RESPIRATORY ASSESSMENT

INTRODUCTION

A prompt initial assessment allows immediate evaluation of severity of illness and

appropriate treatment measures may warrant instigation at this point. Following this, a
comprehensive patient history will be elicited. Clinical examination of the patient follows and
involves inspection, palpation, percussion and auscultation. At this point, consideration must
be given to preparation of a light, warm, quiet, private environment for examination and
suitable patient positioning. Inspection is a comprehensive visual assessment, while palpation
involves using touch to gather information. The next stages are percussion and auscultation.
While percussion is striking the chest to determine the state of underlying tissues,
auscultation entails listening to and interpreting sound transmission through the chest wall via
a stethoscope.

DEFINITION

The respiratory system is a biological system consisting of specific organs and structures
used for gas exchange. The anatomy of a typical respiratory system is the respiratory tract.
The tract is divided into an upper and a lower respiratory tract. The upper tract includes the
nose, nasal cavities, sinuses, pharynx and the part of the larynx above the vocal folds. The
lowertract includes the lower part of the larynx, the trachea, bronchi, bronchioles and the
alveoli

ANATOMY PHYSIOLOGY OF RESPIRATORY TRACT

The respiratory tract can also be divided into a conducting zone and a respiratory zone, based
on the distinction of transporting gases or exchangingthem. The conducting zone includes
structures outside of the lungs – the nose, pharynx, larynx, and trachea, and structures inside
the lungs – the bronchi, bronchioles, and terminal bronchioles. 

The respiratory tract is divided into the upper airways and lower airways. The upper
airways or upper respiratory tract includes the nose and nasal passages, paranasal sinuses,
the pharynx, and the portion of the larynx above the vocal folds(cords). The lower airways or
lower respiratory tract includes the portion of the larynx below the vocal
folds, trachea, bronchi and bronchioles. The lungs can be included in the lower respiratory
tract or as separate entity and include the respiratory bronchioles, alveolar ducts, alveolar
sacs, and alveoli

Upper respiratory tract

The upper respiratory tract, can refer to the parts of the respiratory system lying above
the sternal angle (outside of the thorax), above the vocal folds, or above the cricoid
cartilage.The larynx is sometimes included in both the upper and lower airways. The larynx is
also called the voice box and has the associated cartilage that produces sound. The tract
consists of the nasal cavity and paranasal sinuses, the pharynx.

1. NASAL CAVITY

The nose formed from both bone and cartilage. The nasal bone forms the bridge, and the
remainder of the nose is composed of the cartilage and connective tissue. Each opening of the
nose on the face (nostrils or nares) leads to a cavity( vestibule). The vestibule is lined
anteriorly with skin and hair that filter foreign objects and prevent them from being inhaled.
The posterior vestibule is lined with a mucous membrane, composed of columnar epithelial
cells, and goblet cells that secrete mucous. The mucous membrane extends throughout the
airways, and cilia (hair liked-projection) propel mucous to the pharynx for elimination by
swallowing or coughing.

2. PHARYNX

The pharynx is a funnel-shaped tube that extends from the nose to the larynx. It can be
divided into three sections,
 The nasopharynx is located above the margin of the soft palate and receives air from the
nasal cavity. From the ear , the Eustachian tubes open into the nasopharynx. The
pharyngeal tonsils (called adenoids when enlarged) are located on the posterior wall of
the nasopharynx.
 The oropharynx serves both respiration and digestion. It receives air from the
nasopharynx and food from the oral cavity. Palatine (facial) tonsils are located along the
sides of the posterior mouth, and the lingual tonsils are located at the base of the tongue.
 The laryngopharynx (hypopharynx) , located below the base of the tongue, is the most
inferior portion of the pharynx. It connects the larynx and serves both respiration and
digestion.

3. LARYNX:
The larynx is commonly called the voice box. It connects the upper (pharynx) and lower
(trachea) airways. The larynx lies just anterior to the upper esophagus. Nine cartilages from
the larynx: three large unpaired cartilages (epiglottis, thyroid, cricoid) and three smaller
paired cartilages (arytenoids, coriculate, cuneiform). The cartilages are attached to the hyoid
bone above and below the trachea by muscles and ligaments, all of which prevent the larynx
from collapse during inspiration and swallowing.

Lower respiratory tract

The lower respiratory tract or lower airway is derived from the developing foregut and
consists of the trachea, bronchi (primary, secondary and tertiary), bronchioles (including
terminal and respiratory), and lungs (including alveoli). It also sometimes includes the larynx.

The lower respiratory tract is also called the respiratory tree or tracheobronchial tree, to

describe the branching structure of airways supplying air to the lungs, and includes the
trachea, bronchi and bronchioles.

 trachea
 main bronchus (diameter approximately 1 – 1.4 cm in adults)
 lobar bronchus (diameter approximately 1 cm)
 segmental bronchus (diameter 4.5 to 13 mm)
 subsegmental bronchus (diameter 1 to 6 mm)
 conducting bronchiole
 terminal bronchiole
 respiratory bronchiole
 alveolar duct
 alveolar sac
 alveolus

1. TRACHEA:

The trachea (windpipe) extends from the larynx to the level of the seventh thoracic
vertebra, which it divides into two main (primary) bronchi. The point at which the trachea
divides is called the carina. The trachea is a flexible, muscular 2- cm- long air passage
with C-shaped cartilaginous rings.

2. BRONCHI AND BRONCHIOLES:

The right main stem bronchus is shorter and wider, extending more vertically downward
than the left main stem bronchus. Thus foreign bodies are more likely to lodge there than
the left main stem bronchus. The segmental and sub-segmental bronchi are subdivisions
of the main bronchi and spread in a inverted, tree-like formation through each lung.
Cartilage surrounds the airway in the bronchi, but the bronchioles (the final pathway to
the alveoli) contain no cartilage and thus can collapse and trap air during active
exhalation.
 3. LUNGS

The lungs lie within the thoracic cavity on either side of the heart. They are cone-shaped,
with the apex above the first rib and the base resting on the diaphragm. Each lung is
divided into superior and inferior lobes by an oblique fissure. The right lung is further
divided by a horizontal fissure, which creates a middle lobe. The right lung, therefore, has
three lobes; the left lobe has only two. In addition to these 5 lobes, which are visible
externally , each lungs can be subdivided into about 10 smaller units (broncho-pulmonary
segments).

LUNG VOLUMES

The volume of air that move in and out with each breath is called the tidal volume.
During quite breathing , tidal volume is about 500 ml. The amount of air inhaled, beyond
the tidal volume is called the inspiratory reserved volume; the extra air that can be
exhaled after a forced breath is called the expiratory reserved volume.

ALVEOLI:

The lung parenchyma, which consist of millions of alveolar units, is the working area of
the lung tissue. At birth the person has approximately 24 million alveoli; by the age 8
years, a person has 300 million. The total working alveolar surface area is approximately
750 to 860 square feet.The blood supply flowing towards the alveoli comes from the right
ventricle of the heart.

4. THORAX:

The bony thorax provide protection to the heart, lungs, and great vessels. The outer shell of
the thorax is made up of 12 pairs of ribs. The ribs connect posteriorly to the transverse
processes of the thoracic vertebrae of the spine. Anteriorly, the first seven pairs of ribs are
attached to the sternum by cartilage . The 8th, 9th , an 10th ribs are attached to each other by
costal cartilage.

5. DIAPHRAGM:

The diaphragm is the primary muscle of breathing and serves as the lower boundary of the
thorax. The diaphragm is dome-shaped in the relaxed position, with central muscular
attachments to the xiphoid process of the sternum and the lower ribs.

6. PLEURAE:

The pleurae are serous membranes that enclose the lung in a double wall sac. The visceral
pleura covers the lung and the fissures between the lobes of the lung. The parietal pleura
covers the inside of each hemithorax, the mediastinum and the top of the diaphragm.
Normally, no space exists between the pleurae: the pleural space is a potential space between
the two layers of pleura.

FUNCTION OF RESPIRATORY SYSTEM:

The respiratory system enhances gas exchange. Inspiration brings oxygen- rich air into the
alveoli. The upper and lower airways filter and humidify inspired air. Gas exchange between
the air ad the blood occurs in the alveolus. Oxygen diffuses into the blood, and co2 diffuses
from the blood into the alveolar air. The co2-enriched air is removed from the body during
expiration. The large number and large surfaces area of alveoli are necessary to meet both
resting and exercise exchange requirements. The thorax ad diaphragm alter pressures in the
thorax to drive air movement.

1. Inhalation and Exhalation

The respiratory system aids in breathing, also called pulmonary ventilation. In pulmonary
ventilation, air is inhaled through the nasal and oral cavities (the nose and mouth). It moves
through the pharynx, larynx, and trachea into the lungs. Then air is exhaled, flowing back
through the same pathway. Changes to the volume and air pressure in the lungs trigger
pulmonary ventilation. During normal inhalation, the diaphragm and external intercostal
muscles contract and the ribcage elevates. As the volume of the lungs increases, air pressure
drops and air rushes in. During normal exhalation, the muscles relax. The lungs become
smaller, the air pressure rises, and air is expelled.

2. External Respiration (Exchanges Gases Between the Lungs and the Bloodstream)

Inside the lungs, oxygen is exchanged for carbon dioxide waste through the process called
external respiration. This respiratory process takes place through hundreds of millions of
microscopic sacs called alveoli. Oxygen from inhaled air diffuses from the alveoli into
pulmonary capillaries surrounding them. It binds to hemoglobin molecules in red blood cells,
and is pumped through the bloodstream. Meanwhile, carbon dioxide from deoxygenated
blood diffuses from the capillaries into the alveoli, and is expelled through exhalation.

3. Internal Respiration( Exchanges Gases Between the Bloodstream and Body Tissues )

The bloodstream delivers oxygen to cells and removes waste carbon dioxide through internal
respiration, another key function of the respiratory system. In this respiratory process, red
blood cells carry oxygen absorbed from the lungs around the body, through the vasculature.
When oxygenated blood reaches the narrow capillaries, the red blood cells release the
oxygen. It diffuses through the capillary walls into body tissues. Meanwhile, carbon dioxide
diffuses from the tissues into red blood cells and plasma. The deoxygenated blood carries the
carbon dioxide back to the lungs for release.
4. Air Vibrating the Vocal Cords Creates Sound

Phonation is the creation of sound by structures in the upper respiratory tract of the
respiratory system. During exhalation, air passes from the lungs through the larynx, or “voice
box.” When we speak, muscles in the larynx move the arytenoid cartilages. The arytenoid
cartilages push the vocal cords, or vocal folds, together. When the cords are pushed together,
air passing between them makes them vibrate, creating sound. Greater tension in the vocal
cords creates more rapid vibrations and higher-pitched sounds. Lesser tension causes slower
vibration and a lower pitch.

5. Olfaction, or Smelling, Is a Chemical Sensation

The process of olfaction begins with olfactory fibers that line the nasal cavities inside the
nose. As air enters the cavities, some chemicals in the air bind to and activate nervous system
receptors on the cilia. This stimulus sends a signal to the brain: neurons take the signal from
the nasal cavities through openings in the ethmoid bone, and then to the olfactory bulbs. The
signal then travels from the olfactory bulbs, along cranial nerve 1, to the olfactory area of the
cerebral cortex.

6. Regulation of acid-base balance:

The lungs through gas exchange, have a key role in regulating the acid-base balance of the
body. Pulmonary disorders that change the CO2 level in the blood cause either respiratory
academia or respiratory alkalemia . Insufficient ventilation causes hypercapnia, a respiratory
academia caused by retention of excessive amounts of CO2. Hyperventilation, conversely,
causes hypocapnia, a respiratory alkalemia caused by the low amounts of CO2 in the blood.
The effectiveness of ventilation is best measured by the PCO2 in the arterial blood.

PURPOSES

 To ascertain the respiratory status of the patient.

 To confirm data obtained in the nursing history.
 To obtain data that will help established nursing diagnosis and plan of care.
 To evaluate the physiologic outcome of health care and thus the progress of the
client’s health problem.
 To make clinical judgements about a client’s health status.
 To identify areas for health promotion and disease prevention.
PREPARING THE ENVIRONMENT

 It is important to prepare the environment before starting the assessment.

 The time for the physical assessment should be convenient to both the client and the
nurse.
 The environment needs to be well lighted and the equipment should be organized for
efficient use.
 The room should be warm enough to be comfortable for the client.

PREPARATION OF THE PATIENT

 Greet patient.
 Explain assessment techniques.
 Quiet ,well light examination.
 Wash hands.
 Introduce yourself.
 Confirm the patients details.
 Explain to the patient that you are going to perform a lung examination.
 Position the patient’s at 45˚.
 Ask if the patient has any pain before you begin.

ASSESSMENT OF RESPIRATORY SYSTEM

1. HISTORY COLLECTION
a) SUBJECTIVE DATA

1.HISTORY COLLECTION:

 The history includes demographic data , current clinical manifestations, pat health
history, family healh history, psychosocial history and review of systems. A structures
physical examination allows the nurse to obtain a complete assessment of the patient.
Observation, palpation, percussion, and auscultation are techniques used to gather
information. Clinical judgment should be used to decide on the extent of assessment
required.
 Demographic data includes client’s age, name, address, date and time, place , name
of referring practitioner etc.

2.PRESENT HISTORY OF ILLNESS: Knowing the chief complaints will help the
examiner in focusing more in that area and will help him in ruling out the disease.

The most common respiratory complaints are:

 Shortness of breath
 Wheezing
 Sputum production
 Pain with breathing
 Cough
 Cold sores
 Allergies
 Sinus problems
 Chest tightness
 Runny nose

3.PAST HISTORY OF ILLNESS: The examiner is to collect information whether the

patient has experienced any of the symptoms before and if any treatment is taken or not.

4.PAST SURGICAL HISTORY: Information should be collected regarding any surgical

treatment done in the past relating to respiratory system.

5.PERSONAL AND SOCIAL HISTORY:

a) Family history: Information should be collected whether any family members in suffering
from asthma, COPD, pneumonia, tuberculosis etc.

b)Lifestyle: Smoking is the risk factor for COPD and lung cancer. Ask about cigarette use,
and find out about the use of any tobacco products, including cigars, pipes, chewing tobacco,
electronic cigarettes and hookah. Excessive use of alcohol also leads to respiratory problems.

c)Occupational history: It includes such as coal mining ,asbestos work ,farming.

b) OBJECTIVE DATA

1.Vital signs: Vital signs i.e temperature, pulse, respiration, blood pressure and SPO2 should
be obtained for baseline information.

2.General appearance: The following should be assessed for indication of the general status
of the patient.

 apparent state of health

 appearance of comfort or distress
 nutritional status
 state of hydration

2. PHYSICAL EXAMINATION
Hypoxia as a result of respiratory conditions may precipitate subtle neurologic alterations,
such as restlessness, fatigue, disorientation, and personality changes. Tachycardia usually
accompanies respiratory problems as the body attempts to compensate for decreased oxygen
delivery. Anorexia and weight loss are seen in many chronic respiratory conditions.

GENERAL ASSESSMENT
Assess the clients level of consciousness and orientation. Noth the skin and lip colour. Assess
the nail beds for color and the presence of clubbing, which occurs as a compensatory measure
for chronic hypoxia.

NOSE AND PARANASAL SINUSES

External nose
Inspect and palpate the external nose for deviations from normal alignment, symmetry, color,
discharge, nasal flaring, lesions, and tenderness. Ask the client to tip the head back, and
inspect the outer nares for crusting, bleeding, or dryness, which should be absent.

INTERNAL NOSE
Next inspect the vestibules with a penlight while the client’s head is tipped back. Normal
findings include coarse hairs, dark red nasal mucosa, a clear passage without discharge, and a
midline septum. Further examination of the internal nose requires the use of a nasal speculum
and is not conducted unless indicated. Inspection may be hampered by nasal congestion.

PARANASAL CONGESTION
Palpate and percuss the frontal and maxillary sinuses to assess for swelling and tenderness,
which are normally absent. Palpate the frontal sinuses simultaneously by placing the thumbs
above the eyes, just under the bony ridge of the eye orbits, and apply gentle pressure.

SMELL
The senses of taste and smell are closely related. smell is perceived mainly via the olfactory
nerves, although some smell is perceived through the trigeminal nerves. Many conditions
affect taste and smell, such as viral infections, normal aging, head injuries, and local
obstruction. Smell impairment may be (1) hyposmia(a decrease in smell sensitivity) or (2)
anosmia (bilateral and complete absence of smell sensitivity). Assess smel by having the
client identify various odors by testing each nostril separately.

THORAX AND LUNGS

Accurate physical examination of the thorax and lungs requires being familiar with the
anatomic landmarks of the posterior, anterior, and lateral thorax. When performing
inspection, palpation, percussion, and auscultation of the respiratory system, the examiner

should compare one side of the thorax to the other side to help determine the presence or
absence of abnormalities.

Four primary techniques are used in the respiratory assessment:

 Inspection
 Palpation
  Percussion
 Auscultation

INSPECTION:

 It is a visual examination that is assessing by using the sense of sight. It should be

deliberate, purposeful and systematic.
 The patient’s anterior chest wall should be exposed while sitting upright or with the head
of the bed upright.
 The patient may need to lean forward for support on the bed side table to facilitate
breathing.
 Shape of the chest:
The normal chest is bilaterally symmetrical and elliptical in cross section. The transverse
diameter > anteroposterior diameter
Common abnormalities of shape
 Kyphosis : forward bending of vertebral column
 Scoliosis: Lateral bending of vertebral column
 Barrel shaped chest: Increase in anteroposterior diameter
 Pectus excavatum: Sternum sunken into the chest
 Pectus carinatum: Sternum protruding from the chest

 Rate and rhythm of respiration:

 Normal respiration:12-20 breaths/min
 In elderly, it is 16-25 breaths/min
Abnormal breathing patterns:
o Kussmaul syndrome:
o Cheyne stroke:
o Biot’s respiration:
 Skin colour provides clues to respiratory status, cyanosis is a late sign of hypoxemia.The
finger should be inspected for evidence of long standing hypoxemix known as clubbing
of nails.
 Measurement of chest expansion:
 Chest expansion can be measured with a tape measure around the chest just below
the nipples =3-5cm
 Symmetry of chest expansion:
 Chest expansion is equal on both sides of a healthy adult
 Movements of the chest wall:
 Presence of intercostals recessions or the use of accessory muscles

PALPATION:

The nurse determines tracheal position by gently placing the index fingers on either side of
the trachea just above the suprasternal notch and gently pressing backward. Normal tracheal
position is midline, deviation to the left of right is abnormal.
The nurse determines symmetry of the chest expansion and extent of the movement at the
level of the diaphragm. The nurse places the hands over the lower anterior chest wall along
the costal margin and moves them inward until the thumbs meet at the midlines. The patient
is asked to breath deeply, and the nurse observes the movement of the thumbs away from
each other. Normal expansion is 1 inch (2.5cms) on the posterior side of the chest the nurse
places the hands at the level of the tenth ribs and moves the thumbs until they meet over the
spine. The nurse check the expansion anteriorly or posteriorly.

Normal chest movement is equal. Unequal expansion of occurs when air entry is limited by
conditions involving the lungs or the chest wall.

Fremitus is vibration of the chest wall produced by vocalization. To elicit tactile fremitus, the
nurse places the palmar surface of the hands with the hyperextended fingers against the
patient’s chest and asks the patient to repeat the phrase such as ninety-nine in a deeper.
Louder than normal voice. The nurse moves hands form side to side at the same time from
the top to bottom on the patient’s chest.

An increase, decrease or absence or fremitus should be noted. Increased fremitus occurs

when the lungs becomes filed with fluid or more dense. As the patient’s voice moves through
a dense tissue or fluid, the vibration felt by the examiner is increased.

PERCUSSION:

Percussion is done to assess density or aeration of the lungs. Percussion sounds are

Resonance: low-pitched sound heard over normal lung

Hyper-resonance: loud, lower pitched sound than normal resonance heard over
hyperinflated lungs, such as in chronic obstructive lung disease and acute asthma.

Tympany: sound with drumlike, loud, empty quality heard over gas filled stomach or
intestine or pneumothorax.

Dull: sounds with medium intensity pitch and duration heard over areas of mixed solid and
lung tissue such as over top area of liver partially consolidated lung tissue.

Flat: soft, high pitch sounds or short duration heard over very dense tissue where air is not
present such as posterior chest below level of diaphragm.

The anterior chest wall is usually percussed with the patient in a semi sitiing or supine
position. Starting above the clavicle, the nurse purcusses downward interspace by interspace.
The area over lung tissue should be resonant, with the exception of the area of cardiac
dullness.

AUSCULTATION:During chest auscultation, the patient is instructed to breathe slowly and

a little deeper than normal through the mouth. The nurse proceed from the lungs apices to the
bases, comparing opposite areas of the chest.
The stethoscope should be placed over the lung tissue, not over the bony prominences. The
nurse should listen one cycle of inspiration and expiration.

The lung sounds are heard anteriorly from the line drawn perpendicular to the xiphoid
process lateral to the midclavicular line. Then the nurse should palpate inferiorly two ribs in
the midaxillary line and around the posterior chest. This gives the examiner a fairly accurate
and easy way to determine the lung fields to ausculated.

There are three normal sounds:

Vesicular: It has a 3:1 ratio, with inspiration 3 times longer than the expiration.

Bronchovesicular sounds: It has a medium pitch and intensity and are heard anteriorly over
the mainstem over bronchi on either side of the sternum and posteriorly between the
scalpulae.

Bronchial sound: They are louder and higher pitched and resembles air blowing througha
hollow pipe.

CONCLUSION:

Respiratory assessment is one of the most important to rule out the abnormalitypresent in the
patient so the necessary care plan can be taken out and the nursing diagnosis can be
formulated.