NURS 50004

Assessment of the Respiratory System

Rosemary Turner
RN, BHSc, GDip Critical Care, MPH
Code of Conduct for Nurses

• Domain: Practice legally

• Legal compliance
• Domain: practice safely, effectively and collaboratively
• Person-centred practice
• Cultural practice & respectful relationship
• Domain: Act with professional integrity
• Professional behaviour
• Teaching, supervising and assessing
• Research in health
• Domain: Promote health and wellbeing
• Health & wellbeing

NMBA, 2018 2
Registered Nurse standards for practice
1. Thinks critically and analyses nursing practice.

2. Engages in therapeutic and professional relationships.

3. Maintains the capability for practice.

4. Comprehensively conducts assessments.

5. Develops a plan for nursing practice

6. Provides safe, appropriate and responsive quality nursing practice.

7. Evaluates outcomes to inform nursing practice.

NMBA, 2016 3
National Safety & Quality Health Service
• The Commission developed the National Safety and Quality Health
Service (NSQHS) Standards to improve the quality of health service
provision in Australia.
• There are 8 NSQHS Standards focusing on areas that are essential to
drive the implementation and use of safety and quality systems:
• Clinical Governance Standard
• Partnering with Consumers Standard
• Preventing and Controlling Healthcare Associated Infections
Standard
• Medication Safety Standard
• Comprehensive Care Standard
• Communicating for Safety Standard
• Blood Management Standard
• Recognising and Responding to Acute Deterioration Standard
 • Understand the importance of undertaking a systematic health
assessment as the basis of nursing care

• Identify key considerations and patient preparations required

before & during assessment of the respiratory system

Learning • Apply core physical assessment skills relevant to the respiratory

system and reflect on the use of these skills in nursing practice

Objectives • Differentiate normal from abnormal assessment findings

• Analyze assessment data to determine the patient health problems

and clinical priorities

• Document and communicate a systematic health assessment

 • You will be allocated to a breakout room in
groups of 8-10 where you will discuss the
questions presented on the next slide.
• Please accept the invitation to join your
Class breakout group when it appears at the bottom

Activity
of your screen
• The breakout room will end in 10 minutes and
you will rejoin the group session automatically
• Now consider the questions that follow
 • What is a respiratory assessment?
• What is the value of a respiratory assessment
Respiratory • What do you feel confident about?
assessment • What do you think will challenge you in
practice?
 8

Nursing Handover

Jessica Jones 68 yrs. DX

infective exacerbation
COAD Ex smoker, PMHx HT,
PVD, Leg ulcers, R(CVA),Cor
Pul, NIDDM, Home O2, #
SPR, Altered Met call
criteria, NFR, NHP, Falls
risk.
 9

Nursing Handover

Xiuxan Tan, 39yrs Dx

Asthma, Post ICU, MV 4/7,
IVC, Pre & Post Peak flows,
SW Review.
Structure and function

• Thoracic cage
• 12 pairs of ribs
• 12 thoracic vertebrae and cartilage
• Support & protection

• Sternum & Clavicles

• Manubrium, the body and the xiphiod
process
• Substernal notch

• Ribs & thoracic vertebra

10
 Thoracic cavity
Lungs
• Apex, base, diaphragm
• Lobes, fissures
• R) three lobes / L) two lobes

Pleural membranes

Trachea & Bronchi

11
Lung lobes
Left upper image:
Left lower image:
Right upper image:
Right lower image:

12
Function of the Respiratory System

• Function is to provide life sustaining

oxygen (02) to all cells of the body and to
remove the by products of cellular
metabolism, carbon dioxide (CO2)

• Respiration

• Ventilation

• Diffusion & Perfusion

Lewis & Foley p. 349 13

 • Respiration – 3 main processes

The Process • Transfer of O2 across the alveolus

of • Transport of O2 to the tissues

• Removal of CO2 from blood → alveoli →
Respiration environment
Mechanics of Breathing - Ventilation

• Movement of gases into and out of the lungs

• Coordination of the muscular & elastic properties

of the lungs & thorax

• Intact CNS

• Role of the Diaphragm

15
 • Diffusion & Perfusion

The Process
of
Respiration
 • Boyles Law
• Volume and pressure

• Daltons Law
Gas Laws • Law of partial pressures

• Fick's Law
• Diffusion of O2 and CO2
 • Knowledge of normal respiratory structure and
function
• Knowledge of terminology
Respiratory • Gathering information
• A systematic approach
assessment • Documentation
begins with
 Gathering • What do you need to know about the patient?
• What type of assessment approach will you
information use?
 • Hx of Present Health Concern

• Past health Hx
Collection of
Subjective • Family Hx
Data
• Life Style & Health Practices
 • Character
• Describe the sign or symptom

Use • Onset
• When did it begin

COLDSPA to • Location
• Where is it ? Does it radiate? Does it occur anywhere else?

guide your • Duration

• How long does it last / Does it reoccur ?

collection of
• Severity
• How bad is it or How much does it bother you?

information
• Pattern
• What makes it better or worse
• Associated Factors
• What other symptoms occur with it? How does it affect you ?
 • Do you ever experience difficulty with breathing?
Describe the difficulty
• Do you experience any other symptoms when you have
difficulty breathing ?
• Do you have difficulty breathing why you are resting or
History of doing any specific activities
• Difficulty breathing with ADL’s ?
present • How many pillows do you sleep on?
• Do you have chest pain ?
health • Do you have a cough ?
• How often does it occur
concern • Is the cough productive
• What color is your sputum
• Do you have a wheeze
• Do you produce any sputum when you cough ?
• Do you wheeze or cough
• Do you have any GI symptoms e.g. heart burn
 • Prior respiratory problems

• Previous thoracic surgery, biopsy or trauma

• Allergies

• Previous pulmonary studies i.e. chest x-ray (CXR)

Past health
• Recent travel overseas
Hx
• Current medications

• Hx of lung disease in your family

• Does anyone in your household smoke ?

 • Is there a Hx of lung disease in your family

Past Family • Did any family members in your home smoke

when you were growing up
History
• Is there a hx of other pulmonary illnesses/
disorders in the family e.g. asthma?
 • Have you ever smoked ? What did you smoke ? Do
you currently smoke ?
• Are you exposed to any environment conditions
that affect your lungs ? Where do you work ? Are
you around smokers ?
Lifestyle and • Do you have difficult preforming your ADLs ?

health • Any you experience any stress at this time ? How

does it affect your breathing ?
practices • Any you taking any medications for breathing
problems or other medications ?
• Do you use any other RX at home for your
respiratory problems ?
• Have you used any herbal medicines or alternative
Rx to mange colds or tother respiratory problems ?
 • Dyspnea

Common • Cough characteristics

symptoms • Sputum characteristics
and
conditions • Wheezing and stridor

• COPD
Dyspnea

• Subject sensation of difficulty or uncomfortable

breathing
• Breathlessness

• Clinical sign of hypoxia

• Physiological - associated with exercise or
excitement
• Pathological – inability to catch a breath
without related activity or exercise

• Look for other clinical signs & symptoms

• Exaggerated respiratory effort, use of accessory
muscles, nasal flaring, increased rate and depth
of respirations
• Circumstances under which it occurred, how
does the dyspnea affect the patients ADL’s

27
 • Protective response to irritation of sensory
receptors in the submucosa of the upper
airways or bronchi

• Muffled wheezy cough

• Loose productive cough
Cough • Dry irritating cough
Characteristics • ACE inhibitor drugs
• Barking or croupy cough

• Assess – timing (continuous, early morning,

late evening etc.)
 • Colour
• Clear, white, yellow, green, brown, red, streaked with
blood
• Changes in colour
• Clearing with cough, progressively darker
• Odour
Sputum • Foul

Characteristics • Quality
• Teaspoon, tablespoon, cupful. Increased or decreased
• Consistency
• Frothy, watery, tenacious
• Presence of blood (Hemoptysis)
• Occasional, early morning, bright red, dark red, blood
tinged
 Wheeze
High pitch musical sound caused by
Wheezing & high velocity movement of air
through a narrowed lower airway
Stridor Associated with asthma, acute
bronchitis or pneumonia etc.
Inspiration, expiration or biphasic
Stridor
High pitched sound resulting from
turbulent air flow or obstruction in
the upper airway
Associated with foreign bodies, croup,
epiglottitis etc.
It can be inspiratory, expiratory or
biphasic.
Inspiratory stridor is most common
30
 • Conditions that obstruct airflow to and from the alveoli
• Emphysema and chronic bronchitis
• 1 in 20 people age over 45 have some from of COPD
Chronic
Obstructive • In 2017-2018 31% of Australians had chronic respiratory
conditions- almost 7.4 million people.

Pulmonary • Risks

Disease • Cigarette smoking, occupational exposure , age 40+,

genetic (rare)

(COPD) • Reduction tips

• Smoking and passive smoking
• Influenza vaccines
• PPE
Indigenous Australians
• Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis are significant contributors to
Aboriginal and Torres Strait Islander health disadvantage.

• Indigenous Australians were nearly 3 times as likely to die from COPD as were non-Indigenous
Australians during the period 2007-2011.

• Nationally, COPD affects approximately 20% of indigenous adults but the prevalence exceeds this
in remote regions.

• In addition to the considerable under diagnosis of COPD in Australia there are many identified
issues that can form barriers to Aboriginal and Torres Strait Islander People accessing effective
health care in their local area.; lack of transport to and from services, fear and distrust of
services and a lack of available, culturally safe services.

Lung Foundation Australia 32

 • Eye ball assessment
• Inspection
Respiratory •
•
Palpation
Auscultation
Assessment • Percussion
• Alteration to breathing pattern
• Signs of respiratory deterioration
 • Observe airway patency and ability to speak & cough
• Observe work of breathing, skin colour and mental
status
• Measure respiratory rate, depth and pattern of
breathing
• Measure peripheral oxygen saturation. Note the pt 02
LOOK at requirements
• NOTE
your • Increased respiratory rate

PATIENT ! • Use of accessory muscles, tracheal tug, rib and/or

abdominal recession
• Increased pulse rate
• Increased sweating (diaphoresis) or clamming skin
• Anxiety agitation &/or confusion
 Examination
of the Neck –
“TWELVE C”
• Trachea
• Wounds
• Oedema (Edema)
• Larynx
• Veins
• Oesophagus (Esophagus)
• Carotid bruit and C spine

35
 Assessment Normal findings Abnormal findings

Nasal flaring and Nil abnormalities Nasal flaring – children indicative

pursed lips noted (NAD) oh hypoxia
Colour face, lips & Pursed lips asthma, emphysema
Physical chest
Colour and shape of
or CHF
*helps to slow down

Assessment
•
nails
Configuration of the
expiration and keep alveoli
open

Inspection
chest Ruddy or purple complexion
Use of accessory Pale, cyanotic nails, clubbing
muscles Use of trapezius & shoulder
Patient positions muscles
Phonation Tripod position *uses arms to
support weight and lifts chest to
increase breathing capacity
Speaks in words or sentences

36
 Assessment Normal findings Abnormal findings

Physical Tenderness and

sensation
Normal findings
Nil pain, tenderness
Hyperresonance
*air trapping
Assessment Crepitus or unusual emphysema or

: Palpation
Surface sensations pneumothorax
characteristics No crepitus Dullness *solid
Fremitus Skin free from tissue resplices air
Chest expansion lesions and masses in the lings :
tumour, pleural
effusion or
pneumonia

37
 Tactile
fremitus
• (N) lung transmits a palpable
vibratory sensation to the chest
wall

• Consolidation

• Pleural effusion

38
 Assessment Normal findings Abnormal findings

Start at the apices of Resonance in Hyperresonance

Physical the scapula and

percuss across the
lungs fields
Flat tones over
*air trapping
emphysema or
Assessment tops of both
shoulders
the scapula pneumothorax
Dullness *solid
: Percussion Percuss the
intercostal spaces
tissue resplices air
in the lings :
across & down tumour, pleural
comparing sides effusion or
Percuss to the lateral pneumonia
aspect at the bases of
the lungs comparing
sides

39
 • Use diaphragm of stethoscope (Lewis & Foley p.
355)

• Patient relaxed and breathing deeply through the

mouth
• Avoid prolonged deep breathing

Auscultation • Requires methodical assessment to compare lung

- Technique fields bilaterally
• Anterior and / or posterior approach

• Listen to whole respiratory cycle

• Inspiration → Expiration → Inspiration
 Assessment Normal findings Abnormal findings

Auscultate from the Normal breath sounds Crackles coarse &

Physical apices of the lungs

above the clavicles to
fine
Pleural friction rub
Assessment: the bases of the lungs
at the 6th rib
Wheeze

Auscultation Ask the pt. to breathe

deeply through their
mouth – be alert for
pt. discomfort

41
42
43
 Normal Breath
Sounds
• Vesicular
• Low, breezy, soft
• Long in inspiration short expiration
• Peripherial lung fields

• Bronchial
• High, loud, harsh or hollow
• Duration : Inspiration short / expiration long
• Trachea and thorax

• Bronchovesicular
• Moderate, mixed
• Same in inspiration and expiration
• Posterior between the scapula
• Anterior around the upper sternum, 1st and 2nd intercostal
space

44
 • flat—a short, soft, high-pitched, and extremely dull sound as
heard over bone or muscle; indicates consolidation, such as in
atelectasis or extensive pleural effusion

• dull—a thudlike sound as heard over solid organs such as the liver;
may replace resonance in the lungs when fluid is present as in
pneumonia

Terminology • resonant—a long, loud, low-pitched, and slightly hollow sound as

heard over the lungs or abdomen; indicates bronchitis

• hyperresonant—a very loud, lower-pitched sound as heard over

the stomach; indicates a hyperinflated lung as in emphysema or
pneumothorax

• tympanic—a loud, high-pitched, drum-like sound as heard over a

puffed-out cheek; indicates excess air as in a large pneumothorax.
 • crackles (course or fine)—discontinuous popping or
bubbling sounds that occur when air is forced through
fluid-filled airways, causing the airway to suddenly open;
if you hear crackles, suspect pulmonary edema, chronic
CHF, or pneumonia

• wheezes (sonorous or sibilant)—musical sounds that

Terminology occur when air moves quickly through mucus-filled,

narrowed airways, heard on inspiration or expiration; if
you hear wheezes, suspect pulmonary disease, such as
asthma, COPD, or an acute allergic reaction

• pleural friction rub—a creaking or grating sound caused

by the inflamed pleural surfaces rubbing together;
sometimes heard in the presence of pneumonia.
 • Bronchophony
• Voice sounds are increased and clearer
• Due to lung consolidation but clear airways

Abnormal • Whispering pectoriloquy

• Normally whispering is poorly heard using a
Voice stethoscope
• Words can be clearly heard during whispering
Sounds • Due to lung consolidation but clear airways

• Egophony
• E sounds like A when listening with stethoscope
• Due to consolidation and pleural effusion
Assessment • Altered breathing patterns
of • Signs of deterioration
respiratory •
•
Tissue hypoxia
Cyanosis
alterations
 Putting it all together

• https://protect-
au.mimecast.com/s/A0sTCJypvAfq8PpP7SV8dFA?domain=yout
u.be

49
Alteration in
breathing
Alteration Description
Apnoea
patterns
Bradypnea

Cheyne-Stokes respiration

Hyperventilation

Hypoventilation

Kussmauls respiration

Tachypnea

50
 EARLY warning signs LATE warning signs

Signs of Pulse rate 40 – 49 or 120-140 /min

Alteration in mentation
Pulse rate <40 or > 140
Unresponsive to verbal stimuli
Respiratory Partial airway obstruction
RR 5-9 or 30 – 40 breaths/min
Airway obstruction or stridor
RR > 5 or < 40
Deterioration Sp02 90 – 95%
Pa02 50 – 60 mmHg
Sp02 < 90 %
PaO2 < 50 mmHg
PaC02 50 – 60 mmHg PaC02 . 60 mmHg
pH 7.2 7.3 pH < 7.2
Failure to reverse waring sign within 1/24

51
 Caused by
• A decrease Hb level and lowered O2 caring capacity of the
blood

• A diminished concentration of inspired oxygen, which may

occur at high altitudes

Tissue • The inability of tissue to extract oxygen from the blood, e.g.

hypoxia
cyanide poising

• Diffusion impairment e.g. pneumonia

• Poor tissue perfusion with oxygenated blood e.g. hypovolemic

shock

• V/Q mismatch as with multiple rib fractures or chest trauma

 Abnormal findings

Restlessness Behavioural changes

Apprehension, anxiety Increased pulse rate

Tissue Decreased ability to concentrate

DLOC
Increased rate and depth of breathing
Elevated blood pressure

hypoxia Increased fatigue

Dizziness
Cardiac arrhythmias
Pallor

S&S
Hypoventilation
Clubbing
Dyspnoea

53
 Cyanosis

• Blue discolouration of the skin and mucous

membranes caused by the presence of desaturated
haemoglobin in the capillaries : a LATE sign of
hypoxia.
• Metabolic acidosis due to anaerobic metabolism
• Administration of oxygen and id and Rx cause

• Central V peripheral cyanosis – cause ?

• Where do you observe for cyanosis ?

• Obvious when arterial oxygenations falls below 90 %

in a person with a (N) Hb
• Anaemia ?
• The absence of cyanosis does not exclude
hypoxia 54
Cyanosis
Mnemonic

55
 • flat—a short, soft, high-pitched, and extremely dull sound as
heard over bone or muscle; indicates consolidation, such as in
atelectasis or extensive pleural effusion

• dull—a thudlike sound as heard over solid organs such as the liver;
may replace resonance in the lungs when fluid is present as in
pneumonia

Terminology • resonant—a long, loud, low-pitched, and slightly hollow sound as

heard over the lungs or abdomen; indicates bronchitis

• hyperresonant—a very loud, lower-pitched sound as heard over

the stomach; indicates a hyperinflated lung as in emphysema or
pneumothorax

• tympanic—a loud, high-pitched, drum-like sound as heard over a

puffed-out cheek; indicates excess air as in a large pneumothorax.
 • crackles (course or fine)—discontinuous popping or
bubbling sounds that occur when air is forced through
fluid-filled airways, causing the airway to suddenly open;
if you hear crackles, suspect pulmonary edema, chronic
CHF, or pneumonia

• wheezes (sonorous or sibilant)—musical sounds that

Terminology occur when air moves quickly through mucus-filled,

narrowed airways, heard on inspiration or expiration; if
you hear wheezes, suspect pulmonary disease, such as
asthma, COPD, or an acute allergic reaction

• pleural friction rub—a creaking or grating sound caused

by the inflamed pleural surfaces rubbing together;
sometimes heard in the presence of pneumonia.
 • Mick O’Keeffe is a 68 year old man with a history of COPD. He has
been referred to hospital by his LMO with a three week history of

Mick
increased breathlessness, reduced exercise tolerance and green
sputum.
• He has a past medical history of depression and he has been a
O’Keeffe pack a day smoker for the last fifty years. “Mick” is normally
capable of walking 500 m but now is having difficulty dressing and
is breathless at rest. He is using his Salbutamol inhaler every 2 – 3
hours, with little effect.
• O/A his GCS is 15, T 38.6 , HR is 96, RR 26, BP 145/90mmhg, Sa02
is 94 % on room air.
• He is using accessory muscles of respiration and breathing through
pursed lips.
• He has a barrel chest and on auscultation has coarse crackles in his
right lower lobe.
• Mick is complaining of insomnia, poor appetite, pain on inspiration
and fatigue.
• You note since the last admission, Mick has lost 5kg in weight.
 Activity

• Identify two (2) actual and one (1) potential healthcare

problems/issue that the nurse is accountable and responsible
to treat.
• Discuss in breakout room groups
• 10 minutes

59
 • Identify two (2) actual and one (1) potential healthcare
problems/issue that the nurse is accountable and
responsible to treat.
• Discuss a plan of care that your group would initiate that is
specific, realistic, evidence based and individualised to
resolve Mr O’Keeffe’s problems.
• Be sure to outline an evidenced based rationale for the
Nursing nursing practices/interventions identified
• Discuss the expected benefit to Mr O’Keeffe’s from the
Process implementation of your nursing care i.e. the goal of your
nursing actions
• An outline of how you would evaluate Mr O’Keeffe’s
response to the nursing practices/interventions outlined
• Construct a concept map that demonstrates all the
significant assessment data and the relationship or links
among these data
Health Promotion

61
 • Maintain ideal body weight
• Eat a low fat, low-salt, kilojoule-appropriate diets
• Monito cholesterol and triglycerides levels
• Engage in day aerobic exercise
• Use stress reduction techniques
• Be smoke free
Cardiopulmonary • Avoid second have smoke and other pollutants
health promotion • Use a filer mask when exposed to occupation
hazards
• Monitor BGL
• Get annual influenza vaccine for those at risk
• Reduce exposure to secondary infection
• Get pneumococcal vaccine
 • Understand the importance of undertaking a systematic health
assessment as the basis of nursing care

• Identify key considerations and patient preparations required

before & during assessment of the respiratory system

• Apply core physical assessment skills relevant to the respiratory

In summary system and reflect on the use of these skills in nursing practice

• Differentiate normal from abnormal assessment findings

• Analyze assessment data to determine the patient health problems

and clinical priorities

• Document and communicate a systematic health assessment

 • Crisp, J., Taylor, C., Douglas, C., & Rebeiro, G. (Eds.).
(2017). Potter & Perry’s fundamentals of nursing /
Australian and New Zealand edition. (5th ed.).
Chatswood: Elsevier.

• Lewis L., & Foley, D. (Eds.).(2014). Health assessment in

nursing. (2nded.). Sydney: Wolters Kluwer.

References • Tollefson, J. (2016). Clinical psychomotor skills:

Assessment skills for nurses (6th ed.). Melbourne:
Cengage learning.

• Reberio, G., Jack, l., Scully, N., & Wilson, D. (2017).

Fundamentals of nursing clinical skills workbook. (3rd
ed.). Chatswood: Elsevier.
Thank you