Respiratory system assessment

1. Assessment of respiratory system

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3.  The respiratory system categorized to upper & lower
respiratory system.
 The parts superior to the chest cavity are collectively
called the upper respiratory system, &
 Those parts within the chest cavity make up the
lower respiratory system.
 The alveoli of the lungs are the site of gas exchange
between the air and the blood; the rest of the system
moves air into & out of the lungs.
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Physiology
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FIGURE1 Respiratory system, anterior view, with
microscopic view of alveoli and pulmonary
Anatomy & Physiology cont’d…
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5. Definition of Respiration
 All cells require a continuous supply of oxygen (O2)
and must continuously eliminate a metabolic waste
product, carbon dioxide (CO2).
 On the macroscopic level, the term respiration simply
means ventilation, or breathing.
 On the cellular level, it refers to the processes by which
cells utilize O2, convert energy into useful forms, and
produce & remove CO2 as a waste product.
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Stages of Respiration
1. Ventilation: movement of air into and out of airways
(movement of gas b/n the atmosphere & lungs).
2. External Respiration: gas exchange b/n the lungs and
blood (O2 loading and CO2 unloading).
3. Transportation: Transport of gases via movement of
blood (O2 from the lungs is transported to the cell).
4. Internal Respiration: gas exchange b/n the capillaries &
the cells (O2 unloading and CO2 loading).
NB: Gas exchange is entry of O2 & exit of CO2 to & from
the blood
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Basic functions of the Respiratory System
 Gas exchange: supply O2 to aerobic tissues in the body
and remove CO2 as a waste product.
 Regulation of acid-base balance
 Sound production, abdominal compression, and
coughing and sneezing
 Conversion of angiotensin-I to angiotensin-II: by the
action of ACE (angiotensin converting enzyme)
 Involved in defence of BP
 Protection Mechanisms
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Pharynx
Upper respiratory tracts…
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9. Lungs
 Elastic structure lie in thoracic cavity on either side
of the heart
 The lungs are two cone shaped organs.
 Anteriorly
 the apex of each lung raises about 2-4cm above
the inner third of clavicle
 the base crosses the sixth rib at mid-clavicle line
and eighth rib at the mid axillary line9
Lower respiratory tracts…
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 Each lung is divided into lobes by fissures
 Left lung – separated into two lobes
 Upper lobe &
 Lower lobe
 Right lung – separated into three lobes
 Superior (Upper) lobe
 Middle lobe
 Inferior (Lower) lobe
Lower respiratory tracts…
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Lower respiratory tracts…
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 Pleural Coverings: double
layered serosa
 parietal pleura: lines the
thoracic wall
 visceral pleura: covers the
lung surface
• Pleural cavity: is the space
between the two layers
• Pleural fluid: is fluid which
fills the cavity
Lungs and Pleural Coverings
Lower respiratory tracts…
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14. Assessment of respiratory system
Subjective data: you must ask the client about:-
 Coughing (productive, non productive)
 Sputum (type & amount)
 Allergies, dyspnea or SOB (at rest or on exertion).
 Chest pain, history of asthma, bronchitis, emphysema,
tuberculosis.
 Cyanosis, pallor.
 Exposure to environmental inhalants (chemicals,
fumes).
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15. Assessment cont’d…
If the patient relates a specific symptom, redirect the line
of questioning to further assess that symptom.
One such line of questioning is the WHAT’S UP? Format
(the patient should respond with the following questions)
 Where is it? Describe the location.
 How does it feel? Describe the quality.
 Aggravating and Alleviating factors? Does anything else
aggravate it? What do you do to lessen it?
 Timing? When did you first experience it? Does it happen
more at any particular time of day or year?
 Severity? Rate symptom on a scale of 0 to 10
 Useful other data? Do you have any other symptoms that
occur along with it?
 Patient’s perception? What do you think is causing your
symptom?15 8/28/2020Bereket T.

16. Many factors in a patient’s personal & family history
(such as precipitating factors & their durations &
severities) affect respiratory function.
Smoking history
Exposure to allergens and environmental pollutants
Occupational history
Recreational history
Previous personal or family Hx of lung disease
It is also important to be aware of cultural influences
on the patient’s respiratory health
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Assessment cont’d…
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Assessment cont’d…
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18. Technique for Respiratory Exam
 Before beginning, if possible:
 Quiet environment
 Proper positioning (patient sitting for posterior thorax
exam, supine for anterior thorax exam)
 Expose skin for auscultation
 Patient comfort, warm hands and diaphragm of
stethoscope, be considerate of women (drape sheet to
cover chest)
 After that the nurse should apply the four
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19. Initial Respiratory Survey (Inspection)
 Observe the patient’s breathing pattern
 Rate (normal vs. increased/decreased)
 Depth (shallow vs. deep)
 Effort (any sign of accessory muscle use, inspect neck)
 Assess the patient’s color
 Cyanosis
 Normal Respiratory Rates
 FHR= 120-160 BPM
 Infant 30-60
 Toddler 24-40
 Preschooler 22-34
 School-age child 18-30
 Adolescent 12-16
 Adult 16-2019 8/28/2020Bereket T.

20. Inspection and assessment of respiration patterns
 Assess the skin and overall symmetry and integrity of
the thorax.
 Assess thoracic configuration.
 Client must be uncovered to the waist, and in sitting
position without support.
 Observation of skin may give you knowledge about
nutritional status of the client.
 Anterior- posterior diameter of thorax in normal person
less than the transverse diameter = (1:2).
 Assess for abnormality of configuration, e.g. pigeon
chest, funnel chest, spinal deformities.
 Assess ribs and inter spaces on respiration – may give
information about obstruction in air flow e.g. bulging of
inter spaces on expiration may be from obstruction to air8/28/2020Bereket T.20

21. Assess pattern of respiration
 Normally: men and children – breathe
diaphragmatically and Women breathe thoracically
or costally.
 Tachypnea: respiratory rate over than 20/m for adult.
 Bradypnea: respiratory rate less than 10/m.
 Palpation: palpate areas of chest especially areas of
abnormalities.
 If clients complains: all chest areas must palpated
carefully for tenderness, bulges, or any movements21 8/28/2020Bereket T.

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Cyanosis
blue
Assessment cont’d…
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Clubbing of fingers
>180 degree
Assessment cont’d…
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FIGURE
Abnormal
respiratory
patterns
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Irregular
respirations,
or periods of
apnea
(absence of
respirations)
, can
indicate a
pathological
condition

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Table: Summary of objective assessment of the
RS
Assessment cont’d…
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26. Palpation
Palpation has four potential uses
 To determine tracheal location
 For identification and checking of tender areas and
abnormalities such as masses and intercostals
bulging (emphysema)
 To determine respiratory expansion
 For assessment of tactile fremitus (or detection of
sound vibration)
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Assessment cont’d…
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27. Palpate the frontal and maxillary sinuses if sinus
inflammation is suspected.
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 Tenderness may indicate sinus inflammation or infection.
Paranasal sinuses 8/28/2020Bereket T.

28. Assess thoracic expansion:
 Anterior: put your hands over anterior-lateral chest
and thumbs extended along costal margin pointing
to xiphoid process.
 Posterior: thumbs placed at level of T 10 with palms
placed on posterior-lateral chest.
 By two ways you feel amount of thoracic expansion
during quiet and deep breathing, and symmetry of
respiration between left and right hemi thoraces.
 Assessment of tactile fremitus: which is vibration
perceptible on palpation"
 In subcutaneous emphysema: you must palpate the
tissue, audible cracking sounds are heard – these
sounds are termed Crepitation28 8/28/2020Bereket T.

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30. Percussion
Percussion involves
tapping on the anterior and posterior chest, in each
intercostal space, and
comparing sounds from side to side.
A normal chest sounds resonant and is the same on
both the right and left sides except over the heart.
If other percussion notes are heard, they may indicate
a pathological condition and should be reported.
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Assessment cont’d…
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Howtopercuss
Assessment cont’d…
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Percussion: Anterior Posterior
Assessment cont’d…
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33. Purcussion…
Abnormal findings:
Dullness – if fluid or solid replaces air. It indicates lobar
pneumonia.
Pneumothorax produces a tympanic or drums-like
sound.
Hyper resonance replaces resonance in patient with
emphysema or asthma.
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Assessment cont’d…
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34. Percussion of chest:
 Done to determine relative amounts of air, liquid, or solid
material in the underlying lung, and to determine positions
and boundaries of organs.
 Percussion done for posterior and anterior and lateral
aspects of chest with all directions, and with about “5”cms
intervals.
Auscultation:
 To obtains information about the function of respiratory
system & to detect any obstruction in the passages.
 Instruct the client to breathe through the mouth more deeply
and slowly than in usual respiration and then to hold the
breath for a few seconds at the end of inspiration to increase
intrapleural pressure and reopen collapsed alveoli.
 Auscultate all areas of chest for at least one complete
respiration: 12 anterior locations and 14 posterior locations8/28/2020Bereket T.34

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36.  Breathe sounds: are analyzed according to pitch,
intensity, quality, and relative duration of inspiratory and
expiratory phases.
 Bronchial breathe sounds: are normally heard over
manubrium of sternum.
 If heard over lung tissue – indicate pathologic condition,
these sounds “high-pitched loud sounds with decrease
inspiratory and lengthened increase expiratory phases.
 Absent or decreased breath sounds can occur in:
 Foreign body.
 Bronchial obstruction.
 Shallow breathing.
 Emphysema
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37. Breath Sounds
 Normal breath sounds are distinguished by their
location over a specific area of the lung and are
identified as tracheal, vesicular, bronchovesicular, and
bronchial (tubular) breath sounds as the next:
1. Tracheal
 Very loud, high pitched sound
 Inspiratory = Expiratory sound duration
 Heard over trachea in the neck
2. Bronchial
 Loud, high pitched sound
 Expiratory sounds > Inspiratory sounds
 Heard over manubrium of sternum
 If heard in any other location suggestive of37 8/28/2020Bereket T.

38. 3. Bronchovesicular
 Intermediate intensity, intermediate pitch
 Inspiratory = Expiratory sound duration
 Heard best 1st and 2nd ICS anteriorly, and between
scapula posteriorly
 If heard in any other location suggestive of
consolidation
4. Vesicular
 Soft, low pitched sound
 Inspiratory > Expiratory sounds
 Major normal breath sound, heard over most of lungs
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39. Adventitious Breath Sounds
 An abnormal condition that affects the bronchial tree and
alveoli may produce adventitious (abnrmal= addtional)
sounds. Adventitious sounds are divided into two
categories: discrete, noncontinuous sounds (crackles) and
continuous musical sounds (wheezes) as the next:
1. Crackles (Rales)
 Discontinuous, intermittent, nonmusical, brief sounds.
Heard more commonly with inspiration
 Classified as fine or coarse
 Its may associated with Prolonged recumbency
 Crackles caused by air moving through secretions and
collapsed alveoli and associated with the following
conditions: pulmonary edema, early CHF, and pnumonia
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40. 2. Wheeze
 Continuous, high pitched, musical sound, longer than
crackles
 Whistle quality, heard during expiration, however, can
be heard on inspiration
 Produced when air flows through narrowed airways
 Associated conditions: asthma, chronic bronchitis, and
COPD
3. Rhonchi
 Similar to wheezes (subtype of wheeze)
 Low pitched, snoring quality, continuous, musical
sounds
 Implies obstruction of larger airways by secretions
 Associated condition: acute bronchitis
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41. 4. Stridor
 Inspiratory musical wheeze
 Loudest over trachea
 Suggests obstructed trachea or larynx
 Medical emergency requiring immediate attention
 Associated condition
 inhaled foreign body
5. Pleural Friction Rub
 Pleural friction rubs are specific examples of crackles.
Discontinuous or continuous brushing sounds
 It is a loud dry, cracking or grating sound indicating of pleural
irritation, heard over lateral and anterior lung in sitting
position that heard during both inspiratory and expiratory
phases
 Occurs when pleural surfaces are inflamed and rub against
each other
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Table: Abnormal Lung
Sounds
Assessment cont’d…
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Assessment cont’d…
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44. Medical conditions associated with decreased or
absent of breath sounds
 Asthma
 COPD
 Pleural Effusion: fluid accumulating within the pleural
space
 Pneumothorax: caused by accumulation of air or gas in
the pleural space.
 ARDS( adult respiratory distress syndrome)
 Atelectasis : is defined as a state in which the lung, in
whole or in part, is collapsed or without air entery
Five Main Symptoms of Respiratory Disease
 Cough Sputum Pain
 Breathlessness Wheeze 8/28/2020Bereket T.44