1. Respiratory Assessment
Skills Learning Plan 21
Upper Respiratory System
Anatomy of Respiratory System
Alveoli
Surfactant
* Fatty protein that decreases surface tension of alveoli
* Prevents collapse of alveoli
* Increases lung compliance
* Decreases work of breathing
Respiratory Assessment Components
* Breathing: the movement of air between the atmosphere and lung alveoli
* Diffusion: there is an exchange of CO2 for O2 between the pulmonary capillaries
and alveoli.
* Transport: of O2 and CO2 via the blood stream to and from tissues.
Inspection
* Chest Variations

2. Changes with Aging
Inspection / Assessment
* General appearance/subjective comments
* C/o shortness of breath?
* Use of accessory muscles?
* Purse lip breathing?
* Cyanosis –peripheral or circumoral (blue lips)?
* Finger clubbing?
* Restlessness?
* Decreased Level of Consciousness?
* Capillary refill time (CRT)
Finger Clubbing
Inspection / Assessment
* Check respiratory rate and rhythm
* Depth and effort of breathing
* Pulse oximetry

3. * Check skin color
* Check skin temperature
* Chest configuration
* Retractions
Retractions
* Intercostal
* Substernal
* Suprasternal
Inspection/Assessment
* Lung sounds
* Quality and frequency of cough
* Sputum- color and consistency
* Nasal flaring
* Level of alertness

4. * Chest pain
Respiratory Assessment
* Medical history
* Past medical conditions
* Family history of respiratory disorders
* Personal History
* Allergies
* Smoking (ppd) or history of
* Drug use
* Recent travels
* Diet and Weight
* Occupational History
Auscultation:
* Location of normal breath sounds
Auscultation:
* Listen to Breath Sounds

5. * Bronchial
-loud, high-pitched and hollow
* -like air blowing through a hollow tube
* -heard over the throat
* Bronchovesicular
-heard over the main bronchi
* -around sternum
* Vesicular -heard over most of the peripheral lung tissue
Auscultation of Breath Sounds
* Client should be in sitting position if possible
* Listen to both sides of the chest-front and back
* Work from top of chest downward
* Systematically compare breath sounds over right and left sides
Adventitious Breath Sounds
* Crackles (Rales) –high pitched short crackling, popping sounds
* Sound like rice crispies or crushing cellophane

6. * Usually caused by fluid in airways or alveoli
* Sign of fluid overload
* Gurgles (Rhonchi)-Wheeze (Sonorous)
* low pitched continuous sounds caused by fluid or mucus in larger
airways
* Can be described as sonorous or coarse
Adventitious Breath Sounds
* Wheeze (Sibilant) – high-pitched musical squeaking sounds
* Heard during inspiration or expiration
* Due to narrowing of bronchioles
* Do not clear with coughing
* Pleural friction rub – rubbing/grating sound of sandpaper rubbing in chest
* Inflammation of pleural lining

7. * Stridor – harsh/high pitched sound heard in the upper airway (larynx-
trachea) – swelling associated with croup
* Like a barky seal
* Decreased or diminished breath sounds – unable to hear sounds
where you normally should be able to hear them
Palpation
* Chest expansion
* Tactile fremitus
* Palpate abnormalities found on inspection
Percussion
* Determine lung position and size
* Detect the presence of air, liquids or solids within the lungs
* Assess intensity, pitch, duration, and quality of sounds produced
* Normal percussion tone is resonance
* Flat tone over bony prominences

8. * Hyperresonance over emphysematous tissue
Diagnostic Assessment
* Lab tests
* CBC, Hgb
* Arterial blood gases (ABG’s)
* X-ray
* Non-invasive diagnostic exams
* Pulse oximeter
* Pulmonary function tests
* Invasive diagnostic exams
* Thoracoscopy
Respiratory Terms
* Eupnea- Normal respiratory rate- 12-20 bpm
* Apnea- the absence of breathing
* Bradypnea- decreased rate <12 bpm

9. * Tachypnea- rapid rate >20 bpm
* Hyperventilation- increased rate and depth of respirations
Respiratory Terms
* Kussmaul respirations- abnormally deep respirations- sign of diabetic ketoacidosis
* Cheyne-Stokes- variable respirations
* May be periods of apnea
* Orthopnea- difficulty breathing lying down
* Dyspnea- difficulty breathing, shortness of breath
Lifespan Changes
* Respiratory rate is highest and most variable in newborn
* Infant: 30-60 breaths per minute
* Preschool: 25 per minute
* Adolescent & Adult: 12-20 per minute
Respiratory System in Children
* Newborns use abdominal muscles to breathe

10. * Heart rate in children varies with respirations---sinus arrhythmia.
* Infants and preschoolers are at risk for airway obstruction because of their small
airways.
* Increased mucus membranes lining respiratory tract
Respiratory System in Children
* Immature immune system
* Decreased action of cilia
* Decreased cough reflex
* Thinner chest walls
* Chest retractions more common
* Epiglottis more relaxed
Respiratory Changes in Elderly
* Decrease in elastic recoil in lungs
* A-P diameter of thoracic cage increases
* Decrease in depth of breathing

11. * Decrease in functional alveoli
* Less forceful cough
* Fewer and less functional cilia
* Immune system less resilient
* Elderly are more at risk for Pneumonia, COPD and Chronic Bronchitis
Physiology of Respirations:
* The stimulus to breathe in the normal person is rising levels of CO2
Techniques for maintaining adequate respiratory function
* Positioning- HOB up
* Exercises- Pursed lip breathing
* Incentive Spirometer
* Deep breathing and coughing
* Increasing liquids
* Ambulation
* Turn side-to-side

12. Chest Physiotherapy
* Postural Drainage
* Positioning to assist
in removal of retained
lung secretions
* Chest Clapping
* Create a vibration with the cupping of hands
Applicable Nursing Diagnoses
* Ineffective Airway Clearance- The state in which an individual experiences a
threat to respiratory status related to inability to cough effectively
* Ineffective or Absent cough
* Inability to remove airway secretions
Applicable Nursing Diagnoses
* Ineffective Breathing Pattern- The state in which a client experiences an actual or
potential loss of adequate ventilation related to an altered breathing pattern
* Changes in respiratory rate or pattern (from baseline)

13. * Changes in pulse (rate, rhythm, quality)
Applicable Nursing Diagnoses
* Impaired Gas Exchange-The state in which an individual experiences an actual (or
potential) decrease in the passage of gases between the alveoli of the lungs and
the vascular system
* Dyspnea upon exertion
* Decreased O2 saturation, cyanosis
Applicable Nursing Diagnoses
* Activity Intolerance- The state in which a person experiences a reduction in one’s
physiologic capacity to endure activities to the degree desired or required
* Activities tire the person out and increase respiratory rate and pulse rate
Time to Practice!
* Case Study