Module 4 Respiratory 0 1 PDF

King Saud University Application of Health Assessment
Nursing College NUR 225

Medical Surgical Nursing
Department
Module Four
Physical examination of
Respiratory Assessment
1
Health assessment in nursing fifth edition
Janet R. Weber / Jane H. Kelley
Department
THORACIC CAGE:
Anterior thoracic cage
Posterior thoracic cage
2
Department
Reference lines:
Anterior vertical lines Lateral vertical line
Posterior vertical lines
3
Department
Position of the Lungs:
(A) Anterior view of lung position (B) Posterior view of lung position
(C)Lateral view of left lung position (D) Lateral view of Right lung position
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Department
Equipment:
EXAMINATION GOWN AND DRAPE
GLOVES
STETHOSCOPE
LIGHTSOURCE
MASK
SKIN MARKER
METRIC RULER
Assessment Procedure Normal finding Abnormal finding

General
Inspection
Inspect for nasal flaring and pursed Nasal flaring is not observed. Nasal flaring is seen with
lip breathing. labored respirations
(especially in small children)
and is indicative of hypoxia.
Pursed lip breathing may be

seen in asthma, emphysema,
or CHF.
Observe color of face, lips, and chest. The client has evenly colored skin Ruddy to purple complexion may
tone, without unusual or be seen in clients with COPD or
prominent discoloration. CHF as a result of polycythemia.
Cyanosis may be seen if client is
cold or hypoxic.
Cyanosis makes white skin

appear blue-tinged, especially
in the perioral, nailbed, and
conjunctival areas. Dark skin
appears blue, dull, and lifeless
in the same areas.
Inspect color and shape of nails. Pink tones should be seen in the Pale or cyanotic nails may indicate
nailbeds. There is normally a 160- hypoxia. Clubbing can occur from
degree angle between the nail base hypoxia.
and the skin.
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Department
Posterior Thorax
INSPECTION
Inspect configuration. While the client Scapulae are symmetric and Spinous processes that deviate
sits with arms at the sides, stand behind nonprotruding. Shoulders and laterally in the thoracic area
the client and observe the position of scapulae are at equal horizontal may indicate scoliosis.
scapulae and the shape and positions. The ratio of
configuration of the chest wall. anteroposterior to transverse
diameter is 1:2.
Spinous processes appear straight,

and thorax appears symmetric,
with ribs sloping downward at
approximately a 45-degree angle
in relation to the spine.
OLDER ADULT
Spinal configurations may
CONSIDERATIONS
have respiratory implication.
Kyphosis (an increased curve of the Ribs appearing horizontal at
thoracic spine) is common in older an angle greater than 45
It results from a loss of lung degrees with the spinal
resiliency and a loss of skeletal column are frequently the
muscle. It may be a normal finding. result of an increased ratio
between the
anteroposterior transverse
diameter (barrel chest).
This condition (barrel chest) is

commonly the result of
emphysema due to
hyperinflation of the lungs.
6
Department
Observe use of accessory muscles. The client does not use accessory Trapezius, or shoulder, muscles
Watch as the client breathes and note (trapezius/ shoulder) muscles to are used to facilitate
use of muscles. assist breathing.
inspiration in cases of acute
and chronic airway obstruction
or atelectasis.
Inspect the client’s positioning. Note Client should be sitting up and Client leans forward and uses arms
the client’s posture and ability to relaxed, breathing easily with arms to support weight and lift chest to
support weight while breathing at sides or in l increase breathing capacity,
comfortably. referred to as the tripod position.
This is often seen in COPD.
PALPATION
Palpate for tenderness and Client reports no tenderness, Tender or painful areas may
sensation. Palpation may be pain, or unusual sensations. indicate fibrous connective
performed with one or both hands, but Temperature should be equal tissue.
the sequence of palpation is bilaterally.
established. Use your fingers to Pain over the intercostal spaces
palpate for tenderness, warmth, pain, may be from inflamed pleurae.
or other sensations. Start toward the
Pain over the ribs is a symptom of
midline at the level of the left scapula
fractured ribs.
(over the apex of the left lung) and
move your hand left to right, Muscle soreness from exercise
comparing findings bilaterally. Move or the excessive work of
systematically downward and out to breathing (as in COPD) may be
cover the lateral portions of the lungs palpated as tenderness.
at the bases.
Increased warmth may be
related to local infection.
7
Department
Palpate for crepitus. Crepitus, also The examiner finds no palpable Crepitus can be occurs after
called subcutaneous emphysema, is crepitus. an open thoracic injury,
a crackling sensation (like bones or around a chest tube or
hairs rubbing against each other) tracheostomy. It also may be
that occurs when air passes through palpated in areas of extreme
fluid or exudate. Use your fingers and congestion or consolidation.
follow the sequence when palpating. In such situations, mark
margins and monitor to note
any decrease or increase in
the crepitant area.
Palpate for fremitus. Following the Fremitus is symmetric and easily Unequal fremitus is usually
sequence described previously, use identified in the upper regions of the result of consolidation
the ball or ulnar edge of one hand the lungs. If fremitus is not palpable (which increases fremitus)
to assess for fremitus (vibrations of on either side, the client may need
air in the bronchial tubes Bronchial obstruction, air
to speak louder. A decrease in the trapping in emphysema,
transmitted to the chest wall). As
intensity of fremitus is normal as the pleural effusion, or
you move your hand to each area,
examiner moves toward the base of pneumothorax (which all
ask the client to say “ninety-nine.”
the lungs. However, fremitus should decrease fremitus).
Assess all areas for symmetry and
intensity of vibration. remain symmetric for bilateral
positions. Diminished fremitus even
with a loud spoken voice may
indicate an obstruction of
CLINICAL TIP the tracheobronchial tree.
The ball of the hand is best for

assessing tactile fremitus because the
area is especially sensitive to vibratory
sensation
8
Department
When the client takes a deep Unequal chest expansion can
breath, the examiner’s thumbs occur with severe atelectasis
Assess chest expansion. Place your should move 5 to 10 cm apart (collapse or incomplete
hands on the posterior chest wall with symmetrically. expansion), pneumonia, chest
your thumbs at the level of T9 or T10 and trauma, or pneumothorax (air in
pressing together a small skin fold. As OLDER ADULT the pleural space).
the client takes a deep breath, observe CONSIDERATIONS
the movement of your thumbs. Decreased chest excursion at the
Because of calcification of the base of the lungs is characteristic
costal cartilages and loss of the of COPD. This is due to decreased
accessory musculature, the older diaphragmatic function.
client’s thoracic expansion may be
decreased, although it should still
be symmetric.
PERCUSSION
Percuss for tone. Start at the apices of Resonance is the percussion tone Hyperresonance is elicited in cases
the scapulae and percuss across the elicited over normal lung tissue. of trapped air such as in
Percussion elicits flat tones over the emphysema or pneumothorax.
tops of both shoulders. Then percuss the
scapula.
intercostal spaces across and down,
comparing sides. Percuss to the lateral
aspects at the bases of the lungs,
comparing sides.
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Department
Percuss for diaphragmatic excursion. Excursion should be equal Dullness is present when fluid
Ask the client to exhale forcefully and bilaterally and measure 3–5 cm in or solid tissue replaces air in
hold the breath. Beginning at the adults. the lung or occupies the
scapular line (T7), percuss the pleural space, such as in lobar
intercostal spaces of the right posterior The level of the diaphragm may be pneumonia, pleural effusion,
chest wall. Percuss downward until the higher on the right because of the or tumor.
tone changes from resonance to position of the liver.
dullness. Mark this level and allow the Diaphragmatic descent may
In well-conditioned clients, be limited by atelectasis of
client to breathe. Next ask the client to
excursion can measure up to 7 or the lower lobes or by
inhale deeply and hold it. Percuss the
8 cm. emphysema
intercostal spaces from the mark
downward until resonance changes to
Other possible causes for
dullness. Mark the level and allow the
limited descent can be pain
client to breathe. Measure the
or abdominal changes such
distance between the two marks.
as extreme ascites, tumors,
Perform this assessment technique on
or pregnancy.
both sides of the posterior thorax.
Uneven excursion may be seen
with inflammation from unilateral
pneumonia, damage to the
phrenic nerve, or splenomegaly
AUSCULTATION
Auscultate for breath sounds. To Three types of normal breath Diminished or absent breath
best assess lung sounds, you will sounds may be auscultated— sounds often indicate
need to hear the sounds as directly bronchial, bronchovesicular, and obstruction within the lungs as
as possible. Do not attempt to vesicular. a result of secretions, mucus
listen through clothing or a drape, plug, or a foreign object
which may produce additional CLINICAL TIP
sound or muffle lung sounds that . It may also indicate
Breath sounds are considered abnormalities of the pleural
exist. To begin, place the diaphragm
normal only in the area speciﬁed. space such as pleural
of the stethoscope firmly and
Heard elsewhere, they are thickening, pleural effusion, or
10
Department
directly on the posterior chest wall considered abnormal sounds. For pneumothorax.
at the apex of the lung at C7. Ask example, bronchial breath sounds
the client to breathe deeply In cases of emphysema, the
are abnormal if heard over the
through the mouth for each area hyperinflated nature of the
peripheral lung ﬁelds.
of auscultation (each placement of lungs, together with a loss of
the stethoscope) in the locations of normal breath elasticity of lung tissue, may
auscultation sequence so that you sounds: result in diminished inspiratory
can best hear inspiratory and breath sounds.
expiratory sounds. Be alert to the
Increased (louder) breath
client’s comfort and offer times for
sounds often occur when
rest and normal breathing if
consolidation or compression
fatigue is becoming a problem.
results in a denser lung area
OLDER ADULT CONSIDERATIONS that enhances the transmission
of sound.
Deep breathing may be especially
difficult for the older client, who
may fatigue easily. Thus offer rest as
needed.
Auscultate from the apices of the lungs Sometimes breath sounds may be
at C7 to the bases of the lungs at T10 hard to hear with obese or heavily
and laterally from the axilla down to muscled clients due to increased
distance to underlying lung tissue.
the seventh or eighth rib. Listen at each
site for at least one complete
respiratory cycle. Follow the
auscultating sequence shown.
11
Department
Auscultate for adventitious No adventitious sounds, such as Adventitious lung sounds, such as
sounds. Adventitious sounds are crackles (discrete and discontinuous crackles (formerly called rales)
sounds) or wheezes (musical and
sounds added or superimposed and wheezes (formerly called
continuous), are auscultated.
over normal breath sounds and rhonchi) are evident.
heard during auscultation. Be careful
to note the location on the chest CLINICAL TIP
wall where adventitious sounds are
If you hear an abnormal sound
heard as well as the location of
during auscultation, always have
such sounds within the respiratory
cycle. the client cough, then listen
again and note any change.
Coughing may clear the lungs.
Auscultate voice sounds.
Bronchophony: Ask the client to repeat Voice transmission is soft, The words are easily understood
the phrase “ninety-nine” while you muffled, and indistinct. The and louder over areas of
auscultate the chest wall. sound of the voice may be increased density. This may
heard but the actual phrase indicate consolidation from
cannot be distinguished. pneumonia, atelectasis, or
tumor.
Over areas of consolidation or

Egophony: Ask the client to repeat the Voice transmission will be soft and compression, the sound is
letter “E” while you listen over the chest muffled but the letter “E” should louder and sounds like “A.”
be distinguishable.
wall.
Over areas of consolidation or

Transmission of sound is very faint compression, the sound is
Whispered pectoriloquy: Ask the client
and muffled. It may be inaudible. transmitted clearly and
to whisper the phrase “one–two–
distinctly. In such areas, it
three” while you auscultate the chest
sounds as if the client is
wall.
whispering directly into the
stethoscope.
12
Department
Anterior Thorax
Inspection
Inspect for shape and configuration. The anteroposterior diameter is Anteroposterior equals
Have the client sit with arms at the less than the transverse transverse diameter, resulting
sides. Stand in front of the client and diameter. The ratio of in barrel chest. This is often
assess shape and configuration. anteroposterior diameter to the seen in emphysema because
transverse diameter is 1:2. of hyperinflation of the lungs.
Inspect position of the sternum. Sternum is positioned at midline and Pectus excavatum is a markedly
Observe the sternum from an anterior straight. sunken sternum and adjacent
and lateral viewpoint. cartilages (often referred to as
OLDER ADULT funnel chest). It is a congenital
CONSIDERATIONS
malformation that seldom
The sternum and ribs may be causes symptoms other than
more prominent in the older self- consciousness.
client because of loss of
subcutaneous fat.
Pectus carinatum is a forward

protrusion of the sternum
causing the adjacent ribs to
slope back word (often referred
to as pigeon chest). Both
conditions may restrict
expansion of the lungs and
decrease lung capacity.
13
Department
Watch for sternal retractions. Retractions not observed. Sternal retraction are noted, with
severely labored breathing.
Observe quality and pattern of Respirations are relaxed, effortless, Labored and noisy breathing is
respiration. Note breathing and quiet. They are of a regular often seen with severe asthma
characteristics as well as rate, rhythm, rhythm and depth at a rate of 10– or chronic bronchitis.
and depth. 20 per minute in adults. Tachypnea
and bradypnea may be normal in Abnormal breathing patterns
CLINICAL TIP some clients. include tachypnea, bradypnea,
hyperventilation,
When assessing respiratory hypoventilation, Cheyne-Stokes
patterns, it is more objective to respiration, and Biot’s
describe the breathing pattern, respiration.
rather than just labeling the
pattern.
Inspect intercostal spaces. Ask the No retractions or bulging of Retraction of the intercostal
client to breathe normally and observe intercostal spaces are noted. spaces indicates obstruction of
the intercostal spaces. the respiratory tract or
atelectasis.
Bulging of the intercostal

spaces indicates trapped air
such as in emphysema or
asthma.
Observe for use of accessory muscles. Use of accessory muscles Neck muscles (sternomastoid,
Ask the client to breathe normally and (sternomastoid and rectus scalene, and trapezius) are used
observe for use of accessory muscles.
abdominis) is not seen with normal to facilitate inspiration in cases
respiratory effort. After strenuous of acute or chronic airway
exercise or activity, clients with obstruction or atelectasis.
normal respiratory status may use
neck muscles for a short time to The abdominal muscles and
enhance breathing. the internal intercostal muscles
are used to facilitate expiration
in COPD.
14
Department
PALPATION
Palpate for tenderness, sensation, No tenderness or pain is palpated Tenderness over thoracic muscles
and surface masses. Use your fingers over the lung area with can result from exercising (e.g.,
respirations. pushups) especially in a previously
to palpate for tenderness and
sedentary client.
sensation. Start with your hand
positioned over the left clavicle (over
the apex of the left lung) and move
your hand left to right, comparing
findings bilaterally. Move your hand
systematically downward toward the
midline at the level of the breasts and
outward at the base to include the
lateral aspect of the lung. The
established sequence for palpating the
anterior thorax serves as a guide for
positioning your hands.
CLINICAL TIP
Anterior thoracic palpation is best for

assessing the right lung’s middle lobe
Palpate for crepitus as you would on No crepitus is palpated. In areas of extreme congestion or
the posterior thorax. consolidation, crepitus may be
palpated, particularly in clients
with lung disease.
15
Department
Palpate for fremitus. Using the Fremitus is symmetric and easily Diminished vibrations, even with
sequence for the anterior chest identified in the upper regions of a loud spoken voice, may indicate
described previously, palpate for the lungs. A decreased intensity of an obstruction of the
fremitus using the same fremitus is expected toward the tracheobronchial tree.
technique as for the posterior base of the lungs. However,
fremitus should be symmetric Clients with emphysema may
thorax. have considerably decreased
bilaterally.
CLINICAL TIP fremitus as a result of air
trapping.
When you assess for fremitus on the
female client, avoid palpating the
breast. Breast tissue dampens the
vibrations.
Palpate anterior chest expansion. Thumbs move outward in a Unequal chest expansion can
Place your hands on the client’s symmetric fashion from the midline. occur with severe atelectasis,
anterolateral wall with your thumbs
pneumonia, chest trauma,
along the costal margins and pointing
pleural effusion, or
toward the xiphoid process. As the client
pneumothorax.
takes a deep breath, observe the
movement of your thumbs. Decreased chest excursion at
the bases of the lungs is seen
with COPD.
16
Department
PERCUSSION
Percuss for tone. Resonance is the percussion tone Hyperresonance is elicited in cases
elicited over normal lung tissue. of trapped air such as in
Percuss the apices above the clavicles. emphysema or pneumothorax.
Then percuss the intercostal spaces Dullness may characterize areas of
increased density such as
across and down, comparing sides.
consolidation, pleural effusion, or
tumor.
Percussion elicits dullness over

breast tissue, the heart, and the
liverand flatness is detected over
the muscles and bones.
Auscultation
Auscultate for anterior breath Three types of normal breath Abnormal voice sounds.
sounds, adventitious sounds, and sounds may be auscultated—
voice sounds. Place the diaphragm of
bronchial, bronchovesicular, and
the stethoscope firmly and directly on
vesicular.
the anterior chest wall. Auscultate
from the apices of the lungs slightly
above the clavicles to the bases of the
lungs at the sixth rib. Ask the client to
breathe deeply through the mouth in
an effort to avoid transmission of
sounds that may occur with nasal
breathing. Be alert to the client’s
comfort and offer times for rest and
normal breathing if fatigue is
becoming a problem, particularly for
the older client. Listen at each site for
at least one complete respiratory
cycle.
17
Department
CLINICAL TIP
Again, do not attempt to listen
through clothing or other materials.
However, if the client has a large
amount of hair on the chest, listening
through a thin T-shirt can decrease
extraneous sounds that may be
misinterpreted as crackles.
18
Department
Performance checklist
Respiratory System
The student nurse should be able to:
Competency Level
Trial 1 Trial 2
Performance criteria Comment
Done Done with Not done Done Done with Not done
correctly assistance (0) correctly assistance (0)
(2) (1) (2) (1)
-Collect appropriate objective data about
respiratory system related to general
survey.
-Collect appropriate subjective data related
to respiratory system.
- Chest pain, shortness of breath (dyspnea),
wheezing, cough dry or produce sputum,
sputum or hemoptysis.
- Sputum or hemoptysis characteristics:
color, odor, amount, frequency and
consistency.
Physical examination
General
Done Done with Not done Done Done with Not done
correctly assistance (0) correctly assistance (0)
Inspection (2) (1) (2) (1)
Inspect for nasal flaring and pursed lip

breathing.
Observe color of face, lips, and chest.
Inspect color and shape of nails.
Posterior Thorax
Trial 1 Trial 2 Comment
Inspection Done
correctly
Done with
assistance
Not done
(0)
Done
correctly
Done with
assistance
Not done
(0)
(2) (1) (2) (1)
- Inspect configuration.
- Observe use of accessory muscles.
- Inspect the client’s positioning.
Palpation
- Palpate for tenderness and sensation.
- Palpate for crepitus.
- Palpate for fremitus.
- Assess chest expansion.
19
Department
Percussion
- Percuss for tone.
- Percuss for diaphragmatic excursion.
Auscultation
- Auscultate for breath sounds.
- Auscultate for adventitious sounds.
- Auscultate voice sounds.
Anterior Thorax
Inspection
- Inspect for shape and configuration.

- Inspect position of the sternum.
- Watch for sternal retractions. .
- Observe quality and pattern of
respiration.
- Inspect intercostal spaces.
- Observe for use of accessory muscles.
Palpation
- Palpate for tenderness, sensation, and
surface masses.
- Palpate for crepitus.
- Palpate for fremitus.
- Palpate anterior chest expansion.
Percussion
- Percuss for tone.
Auscultation
- Auscultate for anterior breath sound,
adventitious sounds, voice sounds.
Documentation.
Evaluated by: __________________________ Date Evaluated: _______________
Name and Signature of Faculty Total grade _________
20

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King Saud University Application of Health Assessment

Nursing College NUR 225

Anterior thoracic cage

Posterior thoracic cage

Anterior vertical lines Lateral vertical line

Posterior vertical lines

Position of the Lungs:

Assessment Procedure Normal finding Abnormal finding

Pursed lip breathing may be

Cyanosis makes white skin

Spinous processes appear straight,

This condition (barrel chest) is

The ball of the hand is best for

Auscultate voice sounds.

Over areas of consolidation or

Over areas of consolidation or

Pectus carinatum is a forward

Bulging of the intercostal

Anterior thoracic palpation is best for

Percussion elicits dullness over

The student nurse should be able to:

Inspect for nasal flaring and pursed lip

- Inspect for shape and configuration.

Evaluated by: __________________________ Date Evaluated: _______________

Name and Signature of Faculty Total grade _________

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Evaluated by: ____________ Date Evaluated: _