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Chapter (7)

Assessment of respiratory system

Faculty of Nursing-IUG
Anatomy of Respiratory System
The lung is a two cone-shaped, elastic structure suspended
within the thoracic cavity.
Lung are paired, they are not complete symmetric, the

right lung contain three lobe, whereas the left lung contain
only two lobes.
The apex of each lung extended slightly above the clavicle,

where the base is at the level of diaphragm


The thoracic cavity contains the nasopharynx, larynx,
trachea, bronchi, bronchioles, alveoli.
The thoracic cavity is lined by a thin, double- layered

serous membrane collectively called the pleural membrane


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Assessment of respiratory system
Subjective data: the nurse 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).

History of smoking (amount and length of time)

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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


techniques; Inspection, Palpation, Percussion and

6 Auscultation
Initial Respiratory Survey (Inspection)
Observe the patients breathing pattern
Rate (normal vs. increased/decreased)
Depth (shallow vs. deep)
Effort (any sign of accessory muscle use, inspect
neck)
Assess the patients color
Cyanosis
Normal Respiratory Rates
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-age child 18-30
Adolescent 12-16
Adult 16-20
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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 air
out flow tumor, aneurysm, cardiac enlargement
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 movements

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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 fremitus: which is vibration
perceptible on palpation"
In subcutaneous emphysema: you must palpate
the tissue, audible cracking sounds are heard
10 these sounds are termed Crepitation
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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 5cms
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 locations
Auscultate symmetrically: Should listen to at least 6
locations anteriorly and posteriorly
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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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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 of
consolidation
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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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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
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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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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
Associated conditions as pleural effusion, Pneumonothorax
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

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