ASSESMENT OF RESPIRATORY SYSTEM

General Respiratory Assessment

1. History
2. Biographical and Demographic Data
3. Current Health
3.1 Most Common Chief complaint
3.1.1 Dyspnea (difficulty breathing)
- clients may define dyspnea as shortness of breath, suffocation,
tightness, being winded, or being breathless
3.1.2 Cough
- clients may describe as hacking, dry, hoarse, congested, barking,
wheezy or bubbling
- determine which medications or treatments the client has used for
the cough ( antitussive, codeine, inhalers, nebulizers, rest, sitting
up)
3.1.3 Sputum production
- substance expelled by coughing or clearing the throat
- observe for sputum color(clear, yellow,green, rusty, bloody),
odor, quality (watery, stringy, frothy, thick), quantity (teaspoon,
tablespoon, cup)
3.1.4 Hemoptysis
- blood expectorated from the mouth in the form of gross blood,
frankly bloody sputum or tinged blood sputum.
- identify the source of blood—lungs, nosebleed, or stomach
-note: blood from the lungs is usually bright red because blood
in
the lungs stimulates an immediate cough reflex.
3.1.5 Wheezing
- produced when air passes through partially obstructed or
narrowed airways on inspiration or expiration
- note: not all wheezing are caused by asthma
3.1.6 Stridor
-high-pitched sounds produced when air passes through a partially
obstructed or narrowed upper airway on inspiration
-associated with respiratory distress
3.1.7 Chest Pain
-may be associated with pulmonary and cardiac problems
- determined the location, duration, and intensity of the chest pain.
-coughing and pleuritic infections can cause chest pain.
-pleuretic chest pain- commonly a sharp, stabbing pain that
occurs at one site on the chest wall and increases with chest wall
movement
-retrosternal pain – pain behind the sternum; pain is
burning,constant, and aching.
 - distinguish the pain with that of cardiac in origin
-is usually described as an aching, heavy, squeezing
sensation with pressure or tightness in substernal area.
4. Symptom analysis
4.1 Onset
4.2 Location
4.3 Duration
4.4 Characteristics/Client perception
4.5 Aggravating and Relieving Factors
4.6 Associated Manifestation
e.g. chills, fatigue, anxiety, and hoarseness.
4.7 Timing
-it encompasse both the onset and period
4.8 Setting- time and place
4.9 Severity – using scale 1 to 10
5. Past Health History
5.1. Childhood and infectious Diseases
- ask regarding common childhood diseases and vaccination
- determine the existence of congenital problems such as cystic fibrosis
5.2. Major illnesses and Hospitalizations
5.3 Medications
-he may have taken antibiotics, bronchodilators, etc
5.4 Allergies and timing of manifestation
5.5 Family Health History
-ask also about fam members who smoke
6. Psychosocial history
6.1 Occupation
- ask for exposure to dust, asbestos, beryllium,silica, and other toxins or
pollutants.
6.2 Geographic location
-ask for recent travels, Asia (tuberculosis), Ohio (histoplasmosis), san
Joaquin Valley (valley fever)
6.3 Environment
-ask about the living conditions
-assess for environmental hazards.
6.4 Habits
- inquire about any history of smoking tobacco products.

Year of smokingXPacks smoked per day = Pack years

- Smoking
- associated with decreased ciliary function of the lungs, increased
mucus production, and development of lung cancer.
 -ask about alchol use
-ciliary action is slowed by alcohol which reduces mucus clearance
from the lungs
- heavy alcohol ingestion depresses cough reflex and inc risk of
respiration
6.5 Exercise
6.6 Nutrition

PHYSICAL EXAMINATION
A. INSPECTION
- it begins during history taking stage
- note any manifestations of respiratory distress at this time such as:
*position of comfort *open mouth
*tachypnea *flared nostril
*gasping *dyspnea
*grunting *color of facial skin and lips
* central cyanosis *use of accessory muscle
*observe speech pattern
A.1 Head and Neck
-note nasal flaring, breathing with purse lips, cyanosis of mucous
membrane
A.2 Chest
-observe chest size and contour
-note the anteroposterior (AP) diameter
A.2.1 Barrel chest
- present when the AP diameter is increased and equals the
transverse diameter
- characteristic finding in clients with chronic disorders that
interfere with ventilation (emphysema)
A.2.2 Pigeon chest (pectus carinatum)
- opposite of funnel chest
- the sternum juts forward and increases the APdiameter.
- the most common cause are congenital atrial, ventricular septal
defects
A.2.3 Funnel Chest (pectus excavatum)
- is a deformity in which the sternum is depresses and the organs
that lie below it are compressed
A.2.4 Thoracic Kyphoscoliosis
-an accentuation of the normal thoracic curve
- clients takes on a hunched-over or hunch back appearance.
A.3 Fingers and Toes
-Observe for clubbing that is present in clients with pulmonary fibrosis,
lung cancer, or bronchiectasis.
- it occurs as a compensatory measure in chronic hypoxia
- with clubbing, the nail bed loses its normal angle of 160 degrees between
 the nail plate and the finger and the angle increases to 180 degress.
- note the color of the nail beds
- observe for the blanch response and capillary refill.

B. Palpation
B.1 Trachea
-gently place the thumb of the palpating hand on one side of trachea and
the remaining fingers on the other side
-move the trachea gently form side to side along its length while palpating
for masses, crepitus, or deviation from the midline
- trachea is slightly movable
B.2 Chest Wall
-holding the heel or ulnar aspect of your hand against client’s chest.
-it should be combined with inspection
-assess for crepitus, defects or tenderness of chest wall, muscle tone,
edema, and tactile fremitus(vibration of air movement through the chest
wall while the client is speaking)
B.3 Thoracic Excursion
- the client sits upright. Placeyour hands on the client’s posterior chest
wall.
- the thumbs oppose each other on either side of the spine, and the fingers
face upward and out like butterfly wings.
B.4. Tactile Fremitus

C. Percussion
- an assessment technique of producing sounds by tapping on the chest wall with
the hand.
- Tapping on the chest wall between the ribs produces various sounds that are
described in relation to the acoustic properties:
C.1 Resonant – sounds are low pitched, hollow sounds heard over normal
lung tissue
C.2 Hyperresonant – increased amount of air in the lungs or pleural space.
These sounds are louder and lower pitched than resonant sounds.
- this are produced by emphysema and pneumothorax
C.3. Dull – occur over dense lung tissue such as tumor or consolidation
-These sounds are thudlike and medium pitched and normally
heard over the liver and heart
C.4 Flat – notes are soft and high pitched
-result from percussion over airless tissues
C.5 Tympanic – notes are high, hollow, drum like sounds heard with
percussion over stomach, a large tension pneumothorax, or a large
air filled chamber.

D. Auscultation
-involves listening to the chest sounds with a stethoscope.
 -assess for the character of the breath sounds, the presence of adventitious sounds,
and the character of the spoken and whispered voice
D.1 Normal Breath Sounds
A. Vesicular breath sounds – heard throughout the chest and heard best in the
bases of the lungs
- they are low-pitched soft, “swishing” sounds best heard during
inspiration
B. Bronchial breath sounds – heard only anteriorly and best heard during
expiration with an expiratory to inspiratory ration of 2;1
-this sounds are high pitched and have a hollow or harsh quality
C. Bronchovesicular – they are heard equally during inspiration and expiration
and have a tubular or breezy-sounding quality
D. Absent or diminished – sounds are confirmed during deep respirations after the
client has been instructed to take deep breaths and sounds cannot be heard

D.2 Adventitious Breath sounds

- are abnormal sounds superimposed on normal breath sounds.

A. Crackles – (formerly called rales), can be reproduced by rubbing a lock of hair

between the thumb and finger close to the ear.
-usually heard during inspiration and do not clear with a cough.

B. Rhonchi – (also called gurgles(, occur as the result of air passing through fluid
filled, narrow passages.
-they are usually heard on expiration and may clear with a cough
C. Wheezes – is a continuous musical or hissing noise that results from the
passage of air through a narrowed airway.
- it is heard during inspiration or expiration or both
D. Pleural Friction Rubs – results of pleural inflammation oten associated with
pleurisy, pneumonia or pleural infarct.
- it is described as creaking, grating, noise similar to that made by two
pieces of leather rubbing together.

DIAGNOSTIC TESTS

TEST TO EVALUATE RESPIRATORY FUNCTION

• Pulmonary function test
• Pulse oximetry
• Capnography
• Arterial blood gas analysis
• Ventilation-perfusion studies

1. Pulmonary Function Tests (PFTs)

- it measures lung volumes, lung mechanics, and diffusion capabilities of the
lungs.
- a measure of expiratory flow obtained with a hand-held device is called “peak
 flow”
1.2. Forced Spirometry
-it measures the volume capacities of the lungs
1.3. Lung Volume Determination
- it measured by a gas dilution techniques or body
plethysmography.

1.4. Diffusion Capacity

- it measure gas transfer of carbon monoxide (CO) across the
alveolar capillary membrane.
- Hemoglobin has 250 times greater affinity for CO than for
oxygen.

2. Pulse Oximetry
- the data are obtained nonivasively and continuously.
- it is so common that it has been called the “fifth” vital sign.
- it gives a reading of the percentage of hemoglobin that is saturated with
oxygen(SaO2)
- it has limitations and it includes, motion at the sensor sight changes light
absorption, hypotension, hypothermia, and vasoconstriction reduce arterial
blood flow to the sensor

3. Capnography
- a noninvasive procedure used to measure exhaled carbon dioxide concentrations
of clients receiving mechanical ventilation
4. Arterial Blood Gas Analysis
- it involves the use of arterial rather than venous blood to measure Pao2., PaCO2,
and ph directly.
- PaCO2 reflects the effectiveness of alveolar ventilation
-PaO2 reflects the efficiency of gas exchange
- Arterial blood is differentiated form venous blood by its bright red color.
- the radial artery is most common used
- an Allen test must be completed before the procedure is initiated.

5. Ventilation-Perfusion Lung Scan

- use to assess lung ventilation and lung perfusion.
- PreprocedureCare
* the test is painless except for local discomfort when radiologic material
is injected for the perfusion scan.
* the client will hear clicking noise during the san, but the noise is not
loud.
*the client can remain dresses with all metal items removed.
5.1 Ventilation scan
- a radioactive gas is inhaled and produces an image of the areas where
ventilation is occurring.
 5.2 perfusion Scan
- radiologic material(non-iodine based) is injected intravenously and
carried into the pulmonary vasculature.

TEST TO EVALUATE ANATOMIC STRUCTURES

• Radiographic imaging
• Radionuclide studies
• Endoscopy
• Alveolar lavage

1. Radiography
1.1 Chest X-Ray studies
- may reveal abnormalities when there are no physical manifestation of
pulmonary disease
-chest films show the bony structures (ribs, sternum, clavicles, scapulae, and
upper portion of the humerus)
- normally heart shadow is clearly outlined
- Chest x –ray studies may be performed for the following reasons:
1.1.1 As part of a routine screening procedure
1.1.2 When pulmonary disease is suspected
1.1.3 To monitor the status of respiratory disorders and abnormalities
1.1.4 To confirm endotracheal or tracheostomy tube placement
1.1.5 After traumatic chest injury
1.1.6 In any situation in which radiographic information helps in the
management of a respiratory problem

- Preprocedure Care
- it is painless, and exposure to radiation is minimal.
- the client must remove all jewelry and under clothes and put a gown
- Assess the pregnancy status
- All gonads should be shielded during the study
- Several positions are as follows
1. Postanterior View
- the client’s shoulder are rotated forward to pull the scapulae away
from the lung filed.
- the x-ray beam penetrates from the back for the posteroanterior
(PA) position.
2. Anteroposterior View
-this are usually taken with the film placed behind the client and
the x-ray beam enters from the front, the heart appears larger
3. Lateral View
-lateral view usually accompanies a standard PA.
-it is taken from the right or left side of the hest.
- the arms are raised above the head and the side of the chest is
 placed against the film

4. Lateral Decubitus View

-from the latin, “lying down”
- the client lies on the right or left side, depending on which side is
to be assessed.
5. Oblique View
- used to visualize behind and around underlying structures.
- the shoulders are rotated to either right or left of the film.
6. Lordotic view
- useful if clearer visualization of the upper lung fields is needed.

1.2 Computed Tomography (CT)

- are particularly helpful in identifying peripheral (pleural) or mediastinal
disorders.
1.3 Magnetic Resonance Imaging (MRI)
- employs magnetic fields rather than radiation to create images of body
structures.
- it more definitive than CT because it creates more detailed images of anatomic
structure.
1.4 Ultrasonography
-ultrasonic waves are used diagnostically to assess various body structure
- it facilitates obtaining an adequate amount of fluid for laboratory analysis
without unnecessary puncturing and probing
1.5 Gallium Scans
- usually done 24 to 48 hours after intravenous injection of radioactive gallium
citrate
- many organs take up radioactive gallium as do some tumors and areas of
inflammation.(it has an affinity to inflammation)
- might be used to distinguish embolism from pneumonitis as the cause of an
infiltrate on chest radiograph

2. Bronshoscopy
-Procedure
* involves passage of a lighted bronchoscope into the bronchial tree.
* Its Diagnostic purposes are:
• Examination of tissue
• Further evaluation of a tumor for potential surgical
resection
• Collection of tissue specimens for diagnosis
• Evaluation of bleeding sites
*Its therapeutic purposes are:
• Remove foreign bodies
• Remove thick, viscous secretions
• Treat postoperative atelectasis
• Destroy and remove lesions
 -Preprocedure Care
*obtained an informed consent
*NPO 6 hours prior
* explain the throat may be sore after bronchospy and some initial
difficulty in swallowing
* Local anesthesia and intravenous sedation are used to suppress cough
and relieve anxiety
* a topical anesthetic agent is also sprayed into the back of the throat.
*DURING the procedure the client lies supine with head hyperextended
- Postprocedure care
* Monitor vital sign
* Observe the client for respiratory distress including dyspnea, changes in
respiratory rate, use of accessory muscle, and changes in or absent lung
sounds.
* observe for hemptysis
*NOTHING IS GIVEN BY MOUTH UNTIL THE COUGH AND
SWALLOW REFLEXES HAVE RETURNED USUALLY IN 1 TO 2
HOURS.
* feeding should start with ice chips and small sips of water.
* If sore throat develops it can be treated with warm saline gargles.

3. Laryngoscopy
- visual examination of the larynx.
- can be performed during bronchoscopy

4. Alveolar lavage
- sterile saline can be injected during bronchoscopy to wash tissues.
-the saline is aspirated and examined for atypical cells.

5. Endoscopic Thoracotomy
-alternative to open-lung biopsy
- Procedure
*3 small incisions are made into the middle chest wall.
* A scope attached to camera and video projector is inserted through the
first incision to inspect tissue.
*chest tube is being inserted for lung expansion
6. Pulmonary angiography
- Pulmonary angiography may be done to detect the following:
• Congenital abnormalities of the pulmonary vascular tree
• Abnormalities of the pulmonary venous circulation
• Acquired diseases of the pulmonary arterial and venous circulation
• Destructive effects of emphysema
• Potential benefits of resection for bronchogenic carcinoma
• Peripheral pulmonary lesions
 • Extent of thromboembolism in the lungs

- Procedure
- contrast medium is injected into the vascular system through an
indwelling catheter.

SPECIMEN RECOVERY AND ANALYSIS

1. Sputum Collection
-normally goblet cells produce 100 ml of mucus but an infectious process can lead to
excessive production of mucus.
-Procedure
*inspect the sputum for color, quantity, quality and presence of blood, food
particles.
*Acid-fast smear and culture specimens are collected in the MORNING
* Sputum can be collected by direct method, indirect method, gastric lavage
*when a specimen is obtained by direct method, the client BRUSHES THE
TEETH, and then coughs into a sputum container.
* Encourage the client to cough, not spit, to obtain sputum/
* the collected sputum is analyzed for Gram’s stain, culture, and sensitivity study.
* gram’s stain is used to classify bacteria as gram-positive or gram-negative.
* After Gram’s stain, the sputum is incubated for 24 hours or longer, this allows
identification of infecting organism

1.1 Nose and Throat Cultures

- Swab the nose and throat using a sterile cotton swab.

2. Thoracentesis
- performed to drain fluid or air found in the pleural space that caused lung compression
and respiratory distress
- the fluid collected is sent to the laboratory for assessment
- Preprocedure Care
- Obtain informed consent
- The client must sit up right while leaning over the tray table so that the fluid
accumulates in the base of the thorax.
- Instruct to hold still
- DURING procedure observe for signs of dyspnea
-Postprocedure Care
-AFTER the procedure the client is turned onto the UNAFFECTED SIDE for 1
hour for lung expansion
- Assess the respiratory status
- record the amount of fluid withdrawn
- chest films may be btained
- there’s a possibility for SUBCUTANEOUS EMPHYSEMA(tissue feel like
lumpy paper and crackle when palpated – crepitus)
3. Biopsy
- specimens are taken from various respiratory tissues for examination.
- the needle removes a small fragment of parietal pleura which is used for microscopic
cellular examination and culture.
- post procedure
*observe for complications; dyspnea, pallor, diaphoresis, excessive pain
-observe for the complications of pneumothora.