ASSESSMENT OF CLIENTS WITH
RESPIRATORY DISORDERS
1. Patient Clinical History
 A review of patient clinical history is an
essential component of the overall
physical assessment process
 Conducting review of the patient’s
history serve as a guide for the
remainder of the physical
examination and the first step to
develop relationship with the client.
 Health history is initially focuses on the
patients presenting problems and
associated signs and symptoms.
 In conducting health history, the nurse
should explore the onset, location,
duration, character, aggravating or
alleviating factors and timing of the
presenting problems and associated
signs and symptoms
 The clinical history of the respiratory
system is divided into six components.
(1) chief complaint, (2) history of
present illness, (3) past medical
history, (4) family history (5) personal
and social history and (6) review of
the respiratory system.
 The nurse should also explore how these
factors impact the patient’s activities of
daily living, usual work and quality of
life.
2. Common Symptoms
1. Dyspnea
 Subjective feeling of difficult or labored
breathing, breathlessness, shortness of
breath
 Commonly seen in patients with
pulmonary and cardiac disorders where
there is increased or decreased lung
compliance
 Associated with allergic reactions,
anemia, neurologic or neuromuscular
disease and advance disease.
 It can occur after exercise in people
without disease
 Acute disease of the lungs produces
more severe grade of dyspnea than
chronic chronic disease
 Sudden dypsnea in healthy person may
indicate Pneumothorax (air in the
pleural cavity) respiratory obstruction,
allergic reaction or MI.
 In immobilized patients sudden dypsnea
indicates Pulmonary embolism,
 Dyspnea and tachypnea (abnormal rapid
respirations) accompanied by
hypoxemia (low blood oxygen level)
indicates lung trauma, shock,
cardiopulmonary bypass, ARDS due to
multiple blood transfusion.
 Dyspnea with expiratory wheeze in
COPD
 Can be associated with noisy breathing
result from narrowing of the airway or
localized obstruction of a major
bronchus by a tumor or foreign body
 High pitch sound (during inspiration)
due to partially blocked upper airway
 Orthopnea- shortness of breath when
lying flat, relieve by sitting or standing.
It is found in patients with heart disease
and occasionally in COPD
 To help better understand the cause of
dypsnea, the nurse should ask the
following questions?
 Is the shortness of breath related to other
symptoms? Is cough present?
 Was the onset of shortness of breath
sudden or gradual?
 Is the shortness of breath occurs when
lying flat?
 Does the shortness of breath or dypsnea
awakes you at night? (paroxysmal
nocturnal dyspnea and orthopnea signify
heart failure but may occur in
pulmonary disorders.
  Does the dypsnea occur only with
exertion?
 How much exertion triggers shortness of
breath? Does it occur with exercise?
Climbing stairs? Or at rest?
 How severe is the shortness of breath?
On a scale of 1-10. If 1 is not at all
breathless and 10 is very breathless, how
hard it is to breath?
 It is important to assess the patient’s
rating of the intensity and distress of
breathlessness, what breathing feels like,
and it’s impact on the patient’s health.
function and quality of life A variety of
valid and reliable instruments including
various Likert scale as a tool in decribed
the dypsnea experiencing by the patients
 Visual analogue Scale- The patient
marks on the line the point that they feel
represents their perception of their
current state. The VAS score is
determined by measuring in millimetres
from the left hand end of the line to the
point that the patient marks.
 Borg Scale- a type of numeric rating
scale. The patient is asked to self rate
the difficulty of breathing is accusing
him or her at present time, with 0
corresponding to no difficulty at all to
10 corresponding to maximal level of
difficulty in breathing.
2. COUGH
 Is a reflex that protects the lungs form
the accumulation of secretions or the
inhalation of foreign bodies
 Its presence or absence can be a
diagnostic clue because some disorders
cause coughing and some supress it.
 Coughing reflex may be impaired by
weakness or paralysis
 The nurse should inquire:
 Onset and duration (When did first
notice a change in your cough?)
3. Chest pain
,
4. Sputum production
5. Hemoptysis
6. Wheezing, Stridor
Chest Inspection
 observe the diaphragm and intercostal
muscles with breathing.
 Frequent use of accessory muscles
indicates respiratory problem
 -look at the diameter of the chest, from
front to back
 -look for symmetry
 -Note for masses, scars that indicate
trauma or surgery
Chest palpation
- Place the palm over the thorax. The
chest wall should be smooth, warm
and dry
- Palpate for tenderness, bulging,
retractions of the chest
- Assess the patient for crepitus-feels like
puffed rice cereal crackling under the
skin
- Tactile fremitus- Place your open palms
on both sides of the client’s back
without touching his back with your
fingers. ask the patient to repeat the
phrase ninety nine loud enough to
produce palpable vibration
- Symmetry and expansion
Chest Percussion tones- when lungs are filled
with air, fluid or solid material
1. Resonant
 heard over normal lung tissue, bronchitis
 Long, loud, low pitch
2. Hyper resonant
 abnormal sound heard during percussion
in adults
 Very loud lower pitch sound
 Hyperinflated lung/air trapping such in
COPD.
3. Flat
 heard over airless tissue
 Short, soft, high pitch, extremely dull
 Atelectasis, and extensive pleural
effusion
4. Dull
 Medium in intensity and pitch
 occur over dense lung tissue such as
tumor and consolidation.
 Lobar pneumonia
5.Tympanic
 Loud, high pitch, moderate length,
musical drum like sound
 Gastric air bubble, air in the intestine
 indicates large tension pneumothorax
Chest Auscultation
Normal Breath Sounds
Vesicular
 low pitch sound and heard all over the
chest and heard best in the bases of
lungs
 best heard on (prolong) inspiration and
shortened during expiration
Tracheal
 Harsh, high pitch sound
 Heard when patient inhale or exhales
 Above supraclavicular notch, over the
trachea
Bronchial
 High pitch and loud sounds created by
air moving through the trachea
 Heard loudest when patient exhales,
discontinuous
 Just above the clavicles on each side of
the sternum, over the manubrium
Broncho vesicular
 Moderate pitch with moderate amplitude
created by air moving through larger
airway
 Heard when pt inhales or exhales,
continuous
 heard between the scapulae and lateral
to the sternum at the first and second
ICS
ADVENTITIOUS Breath Sounds
Crackles/rales (Fine)
 caused by collapse or fluid filled alveoli
popping sounds
 Usually don’t clear with coughing
 Classified by fine or coarse
 Fine- intermittent, non-musical, soft,
high pitch, short crackling popping
sounds, heard during inspiration
 Coarse- Intermittent, loud, low pitch,
bubbling or gurgling sounds heard
during inspiration at bases of lower lung
lobes
 air passing through fluid or mucus in
any air passage.
 Asthma, Bronchitis, CHF
Crackles/ Rales (Coarse)
 loud and low pitch, bubbling and
gurgling sounds.
 Commonly heard in the bases of lower
lung lobes.
Pleural friction rub
 Cause by rubbing of inflamed pleural
surfaces
WHEEZE
 continuous, high pitched musical squeak
or whistling sound occurring on
EXPIRATION and inspiration when air
moves through a narrowed or partially
obstructed airway
 Don’t change with coughing
 Asthma, bronchitis and CROUP.
Gurgling/rhonchi
 continues, low pitch, snoring quality
 best heard on expiration, but could be
heard in both inspiration and expiration
  Cause: air passes through a narrow
passages due to swelling and
secretion/blocks the large airways
Chest Wall Abnormalities
BARREL CHEST
 Unusually round and bulging chest with
a greater than normal front to back
diameter
 Caused by COPD, indicating that lungs
have lost their elasticity and the
diaphragm is flattened
FUNNEL CHEST/PECTUS EXCAVATUM
 A funnel shape depression on all or part
of the sternum
 May interfere with respiratory and
cardiac function
PIGEON CHEST
 Displaced sternum that protrudes in
front of the abdomen that increases the
front to back diameter of the chest
THORACIC KYPHOSCOLIOSIS
 Characterized by spinal curvature to one
side and rotate vertebra
 It cause difficulty in assessing
respiratory status because of the rotation
distorts the lung tissue
Altered Breathing Patterns
TACHYPNEA
 Shallow breathing with a respiratory rate
greater than 20 breath/minute
 Seen in patients with restrictive lung
disease, pain, fever, obesity or anxiety
BRADYPNEA
 Decrease RR usually below
10breath/min
 CNS depression caused by sedation,
tissue damage or Diabetic coma
APNEA
 Absence of breathing
HYPERPNEA
 Deep rapid breathing
 Can occur during or after excersize or
result from pain, anxiety or metabolic
acidosis
 Indicate hypoxia or hypocalcemia in a
coma patinet
Cheyne-stokes breathing
 marked rhythmic, waxing and waning
respirations from very deep and very
shallow breathing and temporary apnea.
 Seein heart failure, kidney failure or
CNS damage
Kussmaul’s breathing
 Deep rapid breathing. RR is greater
than 20 and labored breath sounds
 Metabolic acidosis or DKA
Hypoventilation
 very slow respiration
Biot’s breathing
 shallow breaths interrupted by apnea
 irregular
 An ominous sign of severe CNS damage
Apneustic Breathing
 prolonged, gasping inspiration followed
by a very short and inefficient expiration
Normal Findings
1. General appearance
 Breathing is quiet and easy without
apparent effort
2. Breathing Pattern
 Smooth and regular, breathing is quiet
and passive with symmetric chest
expansion.
3. Respiratory rate
 12-20/ minute/ 20-40/minute
4. Skin
 Pink, no cyanosis or pallor present
 Palpation of chest wall reveals smooth
skin and stable chest wall, no crepitus,
masses and painful areas.
5. Nails- no clubbing
6. Chest wall configuration
 symmetric, bilateral muscle development
7. Vocal and Tactile Fremitus
 -the sensation of sound vibrations
produced when the patients speaks.
 place the extended hand gently on the
chest wall
  instruct the patient to say 1, 2, 3…as
these words are spoken, the examiner
feels the for the vibrations.
Abnormal Responses
 Increase Fremitus
- Increase in vibration is felt due to
consolidation of the lung caused by
fluid-filled or solid structures.
- Pneumonia and tumor of the lungs
 Decrease fremitus
Diagnostic Procedure/ Examination
Non Invasive
1. Skin Test/Mantoux Test
 PPD is used
 Route: ID
 48-72 hrs
 POSITIVE- 10mm or more
 HIV patients- 5mm is POSITIVE
 + Mantoux test signifies exposure to
Mycobacterium Tubercle Bacilli
 Mantoux Test will be positive for clients
who have received BCG
CHEST X-RAY
 Instruct the client to hold his breath and
not to do breathing
 Remove metals from the chest.
PULSE OXIMETRY
 To determine o2 saturation in the blood
 Can detect hypoxemia or hypoxia
 95-100%
 The pulse oximeter sensor is place in the
index finger or earlobe.
 The sensor should be covered with
opaque material. The result is affected
by sunlight.
Sputum exam
 To determine the appearance of the
sputum
 Rusty sputum- pneumococcal
pneumonia
 Greenish sputum- Pseudomonas
infection
 Blood tinged- PTB
 Culture and Sensitivity- to detect the
actual microorganisms causing
respiratory infection
 Cytologic exam- to assess for presence
of CA.
 AFB staining-
- to detect PTB
Nursing considerations
 Collect sputum early in the
MORNING. Sputum usually
accumulates in the lungs during sleep
and can easily be coughed in the
morning
 Advise the patient to rinse mouth with
plain water. Do not used mouthwash
that may destroy microorganisms
 Sterile container should be used. To
prevent contamination
 Sputum specimen for C and S is
collected before the first dose of
antibiotic.
 For AFB- collect sputum for 3
consecutives morning
Pulmonary Function Test
- A procedure to determine the
capacity of the lungs to exchange O2
and CO2
Incentive Spirometry
 To prevent and treat atelectasis
 Semi fowlers position
 Done to enhance deep inhalation
 Instruct the client to take in a slow, easy
deep breath from the mouthpiece.
ABG analysis
 to assess ventilation and acid base
balance
 It helps to monitor patients response to
therapy
 Radial Artery is the common site for
withdrawal of specimen
 Allen’s Test is done to assess for
adequacy of collateral circulation of the
hand. May be used to find out if the
blood flow to your hand is normal.
The health professional drawing
your blood will apply pressure to the
arteries in your wrist for several
seconds. This will stop the blood
flow to your hand, and your hand will
become cool and pale
  Use 10 ml heparinized syringed to draw
the blood specimen. To prevent blood
clotting.
 Place the specimen in a container with
ice. To prevent hemolysis. If hemolysis,
OXYGEN and CO2 are release and
cannot be measure accurately.
AVOID INACCURATE ABG VALUES
 Be sure to use proper technique
 Avoid delays in getting the sample to
the laboratory
 Don’t draw blood for ABG ANALYSIS
within 15-20 minutes of a procedure
such as suctioning or administering
respiratory treatment
 Remove air bubbles from the syringe
because they could affect the oxygen
level in the blood
 Don’t get venous blood in the syringe
because it could affect the CO2 and O2
levels and pH
INVASIVE Procedure
THORACENTESIS
 Aspiration of fluid or air from the
pleural space
Nursing Interventions Before the procedure
 Secure written consent- invasive
 Take V/S- aspiration of air/fluid from
the pleural space cause Hypovolemic
shock
 Position: upright, leaning on the over
bed table/Sitting position
 Topical anesthesia is used at the site of
needle insertion
 Pressure sensation is felt on insertion
site
Nursing interventions Post Procedure
 Apply pressure to the puncture site
 Turn the client on the unaffected side.
To prevent leakage of fluid in the
thoracic cavity
 Bed rest. To prevent postural
hypotension
 Check for expectoration of blood. Notify
the doctor. Indicates trauma to the lung
 Monitor for complications:
 Shock, Pneumothorax, and Respiratory
arrest
Bronchoscopy
 Direct inspection and observation of
the larynx, trachea, and bronchi using
bronchoscope.
USES:
 To collect secretions
 To determine pathologic process and
collect specimen for biopsy
 To remove aspirated foreign object and
excise small lesions.
Nursing Intervention before the Procedure
 Informed consent. Invasive procedure
 Atropine sulphate and valium as ordered
 Topical anesthesia sprayed in the throat
followed by local anesthesia in the
larynx
 NPO 6-8 hrs. To prevent aspiration.
 Remove dentures prostheses and contact
lenses. To prevent airway obstruction.
Nursing intervention after Procedure
 Side lying position- to promote drainage
of secretions from the mouth
 Check for cough and gag reflex before
giving fluid. To prevent aspiration
 Prepare suction device at the bedside
 Watch for cyanosis, hypotension,
tachycardia, arrhythmias, dyspnea and
hemoptysis. And notify the physician.
These are signs of perforation of
bronchial tree
LUNG SCAN
 Following injection of radioisotope,
scans are taken with a scintillation
camera.
 Measures the blood perfusion through
the lungs
 Confirms pulmonary embolism and
other blood flow abnormalities
 Instruct the client to remain still during
the procedure
BIOPSY OF THE LUNG
 Transbronchoscopic biopsy- done
during bronchoscopy
 Percutaneous needle biopsy- done
with the use of aspiration needle
 Open lung biopsy- done during
surgery
LYMP node BIOPSY- to assess metastatic
CA
COMMON RESPIRATORY
INTERVENTIONS
OXYGEN THERAPY
 Asses signs of hypoxemia. An indication
of the need for oxygen therapy
 Check for doctor order
 Place pt in Semi fowlers. To enhance
lung expansion
 Regulate oxygen flow accurately.
Excessive administration of O2 can
cause oxygen narcotics/ respiratory
alkalosis
 Place a “NO SMOKING” sign at the
bedside. O2 geratly accelerates
combustion and can cause fire from
small spark
 Avoid use of oil, greases, alcohol and
ether near the client O2. These further
support combustion
 Check electrical appliances that generate
static electricity. Small sparks can cause
fire if there is leakage of oxygen
 HUMIDIFY OXYGEN. Place sterile
water into the oxygen humidifier. To
prevent irritation and dryness of mucous
membrane
 Provide oronasal hygiene. To revent
dryness and irritation of mucous
membrane
 Lubricate nares with water soluble
lubricant to soothe the mucous
membrane
 Assess effectiveness of O2 therapy.
Check RR, quality of respiration, ABG,
O2 saturation.
CHEST PHYSIOTHERAPY
 A group of treatments designed to
improve respiratory efficiency, promote
expansion of the lungs, strengthen
respiratory muscles, and eliminate
secretions from the respiratory system.
 Chest physical therapy includes postural
drainage, chest percussion, chest
vibration, turning, deep breathing
exercises, and coughing.
 Turning- Turning from side to side
permits lung expansion. The child may
turn on his or her own, or be turned by a
caregiver. Turning should be done at a
minimum of every two hours if the child
is bedridden. The head of the bed can
also be elevated in order to promote
drainage.
 Coughing- helps to break up secretions
in the lungs so that the mucus can be
expectorated or suctioned out if
necessary. Patients sit upright and inhale
deeply through the nose. They then
exhale in short puffs or coughs. This
procedure is repeated several times a
day.
 Deep breathing helps expand the lungs
and forces an improved distribution of
the air into all sections of the lungs.
 The patient either sits in a chair or sits
upright in bed and inhales then pushes
the abdomen out to force maximum
amounts of air into the lung. The
abdomen is then contracted, and the
patient exhales. Deep breathing
exercises are done several times each
day for short periods.
POSTURAL DRAINAGE
 uses the force of gravity to assist in
effectively draining secretions from the
smaller airways into the central airway
where they can either be coughed up or
suctioned out. The child is placed in a
head- or chest-down position and is kept
in this position for up to 15 minutes.
 Postural Drainage and Percussion (PD
& P), also known as chest
physical therapy (CPT), is a way to
help people with cystic fibrosis (CF)
breathe with less difficulty and stay
healthy. PD & P uses gravity
and percussion to loosen the thick,
 sticky mucus in the lungs so it can be
removed by coughing
Percussion
 Involves striking the chest wall with
cupped hands.
 It is also called cupping or clapping.
 The purpose of percussion is to break up
thick secretions in the lungs so they can
more easily be removed.
 It is performed on each lung segment
for one to two minutes at a time.
 Mechanical percussors are available and
may be suitable for children over two
years of age. The percussor is moved
over one lobe of the lung for
approximately five minutes, while the
patient is encouraged to performing
coughing and deep breathing techniques.
This process is repeated until each
segment of the lung is percussed.
Vibration
 The purpose of vibration is to help break
up lung secretions.
 Vibration can be either mechanical or
manual.
 It is performed as the patient breathes
deeply.
 When done manually, the person
performing the vibration places his or
her hands against the patient's chest and
creates vibrations by quickly contracting
and relaxing arm and shoulder muscles
while the patient exhales.
 Repeated several times each day for
about five exhalations.
NURSING INTERVENTIONS IN CPT
 Verify doctors
 Assess areas of accumulation of mucous
secretions
 Position to allow expectoration of
mucus membrane by gravity
 DO CPT with upper lobes before lower
lobes
 Place pt in each position for 10 -15
minutes. A total of 30 minutes for each
treatment
 Percussion and Vibration are done to
loosen secretions
 Change position gradually to prevent
postural hypotension
 Done before meal to avoid vomiting or
early in the morning and at bedtime
 Provide oral care after the procedure.
To remove unpalatable taste of
secretions.
TRACHEOBRONCHIAL SUCTIONING
 Semi fowlers or High
 Sterile Technique. Use sterile gloves,
and suction catheter. To prevent
infection
 Hyperventilate the client with 100% O2
before and after suctioning. To prevent
hypoxia
 Insert catheter with glove hand 3-5
inches length of catheter. The trachea is
4-5 inches length
 Apply suction during withdrawal of the
catheter. To prevent trauma of the
mucous membrane and bleeding
 When withdrawing catheter rotate the
catheter while applying intermittent
suction
 Suctioning should take only 5-10 sec
(maximum of 15 sec) to prevent
hypoxia, vagal stimulation and bleeding.
Vagal stimulation can cause
g=hypotension and bradycardia
 Evaluate breath sounds and auscultation
of the chest
CLOSED CHEST DRAINAGE/
Thoracostomy Tube
 To remove air or fluids from the pleural
space
 To re-establish negative pressure and re-
expand the lungs
TYPES of CCD
1. One Bottle system
 The bottle serve as drainage bottle and
water seal bottle
 Immerse tip of the tube in 2-3 cm of
sterile water NSS to create water seal
 Keep bottle at least 2-3 feet below the
level of the chest to allow fluid to drain
from the pleural cavity
 NEVER raise the bottle above the level
of the chest to prevent reflux of the air
or fluid
 Observe the patency of the device
- Observe fluctuation of fluid along the
tube
- Observe for intermittent bubbling of
fluid; continuous bubbling means
presence of air leak
- In the absence of fluctuation. Suspect
for obstruction of the device. Check for
kinks along tubings
- No obstruction consider lung re
expansion
- Air vent should be open to air