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Assessment On Respiratory Problems
Assessment On Respiratory Problems
Assessment On Respiratory Problems
A
lthough the first stethoscope Fig 2. Location of the lung
Authors Jaclyn Proctor is respiratory for auscultation was invented lobes (anterior chest)
advanced nurse practitioner at in 1816 by René-Théophile-
Warrington and Halton NHS Hyacinthe Laennec, the use of
Foundation Trust; Emma Rickards is auscultation dates back to Hippocrates, Right lung Left lung
respiratory nurse consultant at who would place his ear to his patient’s
Horizontal
Liverpool Heart and Chest Hospital chest and listen for sounds. fissure
NHS Foundation Trust and Knowsley Auscultation is an important part of an
Community Respiratory Service. assessment of the respiratory system and Superior
is also used for cardiac and gastrointes- lobe Superior
Abstract Chest auscultation is tinal examination. The procedure should lobe
frequently used in the clinical always form part of an holistic assessment
examination of patients. This article and must be viewed alongside the patient’s Middle
lobe
explains the clinical procedure for chest clinical history (Box 1).
Inferior
auscultation and provides a guide to The Nursing and Midwifery Council lobe Inferior
interpreting findings. (2018) has included chest auscultation and lobe
Oblique fissure
interpretation of findings in the Standards
Citation Proctor J, Rickards E (2020) of Proficiency for Registered Nurses, and stu-
How to perform chest auscultation and dent nurses now learn this skill as under-
interpret the findings. Nursing Times graduates. transmitted to the trachea and bronchi.
[online]; 116: 1, 23-26.. To undertake a thorough assessment of These sounds are audible when ausculta-
the chest, including auscultation, it is tion is performed using a stethoscope.
essential to understand the anatomy and Chest auscultation involves listening to
Box 1. IPPA assessment physiology of the respiratory system. Fig 1 these internal sounds to assess airflow
A commonly used acronym in clinical illustrates the anatomy of the lungs and through the trachea and the bronchial tree
examination of the chest is IPPA: Fig 2 highlights the location of the lung (Sarkar et al, 2015).
Inspection lobes from an anterior chest perspective. Familiarity with the normal vesicular
Palpation Cedar (2018) provides further information breath sounds found at specific locations
Percussion on the physiology of breathing. on the chest enables health professionals
Auscultation to identify abnormal sounds, which are
This is an example of a systemic What is chest auscultation? often referred to as adventitious. It is not
assessment tool but other tools are Vesicular breath sounds occur when the always possible to determine from which
available (Simpson, 2015) vocal cords vibrate during inspiration and lobe of a lung a sound is emanating. Using
expiration, when the vibrations are the four chest X-ray zones can, therefore,
be helpful:
l A
pical zone: above the clavicles;
Fig 1. Anatomy of the lungs
l U
pper zone: below the clavicles and
Respiratory bronchioles, Large airways: above the cardiac silhouette;
with alveoli and Trachea l M
id zone: level of the hilar structures;
pulmonary circulation l L
ower zone: bases.
Right bronchus
Left bronchus
Equipment
The bell of the stethoscope is generally
Smaller airways:
used to detect high-pitched sounds – at the
- dichotomous apex of the lungs above the clavicle; its dia-
branches
phragm is used to detect low-pitched
Pleural sounds in the rest of the chest (Dougherty
membranes – and Lister, 2015). Fig 3 illustrates parts of
Outer parietal the stethoscope.
Inner visceral
Infection prevention
PETER LAMB
Clinical Practice
Practical procedures
Eartips
Binaurals
Brace
Tubing
Chestpiece
Bell
Starting at the top of the chest (first intercostal space),
Diaphragm use a ‘stepladder’ approach to listen to breath sounds on
the anterior chest finishing at the seventh intercostal space
contaminated by micro-organisms Positioning the patient 6. Position the patient comfortably so you
(Longtin et al, 2014). Adherence to local The optimal position for chest ausculta- can access their chest.
infection prevention and control policies, tion is sitting in a chair, or on the side of
including the cleaning of equipment the bed. However, the patient’s clinical 7. Remove or rearrange the patient’s
between every patient contact, is essential. condition and comfort needs to be consid- clothing as necessary to enable you to see
Nurses are advised to have a stethoscope ered during the examination and some the chest.
for their own use, as sharing equipment patients may only tolerate lying at a 45°
may increase infection risk and main- angle. Both these positions will facilitate 8. See whether the stethoscope feels cold.
taining clean ear tips can be difficult. the assessment (Ferns and West, 2008). Warm it between your hands if necessary
Non-sterile gloves are not required rou- You may need help to support the patient before applying it to the chest to avoid dis-
tinely for this procedure. Nurses need to in a comfortable position during the comfort for the patient.
assess individual patients for the risk of examination.
exposure to blood and body fluids (Royal 9. Position the ear tips in your ears so they
College of Nursing, 2018) and to be aware The procedure point slightly forward towards the nose;
of local policies for glove use. 1. Ensure your stethoscope has been this will help to create a seal and will
cleaned following local infection preven- reduce external noise.
Preparing the environment tion and control guidance.
and patient 10. Holding it between the index and
Listening to a patient’s chest to establish 2. Discuss the procedure with the patient middle finger of your dominant hand,
breath and any other sounds requires a quiet and gain informed consent. place the chest piece of the stethoscope
area, so that health professionals can fully flat on the patient’s chest using gentle
appreciate what they hear and interpret 3. Check that the patient is kept warm and pressure.
their clinical relevance (Sarkar et al, 2015). the area is free from drafts.
Chest auscultation requires the chest 11. Using a ‘stepladder’ approach (Fig 4a)
and back to be exposed, so measures should 4. Screen the bed to maintain patient pri- listen to breath sounds on the anterior
be taken to ensure the patient’s privacy and vacy and dignity. chest. This technique allows you to com-
dignity is maintained at all times. A chap- pare one side of the chest with the other
PETER LAMB
erone should be offered for the assessment 5. Decontaminate your hands according to in a systematic manner and detect any
if this is considered appropriate. local policy. asymmetry. The stethoscope should be in
Clinical Practice
Practical procedures
Fig 4b. Posterior chest auscultation Fig 4c. Right lateral chest auscultation
Start at the first intercostal space of the posterior chest Move from the peak of the axilla to between the seventh
moving downwards, avoiding the scapula, to the seventh or eight rib on the right and left.
intercostal space
contact with the chest for a full cycle of 19. Record findings in the patient’s notes often louder than usual breath sounds and
inspiration and expiration at each point on (Box 2). in some patients it is audible from some
the stepladder (Ferns and West, 2008). distance or when the patient breathes
Interpreting findings through the mouth. With a stethoscope
12. Use the step ladder approach for the There are several adventitious sounds but you may also be able to hear a wheeze over
posterior chest (Fig 4b); avoid the scapula the main ones to be aware of are crackles, the patient’s trachea (Sarkar et al, 2015).
as lung sounds cannot be heard through wheeze and absent breath sounds. Wheeze is often referred to as a musical
bone (Ferns and West, 2008). sound and is sometimes considered to be a
Crackle precondition for conditions such as air-
13. Ask the patient to move their right arm Crackles are generated within the small flow obstruction (Simpson, 2015).
to the side so the right lateral chest can be airways; they predominantly occur during Clinical conditions such as asthma are
assessed (Fig 4c). Starting with the upper the inspiratory phase but can happen on associated with a high-pitched musical
lobe move to the middle lobe, and finally expiration. Clinical conditions where wheeze that may be more evident on expi-
the lower lobe at the bottom (Ferns and crackles maybe present include pneu- ration. An inspiratory wheeze (stridor)
West, 2008). monia, pulmonary fibrosis, chronic usually results from an upper airway
obstructive pulmonary disease (COPD), obstruction such as laryngeal oedema or
14. Repeat on the left side where the lung is lung infection and heart failure. the presence of a foreign body. A wheeze
made up of an upper lobe and lower lobe. Crackles can be categorised as coarse or on both inspiration and expiration could
fine; distinguishing between these can be be due to secretions in the airways (Welch
15. Replace the patient’s clothing and make significant – coarse crackles may indicate and Black, 2017) and the patient may need
them comfortable. pneumonia, while fine crackles may sug- to be advised how to clear their chest
gest pulmonary oedema. of secretions.
16. Explain your findings to the patient It takes practice to learn to differentiate
and check whether they have any ques- between coarse and fine crackles and inter- Absent breath sounds
tions. pretation remains subjective. This describes a lack of audible breath
sounds on auscultation. It could be caused
17. Decontaminate your stethoscope. Wheeze by lung disorders that inhibit the trans-
PETER LAMB
Wheeze often occurs on expiration, but mission of sounds, for example, a pneu-
18. Decontaminate your hands. can also occur on inspiration. Wheezing is mothorax, pleural effusion or areas of lung
A. READING COMPREHENSION 1
Read the article on “How to perform chest auscultation and interpret the findings”.
Put “T”, if the statement is true, and “F”, if the statement is false.
1. (____) Vesicular breath sounds occur when the vocal cords vibrate only during inspiration.
2. (____) Chest auscultation involves listening to these external sounds to assess airflow through the
trachea and the bronchial tree.
3. (____) The bell of the stethoscope is generally used to detect high-pitched sounds – at the apex of the
lungs above the clavicle.
4. (____) The diaphragm of the stethoscope is used to detect low-pitched sounds in the rest of the chest.
5. (____) The stethoscope is an important tool for clinical assessment, but can not become contaminated
by micro-organisms.
6. (____) Nurses are advised to have a stethoscope for their own use, as sharing equipment may increase
infection risk and maintaining clean ear tips can be difficult.
7. (____) Nurses do not need to assess individual patients for the risk of exposure to blood and body
fluids.
8. (____) Chest auscultation requires the chest and back to be closed, so measures should be taken to
ensure the patient’s privacy and dignity is maintained at all times.
9. (____) The optimal position for chest auscultation is sitting in a chair, or on the side of the bed
10. (____) The patient’s clinical condition and comfort needs to be considered during the examination and
some patients may only tolerate lying at a 45° angle.
B. READING COMPREHENSION 2
Read the article on “How to perform chest auscultation and interpret the findings”.
Match the sentences in column A with the expressions in column B to give correct keyword
characteristics.
C. CASE STUDIES 1
Read the case study below and organize the assessment using IPPA (inspection, palpation, percussion
and auscultation).
Emma Green*, aged 65, attended the emergency department with history of a productive cough for five
days, reduced exercise tolerance and increased breathlessness. She reported pain on right lower aspect of
the posterior chest. On assessment, Ms Green reported no underlying respiratory disease. Chest
auscultation identified reduced air entry on the right lower lobe and additional coarse crackles on
inspiration in the right mid zone. In this case the auscultation findings and clinical history suggest a
diagnosis of pneumonia.
Clinical examination Clinical findings
Inspection
Palpation
Percussion
Auscultation
D. CASE STUDIES 2
Read the case study below and organize the assessment using IPPA (inspection, palpation, percussion
and auscultation).
Raphael Garbet*, aged 45, was admitted via his GP with increased breathlessness and an audible wheeze.
He had recently started treatment for asthma. His symptoms had been present for 24 hours and he had
been using his salbutamol inhaler but remained symptomatic. His personalized asthma action plan
suggested he should visit his GP. On assessment, Mr Garbet was using accessory muscles to breathe and
was pale. He was only able to complete short sentences and was breathless at rest. Chest auscultation
revealed inspiratory/ expiratory wheeze in all lung fields on the left and right side. In this case, the
auscultation findings along the clinical history suggest a diagnosis of acute exacerbation of asthma
Clinical examination Clinical findings
Inspection
Palpation
Percussion
Auscultation
E. MEDICAL TERMS
Match the sentences in column A with the expressions in column B to give correct keyword
characteristics.