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Program Script
Nursing Assessment
Series Number 126
The Respiratory System (126.2)
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T
he major function of the respiratory system is to supply our body tissues with oxygen and rid them of
carbon dioxide. Two separate processes must work properly for respiration to be successful: ventilation
and gas exchange.
The respiratory system consists of the upper respiratory tract, the lower respiratory tract, and the lungs.
The upper respiratory tract consists primarily of the nose, pharynx, and larynx. The lower respiratory tract
includes the trachea and bronchi, which pass into the lungs.
When we inhale, air typically enters through the nostrils in our nose into the nasal passages. Lining the
nasal passageways, mucus and microscopic hair-like membranes called cilia, trap and remove dust and
germs from the air as it flows through. The cilia can sweep mucus and dust at a speed of about two
centimeters per minute—like a slow escalator—towards the pharynx until eventually it can be swallowed
or coughed out of the body.
The lungs extend from the base of the neck to the diaphragm and fit inside the thoracic cavity. The right
lung consists of three lobes, the left lung of two. The space in between the lungs is called the mediastinum
and contains the heart and blood vessels. The thoracic cage—also called the rib cage—is made up of bone
and cartilage. It protects the lungs and aids in their expansion and contraction during respiration.
Each lung is enclosed by a double-layered membrane called the pleura. The inner layer is connected to the
lung itself, the outer layer is connected to the chest wall forming a sac called the pleural cavity. When we
inhale, the lungs expand and fill the pleural cavity, which contains lubricating fluid. An inflammation of
the pleural membrane, called pleurisy, can by caused by pneumonia and lead to respiratory failure.
The bronchi extend into the lungs branching off all the way down to microscopic-sized respiratory
bronchioles, and terminating in structures called alveoli. Alveoli are microscopic air sacs that look like
clusters of grapes. Pulmonary capillaries surround each alveolus, and it is here that gas exchange actually
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occurs. Through diffusion, carbon dioxide molecules are transferred from blood cells to alveoli, and
oxygen molecules are transferred from alveoli to blood cells. We breathe out the carbon dioxide when we
exhale, and our blood stream delivers the all-important oxygen to every cell in our body.
Breathing is accomplished with the aid of muscle contractions and air pressure. In a resting state the air
pressure inside the lungs, called intrapulmonic pressure, approximates outside or atmospheric air pressure,
while air pressure inside the pleural cavity, called intrapleural pressure, is slightly less.
During inspiration—that is, when we inhale—muscles attached to the chest wall called intercostal muscles,
and a wall of muscle that separates the thoracic cavity from the abdominal cavity called the diaphragm,
contract.
Expiration—or exhaling—is normally passive. As the diaphragm and intercostal muscles relax, the
thoracic cavity contracts and the intrapleural and intrapulmonary pressures rise above atmospheric
pressure, forcing air out of the lungs.
Subjective Data
Important to any assessment is the subjective data, meaning that information given to the examiner by the
patient. Collecting this information at the beginning of the assessment can provide information which will
affect how the physical examination is focused.
It also allows the opportunity for the patient and examiner to establish a sense of rapport and comfort prior
to the need for the patient to disrobe.
In gathering subjective information related to the respiratory system, begin by asking the patient if they
have any specific concerns regarding their breathing. Ask about current difficulties, including cough,
shortness of breath, dyspnea on exertion, and orthopnea. Ask if there is any pain associated with
breathing.
If the patient has a cough, it is important to document the quality and severity, whether it is productive, and
if there is any blood associated with it. Ask how long the cough has been present. Document the
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appearance of any sputum.
Ask about the history of any respiratory disease, or possible exposure to illnesses such as tuberculosis.
Also ask about possible environmental exposure such as asbestos, molds, and soil. Also ask about recent
foreign travel due to the possibility of exposure to microorganisms more common in other countries.
While this program is focused on patient assessment rather than infectious disease, it is important to
remember to use standard precautions with all patients, and to implement respiratory precautions with any
patient if infection with a potential for airborne or droplet transmission is suspected.
Ask the patient about any history of respiratory allergies, and whether he smokes or has a history of
smoking, or lives with someone who smokes.
Note the patient’s speech pattern. Speaking in very short phrases can be an indication of severe shortness
of breath.
Finally, if the patient has been treated for respiratory disease, ask what treatment was received, the degree
of effectiveness of the treatment, and whether there was any undesired side effect of the treatment, such as
GI upset or an allergic response.
Objective Data
The next phase of the assessment focuses on gathering objective data, meaning information that can be
directly observed by the examiner.
Begin by visually assessing the skin color. Note if it is pink, pale, dusky, or blue. In patients with dark
skin tones, color can be assessed by viewing the oral mucosa.
Observe the color of the nail beds, and whether clubbing is present. Clubbing of the nail beds is evidence
of chronic impaired oxygenation from a variety of causes.
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Observe the degree of respiratory effort both at rest and during activity. In a hospitalized patient the
activity may be talking, repositioning themselves in bed or activities of daily living that you can observe.
As you prepare to listen to the chest, observe for signs of increased work of breathing as evidenced by the
use of accessory muscles. Intercostal retractions are seen as an inward pulling of the chest wall into the
spaces between the ribs, while supraclavicular retractions are seen midline at the base of the throat.
Also observe for equal rise and fall on each side of the chest. Unequal chest wall movement and reduced
or absent breath sounds on one side can indicate atelectasis, a partial or complete collapse of the lung.
Palpate the chest with both hands to feel for equal bilateral chest wall expansion during inspiration.
Now auscultate the chest for breath sounds. It is best to listen using the pattern shown, listening at the
same level bilaterally before moving down to the next level.
Ask the patient to breathe normally and tell them you will be listening at multiple locations. Allow one
full respiration for each area when listening. If the patient tends to breathe deeply during auscultation,
allow rest every so often so they do not hyperventilate.
It is important to make opportunities to listen to individuals with normal lungs to become skilled at
identifying normal breath sounds.
Breath Sounds
We will now listen to the sound of normal breath sounds one after the other for comparison.
Bronchial sounds are audible over the trachea and larynx. They have a relatively high pitch, are loud,
harsh, and hollow, and inspiration is shorter than expiration.
Bronchovesicular sounds are heard over the major bronchi and between the scapulae. They are of mixed
quality, moderate in volume and pitch, and the sounds of inspiration and expiration are of equal length.
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Vesicular sounds are heard over the peripheral lung fields. They have a rustling quality similar to the
sound of wind in the trees. They are low-pitched and soft, and inspiration is longer than expiration.
Adventitious sounds indicate respiratory problems. They fall into two categories, discontinuous and
continuous sounds.
Discontinuous adventitious sounds are discrete and crackling in nature, and include crackles and friction
rubs.
Fine crackles, formerly called rales, are high-pitched popping sounds on inspiration that are not cleared by
coughing. They are associated with both restrictive diseases such as pneumonia and obstructive disease
such as asthma.
Crackles, formerly called coarse rales, are loud, low-pitched bubbling and gurgling sounds. They start
early in inspiration and may continue into expiration. Suctioning may reduce them briefly. They are
indicative of pulmonary edema and pulmonary fibrosis.
Atelectatic crackles sound like fine crackles but do not last and are not pathologic. These are more
common in bedridden patients and individuals just roused from sleep, and will usually clear with deep
breathing or a cough.
Pleural friction rub is a coarse, low-pitched, sound that seems just below the surface. It sounds like
sandpaper on wood and gets louder if you press against the stethoscope. They are often heard in patients
with pleuritis and are usually painful.
To differentiate between a pleural rub and a pericardial rub, have the patient hold their breath. If the rub
goes away it is pleural; if it continues, it is cardiac.
Continuous adventitious sounds are connected, musical sounds. They include wheezes and stridor.
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A sibilant wheeze is high pitched, polyphonic sound, meaning ‘containing multiple notes of sound’. They
may occur with both inspiration and expiration, but predominate in inspiration. They denote diffuse
airway obstruction such as seen in acute asthma or chronic emphysema.
The second type of wheeze, formerly called rhonchi, is low-pitched and monophonic, a snoring or
moaning sound. They are also heard throughout the cycle, but tend to be more prominent during
expiration. They are heard in bronchitis, or single bronchus obstruction.
The last of the common adventitious sounds is stridor. It is a high-pitched crowing sound which is louder
in the neck than the chest because it originates in the larynx or trachea. It is common in croup, epiglottitis,
and foreign body aspiration, and mostly occurs in children due to their relatively small airway. Stridor
should be treated as an emergency.
An important adjunct to respiratory assessment is the use of pulse oximetry and noninvasive carbon
dioxide monitoring.
Pulse oximeters read the oxygen saturation level through the skin using a probe applied to the finger or
earlobe. Normal readings are between 95 and 100%, although patients with chronic lung disorders may
never achieve a saturation level this high. Assessment of blood saturation using a portable oximeter with a
finger-probe is now standard in almost all facilities.
It is important to remember that the pulse oximeter only reads oxygen saturation. If the patient is very
anemic, even with a saturation of 100% there may be inadequate oxygenation of the tissues. This is why
arterial blood gas testing is done on patients with significant respiratory compromise.
The non-invasive CO2 monitor is a newer device. It can read end tidal carbon dioxide levels through a
nasal cannula, or via an ear probe. The normal range of CO2 is 35-45 milliequivalents per liter, the same as
the CO2 readings obtained in an arterial blood gas.
Repeat auscultation on the posterior thorax, using a pattern as on the anterior chest. If the patient has
respiratory compromise, you can assess just the posterior chest. This will give adequate information and
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reduce the stress of the exam.
Place your hands on the anterior chest below the scapulae with the tips of your thumbs meeting over the
spinal column. Ask the patient to take a deep breath and observe for equal outward movement of your
hands as the ribcage expands.
Respiratory Abnormalities and Anomalies
The respiratory assessment provides a good opportunity to observe abnormalities and anomalies that may
be present on or within the thorax.
A barrel chest is a finding which is indicative of long term respiratory compromise found in disorders such
as COPD.
As mentioned earlier, both cyanosis and clubbing of the fingers and toes are signs of respiratory problems.
Cyanosis can be acute or chronic, while clubbing takes time to form so is seen only in chronic disorders.
Pectus excavatum, also called funnel chest, is seen as a marked depression of the sternum and surrounding
cartilages. It is a congenital defect that rarely interferes with respiratory function, but may cause
embarrassment or self-consciousness for some patients.
Pectus carinatum, or pigeon breast, is an outward pouching of the sternum which is also congenital and
rarely needs intervention.
The most common abnormalities other than adventitious sounds that will be found on assessment relate to
the respiratory pattern.
Normal resting respirations are regular and of low to moderate depth. The normal rate for an adult is 12 to
20 breaths per minute.
Tachypnea is rapid, shallow breathing at a rate which exceeds 24 breaths per minute.
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Bradypnea is a slow, regular rate usually of less than 10 breaths per minute.
Hyperventilation is both deep and rapid. It occurs normally with extreme exertion or anxiety, but can also
indicate a variety of disorders.
However, respiratory rate must be evaluated against the patient’s tolerance and overall respiratory picture.
The rate alone is not diagnostic of any specific disorder.
Hypoventilation refers to a shallow, irregular breathing pattern seen in overdose, and is sometimes seen in
patients on prolonged bed rest.
Individuals with chronic increased airway resistance, such as that seen in COPD, may develop a breathing
pattern with a normal length of inhalation and prolonged exhalation. Additional stress to the heart can lead
to dyspnea for these patients.
Both Cheyne-Stokes and Biot’s respiration are evidenced by cyclic breathing which waxes and wanes.
While cyclic breathing can be normal during sleep for infants and the aging, in general it is a critical
finding. It is most commonly seen in patients who have declined resuscitation and are near death. The
cyclic pattern in Cheyne-Stokes is regular, while that of Biot’s is irregular.
The ability to quickly and accurately assess the respiratory status of a patient is a critical nursing skill. The
techniques illustrated in this program will assist in developing this ability.
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