inspiration

A. Sub sternal retraction - Indrawing of the abdomen just

below the sternum (breastbone).

2

 This angle, the costal angle, should be less than 90 degrees
in an adult.
 The angle will be larger if the chest wall is chronically
expanded because of an enlargement of the intercostal
muscles, as can happen with chronic obstructive disease
(COPD).
RESPIRATIONS
1) To find the client’s respiratory rate, count for a full minute-
longer if you note abnormalities.
 Don’t tell him what you’re doing or he might alter
his natural breathing pattern.
 One trick is to count respirations while the client
think you’re taking his pulses or listening to his
heart.
 Adults normally breathe at a rate of 12 to 20
breaths/minute. An infant’s breathing rate about 40
breaths/minute.
Respiratory Pattern: Normal: Even, coordinated and regular with
occasional sighs.
 Men, children, infant, athletes and singers use abdominal
or diaphragmatic breathing.
 Most women use thoracic breathing .
 The frequent use ACCESSORY MUSCLE may indicate a
respiratory problem particularly when the client purses his
lips and flares his nostrils when breathing.
 Inspect the skin, tongue, mouth, fingers, and nail beds.
 Bluish tint to skin and mucous membrane:
CYANOSIS
 Clubbing of fingers: long term hypoxia- is a
condition in which the body or a region of the body
is deprived of adequate oxygen supply at the tissue
level
 Watch for paradoxical, or uneven movement of the chest
wall.
 Paradoxical movement may appear as an abnormal
collapse of part of the chest wall when the client
inhales or an abnormal expansion when the client
exhales.
 In either case, this uneven movement indicates a loss
of normal chest wall function.
 PALPATION
 Palpation of the chest provides important about the
respiratory system and the processes involved in breathing.
 To palpate the chest, the palm of your hand (or hands)
lightly over the thorax.
1) Palpate for tenderness, alignment, bulging and retractions
of the chest and intercostal spaces.
2) Assess the client for crepitus.
3) Repeat this procedure on the client’s back.
4) Next, use the pads of your fingers to palpate the front and
back of the thorax.
5) Pass your finger over the ribs and any scars, lumps, lesions,
or ulcerations.
 Note the skin temperature, turgor, and moisture.
 Also, note tenderness and bony or subcutaneous
crepitus.
 The muscles should feel firm and smooth.
Here’s what to look for when palpating the chest:
1. Crepitus
 The chest wall should feel smooth, warm and dry.
 Crepitus indicates subcutaneous air in the chest, an
abnormal condition.
 Crepitus feels like puffed-rice cereal crackling under the
skin and indicates that air is leaking from the airways or
lungs.
2. Pain or Tenderness
 Gentle palpation shouldn’t cause the client pain.
 If the client complains of chest pain, try to find a painful
area on the chest wall.
 Painful costochondral joints are typically located at the
midclavicular line or next to the sternum.
 Rib or vertebral fractures will be quite painful over the
fracture, although pain may radiate around the chest as
well.
3
  Pain may also be caused by sore muscles because of  PERCUSSION
protracted coughing.
 You’ll percuss the chest:
 A collapsed lung may also cause pain.
1. to find the boundaries of the lungs
3. Fremitus
2. to determine whether the lungs are filled with air
 Palpate for tactile fremitus, palpable vibrations cause by or fluid or solid material.
the transmissions of air through the bronchopulmonary
system. 3. To evaluate the distance the diaphragm travels
between the client’s inhalation and exhalation.
 Vibratory tremors can be felt through the chest by
palpation. To percuss the chest:

 Fremitus is increased normally over the large bronchial
tubes and abnormally over areas in which alveoli are filled
with fluid or exudate, as happens in pneumonia.
 When you check the back of the thorax for tactile
fremitus, ask the client to fold his arms across his chest.
 This movement shifts the scapulae out of the way.
1. Hyperextend the middle finger of your left hand.
2. Place your hand firmly on the client’s chest.
3. Use the tip of the idle finger of your dominant hand,
your right hand if you’re right-handed, left hand if
you’re left-handed, to tap on the middle finger of
your other hand just below the distal joint.

 Check for tactile fremitus by lightly placing your open
palms on both sides of the client’s back.
 Ask the client to repeat the phrase “ninety-one” loud
enough to produce palpable vibrations.
 Then palpate the front of the chest using the same hand
positions.
 More prominent in men than women because men have
lower-pitched voices, which conduct more easily though
lung tissue than do higher-pitched voices
 The movement should come from the wrist of
your dominant hand, not your elbow or upper
arm.
 Follow the standard percussion sequence over the
front and back chest walls.
 Remember to compare sound variations from one side with
the other as you proceed. You’ll follow the same
sequence for auscultation.

 Vibrations that feel more intense on one side than the

other indicate tissue consolidation on that side.

 Less intense vibrations in the upper posterior thorax may

indicate bronchial obstruction or a fluid-filled pleural
space.

 Normal findings on palpation include: normal chest size and

shape,... tactile fremitus over the mainstream bronchi in front
and between the scapulae in the back of the chest.

 Vibrations that feel more intense on one side than the

other indicate tissue consolidation on that side.

 Less intense vibrations in the upper posterior thorax may

indicate bronchial obstruction or a fluid-filled pleural
space.

Percussion Sounds
Chest Symmetry and Expansion
 Percussion allows you to assess structures as deep as 3
 To evaluate the client’s chest wall symmetry and inches (7.6 cm).
expansion:
 You’ll hear different percussion sounds in different areas of
1. Place your hands on the front of the chest wall with your the chest.
thumbs touching each other at the second intercostal  Learn the different percussion sounds by practicing on
space. yourself, your clients, and other people.
2. As the client inhales deeply, watch your thumbs.
1. Flat Sounds – short, soft, high-pitched, extremely dull
3. They should separate simultaneously and equally to a sounds, found over the thigh signifying consolidation, as in
distance several centimeters away from the sternum. atelectasis and extensive pleural effusion.
4. Repeat the measurement at the fifth intercostal space. 2. Dull Sounds – medium in intensity and pitch, moderate
length, thud-like, found over the liver indicating solid area,
 The same measurement may be made on the back of
the chest near the tenth rib. as in lobar pneumonia.

 The client’s chest may expand asymmetry if he has
pleural effusion, atelectasis, pneumonia, or
pneumothorax.
 Chest expansion may be decreased at the level of the
diaphragm if the client has emphysema, respiratory
depression, diaphragm paralysis, atelectasis, obesity,
or ascites.
3. Resonance Sounds – long, loud, low-pitched, hollow
signifying normal lung tissue; bronchitis.
4. Hyperresonance sounds – very loud, lower-pitches, found
over the stomach signifying hyperinflated lung, as in
emphysema or pneumothorax.
5. Tympanic sounds – loud, high-pitched, moderate length,
musical, drum-like, found over a puffed-out check

4
 indicating air collection, as in a gastric air bubble, air
in the intestine, or a large pneumothorax.
Lung Sounds
 You’ll hear resonant sounds over normal lung tissue, which
you should find over most of the chest.
3. Bronchovesicular – heard when the client inhales or
exhales; continuous; medium in loudness and pitch found
nest to sternum and between the scapula.
4. Vesicular – are prolonged during inhalation and shortened
during exhalation; soft and low-pitched sound found in the
remainder of the lung field.

 In the left front chest from the third or fourth intercostal  The type of sound you hear depends on where you listen.
space at the sternum to the third or fourth intercostal space
at the midclavicular line, you should hear a dull sound.  Classify each sound according to its,

 Percussion is dull there because that’s the space occupied 1) Intensity-

by the heart. 2) Location-
 Resonance resumes at the sixth intercostal space. 3) Pitch-
 The sequence of sounds in the back is slightly different. 4) Duration-
 When you hear hyper resonance during percussion, it 5) Characteristics-
means you’ve found an area of increased air in the lungs or
pleural space.  Note whether the sound occurs when the client inhales,
exhales, or both.
 Expect hyper resonance with pneumothorax, acute asthma,
bullous emphysema (large holes in the lungs from alveolar
destruction), or gastric distention that pushes up on the ABNORMAL ASSESSMENT FINDINGS OF THE
diaphragm. RESPIRATORY SYSTEM

 When you hear abnormal dullness, it means you’ve found

areas of decreased air in the lungs.
 Expect abnormal dullness in the presence of pleural fluid,
consolidation, atelectasis, or a tumor.
 AUSCULTATION
 As air moves through the bronchi, it creates sound waves
that travel to the chest wall.
 The sounds produced by breathing change as air moves
from larges airways to smaller airways.
 Sounds also change if they pass through fluid, mucus, or
narrowed airways.
 Auscultation of these sounds helps you to determine the
condition of the alveoli and surrounding pleura.
 Auscultation sites are the same as percussion sites.
 Listen to a full inspiration and a full expiration at each site,
using the diaphragm of a stethoscope.
 Ask the client to breathe through his mouth; nose breathing
alters the pitch of breath sounds.
 If the client has abundant chest hair, mat it down with a
damp washcloth so the hair does not make sounds like
crackles.
 To auscultate for breath sounds you will press the
stethoscope firmly against the skin.
 Remember that if you’ll listen through clothing or dry chest
hair, you may hear unusual and deceptive sounds.
o You will hear four types of breath sounds over normal
lungs:
1. Tracheal – heard when client inhales or exhales; usually
harsh and high-pitched found above the supraclavicular
notch.
2. Bronchial – heard loudest when the client exhales;
discontinuous; loud and high-pitched found just above
clavicles on each side of the sternum, between scapula and
over the manubrium.
1. Cough due to
a) Atelectasis – nonproductive cough, pleuritic chest pain,
dyspnea, tachypnea, anxiety, decreased vocal fremitus,
tracheal deviation toward the affected side.
b) Lung cancer – productive cough with small amount of
purulent (or mucopurulent), blood-streaked sputum of large
amounts of frothy sputum, dyspnea, anorexia, fatigue,
weight loss, wheezing, clubbing.
c) Pleural effusion – nonproductive cough, dyspnea, pleuritic
chest pain, decreased chest motion, pleural friction rub,
tachypnea, tachycardia, flatness on percussion, egophony.
2. Dyspnea due to
a) Acute respiratory distress syndrome – acute dyspnea,
tachypnea, crackles and rhonchi in both lung fields,
intercostal and suprasternal retractions, restlessness,
anxiety and tachycardia.
b) Emphysema – progressive exceptional dyspnea, a history
of smoking, barred chest accessory muscle hypertrophy,
diminished breath sounds, pursed-lip breathing,
prolonged expiration, anorexia, weight loss.
c) Pulmonary embolism – acute dyspnea, pleuritic chest
pain, tachycardia, decreased breath sounds, low-grade
fever, dullness of percussion cool, clammy skin.
3. Hemoptysis due to
a) Pneumonia – sputum ranging in color from pink to dark
brown, productive cough, dyspnea, chest pain, crackles on
auscultation, chills, fever.
b) Pulmonary edema – frothy, blood-tinged, pink sputum,
severe dyspnea, orthopnea, gasping, diffuse crackles, cold,
clammy skin, anxiety.
c) Pulmonary tuberculosis – blood-streaked or blood-tinged
sputum, chronic productive cough, fine crackles after
coughing, dyspnea, dullness to percussion, increased tactile
percussion.
4. Wheezing due to

5
 a) Aspiration of a foreign body – sudden onset of wheezing,
stridor, dry, paroxysmal cough, gagging, hoarseness,
decreased breath sounds, dyspnea, cyanosis.
b) Asthma – audible wheezing on expiration, prolonged
expiration, apprehension, intercostal and supraclavicular
retractions, rhonchi, nasal flaring, tachypnea.
c) Chronic bronchitis – wheezing, coarse crackles, hacking 3.
cough that later becomes productive, dyspnea, barrel chest,
clubbing, edema, weight gain.
Abnormal Respiratory Patterns
 Identify abnormal respiratory patterns can help you assess
more completely a patient’s respiratory status and his
overall condition.
4.
1. Tachypnea
 Tachypnea is a respiratory rate greater than 20
breaths/minute with shallow breathing. It is commonly seen
in patients with restrictive lung disease, pain, sepsis,
obesity, and anxiety.
 Fever may be another cause of tachypnea.
The respiratory rate may increase by 4 breaths/minute for
every 1 degree F (0.6 degrees C) rise in body temperature.
2. Bradypnea
 Bradypnea is a respiratory rate below 10 breaths/minute
and is typically noted just before a period of a apnea or full
respiratory arrest.
5. Kussmaul’s Respirations 8.
 Kussmaul’s respirations are rapid, deep sighing breaths that
occur in patients with metabolic acidosis, especially when
associated with diabetic ketoacidosis
6. Cheyne-Stoke Respirations
 Cheyne-stoke respirations have a regular pattern of
variations in the rate and depth of breathing.
9.
 Deep breaths alternate with short periods of apnea.
 This respiratory pattern occurs in patients with heart
failure, kidney failure, or CNS damage.
 However, Cheyne-Stokes respirations may be normal
during sleep in children and elderly patients.
7. Biot’s Respirations
 Biot’s respirations involve rapid, deep breaths that alternate
with abrupt periods of apnea.
 Biot’s respirations are an ominous sign of severe
CNS damage.
 Patients with bradypnea might have CNS depression as a
result of excessive sedation, tissue damage, or diabetic
coma, which all depress the brain’s respiratory control
center.
 The respiratory rate normally decreases during sleep.
Apnea
 Apnea is the absence of breathing or cessation of breathing.
 Periods of apnea may be short and occur sporadically
during Cheyne-Stokes respirations, Biot’s respirations, or
other abnormal respiratory patterns.
 This condition may be life-threatening if periods of apnea
last long enough.
Hyperpnea
 Characterized by deep, rapid breathing, hyperpnea occurs
in patients who exercise or who have anxiety, pain or
metabolic acidosis.
 In a comatose patients, hyperpnea may indicate hypoxia or
hypoglycemia.
Abnormal Breath Sounds
 If you may hear a sound in an area other than where you
would expect to hear it, consider the sounds abnormal.
 For example, if you hear bronchial or bronchovesicular
breath sounds in an area where you would normally hear
vesicular breath sounds, then alveoli and small bronchioles
in that are might be filled with fluid or exudate.
Breath Sounds
 Other breath sounds, called adventitious sounds, are
abnormal no matter where you hear them in the lungs.
 Lung sound:
 Vesicular- NORMAL
 Fine Crackles (fine)
 Coarse crackles (Rales)
 Wheezes
 Rhonchi- Low pitched wheeze
 Bronchial
 Pleural Friction Rub
 Bronchovesicular
6
7