What questions should you ask when you take a history from a patient with a respiratory problem?

9 Tips for Performing a Nursing Health Assessment of the Respiratory System

A nursing health assessment of the respiratory system involves the examination of the thorax and the lungs. A respiratory assessment is performed as part of a routine head-to-toe assessment.

At times a more focused assessment of the respiratory system is necessary. And, as with any other system, knowing possible symptoms and how to focus the interview and physical assessment are important skills for nursing students to have.

As with any study of systems, a good foundation of anatomy and physiology is important. Also, it is important to understand some basic principles of the respiratory system.

Remember to review your anatomy and physiology before you practice your assessment. The article 9 Facts About the Respiratory System Every Nursing Student Should Knowwill be helpful in understanding some foundational respiratory concepts.

During a respiratory assessment, a nursing student will use skills of inspection, palpation, percussion, and auscultation. This article with 9 Helpful Tips for Performing a Nursing Health Assessment of the Respiratory System will help you in your practice.

Tip #1 – Gather Information on Past Medical History

Patients who have a respiratory complaint may have a history of respiratory conditions. Therefore, gathering information about previous illnesses will help you perform a more accurate respiratory assessment.

Ask the following questions to gather more information about the past medical history.

1.  Have you had any type of thoracic surgery? Any surgeries to any part of your chest?
2. Are you on home oxygen, respiratory treatments, or assistive device for sleeping?
3. Do you smoke? If so, how long, and how much? Have you ever quit?
4. What immunizations have you had? Influenza? Pneumonia?
5. Do you have any respiratory diagnoses?
6. When were you last diagnosed with a respiratory illness?
7. What treatments did you receive for the illness?
8. Are there any respiratory problems that are recurring?
9. How have you managed the recurring respiratory problem?
10. Have you ever had a respiratory infection?
11. When were you last diagnosed with a respiratory infection?
12. Has the infection recurred?
13. What treatment did you receive for the respiratory infection?
14. Was the treatment helpful?

Tip #2 – Gather Information on Chief Complaints or Symptoms.

Gathering health information about the patient’s chief complaints and symptoms will help narrow the diagnosis of the respiratory condition. Below are some areas of assessment that focus on symptoms.

Respiratory Rate

Respiration is the delivery of oxygen to the body and the elimination of carbon dioxide from the body. Below are some terms to remember about respiration.

Eupnea is normal respirations.
Tachypnea is an abnormally fast rate of breathing (more than 20 breaths per minute in adults).
Bradypnea is an abnormally slow rate of breathing (less than 12 breaths per minute in adults).
Orthopnea is shortness of breath that starts or get worse when the patient lies down. These patients normally sleep on more than one pillow.
Paroxysmal Nocturnal Dyspnea (PND) is shortness of breath that occurs once a patient has fallen asleep. The onset of PND is sudden.

Ask the patient questions about any abnormal respiratory rates. Below are some questions to begin the conversation to get information.

If a patient is experiencing or has experienced abnormal respiration, ask the following questions.

1. When did you notice the changes in your respiration?
2. Describe your breathing?
3. Was the onset sudden or over a period of time?
4. Is the abnormal breathing continuous or does it come and go?
5. When do the episodes occur?
6. Is your breathing affected when you exert yourself?
7. How do you sleep? Do you have to sleep sitting? How many pillows do you use to sleep?
8. Ask the patient if they have any other symptoms that occur along with the abnormal breathing?

Shortness of Breath

The term for shortness of breath is dyspnea. It is non-painful but the patient feels the level of exertion for breathing is not normal. This symptom needs further investigation because it can be a serious complaint.

If a patient is experiencing or has experienced shortness of breath, ask the following questions.

1. How long have you had shortness of breath?
2. Was the onset, sudden or over a period of time?
3. Do you experience shortness of breath when you are resting?
4. Does your shortness of breath affect your daily activities or lifestyle?
5. Is it harder to inhale or exhale?
6. How do you sleep? Do you have to sleep sitting? How many pillows do you use to sleep?
7. Ask the patient if they have any other symptoms that occur along with the shortness of breath?

Cough

A cough is a respiratory symptom that can be serious or not serious. Usually, a cough is preceded by a deep breath. A cough is a response to some type of irritant along the respiratory tract. The irritants can include mucus, foreign bodies, infectious agents, blood, pus or dust. A cardiovascular problem can also cause a cough.

If a patient is experiencing or has experienced a cough, ask the following questions.

1. How long have you had this cough? Has it been weeks? Has it been a month or more?
2. Was the onset, sudden or over a period of time?
3. Do you cough all the time or only occasionally? Do you cough more at night or day?
4. Is your cough a wet cough or a dry cough?
5. Is your cough productive or nonproductive?
6. How does your cough sound? Is your cough loud, high pitched, soft, low pitched, hacking, barking, or wheezing?
7. Do you wake up in the middle of the night coughing?
8. Does the weather, time of year, talking or exercising affect your cough?
9. Do you take any prescription or over-the-counter medications for a cough?

Sputum Production

Sputum production is associated with a cough. If a patient produces sputum frequently in large amounts, it usually suggests a problem.

If a patient is experiencing or has experienced a cough with sputum production, ask the following questions.

1. How often do you have sputum when you cough?
2. How much sputum do you have? Attempt to help the patient quantify the amount?
3. What does the sputum look like?
4. Describe the color of the sputum?
5. Does the sputum have an odor?
6. Describe the consistency of the sputum? Is it thick or thin?
7. Is there blood in the sputum?

Hemoptysis

Hemoptysis is the coughing up of blood from the lungs. The blood can be frank blood or streaks of blood in the sputum. If a patient is experiencing or has experienced hemoptysis, attempt to assess the volume of blood. Try to find out if the blood may be originating from a source other than the lung.

Chest Pain

A patient may experience chest pain with breathing. Also, systems other than the respiratory system can cause chest pain. Cardiovascular problems can be a cause of the chest pain.

If a patient is experiencing or has experienced chest pain, ask the following questions.

1. Where is the pain located? Have the patient point to the pain.
2. Describe the pain. Is the pain sharp, dull, stabbing or burning?
3. How long have you had the pain?
4. When did the pain start?
5. Does the pain affect your breathing?
6. Does the pain occur during inspiration and expiration?
7. Have the patient rate the pain on a pain scale.

Tip #3 – Know the Landmarks of the Thorax Anteriorly, and Posteriorly

To perform a good respiratory assessment, the nursing student must be able to have a mental picture of the thorax. Visualize the lungs, ribcage, the spine, and other landmarks. Assess the anterior and the posterior thorax separately.

Bony Landmarks

The landmarks of the anterior thorax include the clavicle, sternum (suprasternal notch, manubrium, sternal angle, the body of the sternum, and the xiphoid process) and anterior ribs.

The landmarks of the posterior thorax include the spinal process (spine), scapula and posterior ribs. The images above show the anterior and posterior landmarks of the thorax.

The bony projection that is usually visible at the base of the neck is C7 (cervical vertebrae 7) and T1 (thoracic vertebrae 1).

Imaginary lines of the thorax

There are also some imaginary lines that are helpful with the assessment of the thorax anteriorly and posteriorly.

Anteriorly you have the midsternal line, midclavicular line, and the anterior axillary line.

The midsternal line begins at the sternal notch extending down the middle of the sternum or the middle of a person’s chest. The midsternal line divides the sternum into a right half and a left half.

The midclavicular line begins at the middle of the clavicle and extends down to around the 12th rib. This line should divide the right or left thorax in half.

The anterior axillary line begins at the anterior axillary fold extending downward and ending around the 12th rib.

Posterior imaginary lines include the vertebral line, the scapular line, and the posterior axillary line.

The vertebral line falls down the spinous process of the vertebrae. This line divides the back of the thorax into the right and left sides.

The scapular line begins at the inferior edge of the scapula extending downward ending around the 12th rib. The scapular line divides the right or left side of the back in half.

The posterior axillary line begins at the posterior axillary fold moving downward ending at the 12th rib.

Muscles of the Respiratory System

The muscles of the respiratory system include the diaphragm, the intercostal muscles, the sternocleidomastoid muscle, the scalene muscle, the pectoralis major muscle, the pectoralis minor muscle, and the rectus adominis muscle.

The diaphragm is the major muscle of respiration. The additional muscles expand the neck and lift the ribcage during respiration. Read more about the muscles of respiration here!

Lobes of the Lungs

The lungs are cone-shaped organs. They are made of spongy, elastic tissue. The lungs are divided into sections called lobes.

The right lung has three lobes. These are the upper, middle and lower lobe.

The left lung has two lobes. These are the upper and lower lobe. The left lung is slightly smaller than the right lung because of the position of the heart.

The lobes of the lung are somewhat independent of each other because they each receive air via their own bronchus.

Fissures divide the lobes of the lungs. These fissures extend through the lungs. 

A pleural membrane lines the fissures.

The apices of the lungs extend above the clavicle anteriorly and above the scapular posteriorly.

Because the lung is cone-shaped, it ends between the 6th and 8th rib anteriorly and the 10 rib posteriorly.

Tip #4 – Inspection of the Anterior and Posterior Thorax

Inspection of the thorax is the same anteriorly and posteriorly.

1. Position the patient in a sitting position if possible. Be sure and remove the clothing or lift the gown.
2. The arms are slightly away from the body (abducted).
3. Upon inspection, you are looking at the shape of the thorax.
4. Look at the movement of the thorax.
5. Determine the patient’s respiratory pattern.
6. Note how the chest moves when the patient breaths.
7. Note if the patient uses accessory muscles.
8. Inspect the neck and clavicle area. A patient with difficulty breathing may also use accessory muscles such as the sternocleidomastoid muscle.
9. Check for symmetry and any deformities. Some deformities of the thorax include barrel chest, funnel chest, and pigeon chest.
   • A barrel chestis an increase in the size of the chest from front to back. This is an anterior-posterior increase. The sternal angle becomes more prominent. A patient may have a barrel chest as they age and also with respiratory diseases like chronic obstructive pulmonary disease (COPD).
   • A funnel chest is noted when a patient has a depression in the lower portion of the sternum. This may cause a person to have a murmur if there is compression of the heart or the great vessels.
   • A pigeon chest is when the sternum is displaced and protrudes. The ribs next to the sternum at the xiphoid process are depressed.

Tip #5 – Palpation of the Anterior and Posterior Thorax

Lightly palpate the thoracic area anteriorly and posteriorly. During palpation, you are looking for pain, tenderness, abnormalities, pulsations, lesions, masses or abnormal movement.

Note the expansion of the chest. You may use palpation to check for chest expansion when it is difficult to observe the expansion or when you suspect asymmetry.

To palpate for chest expansion posteriorly

1. Count the ribs or the intercostal spaces next to the spine to the intersection of approximately the 10th rib.
2. Place your thumb at this intersection gently on the left and right side of the spine.
3. Loosely place your opened hand pointed outward to the side or the posterior axillary line.
4. Have the patient take a deep breath while you note the movement of your hand.
5. You are looking for the symmetrical movement of your hands. The distant should only be about 1 inch between the thumbs on inspiration.

To palpate for chest expansion anteriorly

1. Place your thumbs at the costal margin at the xiphoid process.
2. Loosely place your opened hand pointed outward to the side or the anterior axillary line.
3. Have the patient take a deep breath while you note the movement of your hand.
4. You are looking for symmetrical movement of your hands.
5. The distant should only be about 1 inch between the thumbs on inspiration.

Next, palpate for tactile fremitus. Fremitus is the vibration transmitted through the chest wall when a patient speaks. Tactile is the sense of touch. So tactile fremitus is check for fremitus using touch.

The assessment of tactile fremitus is not an assessment tool often used by nurses. You normally will see it used by physicians or advanced practice nurses.

However, you still need to know what it is. It could be an NCLEX question. Tactile fremitus can be checked anteriorly and posteriorly but is usually checked posteriorly.

To check tactile fremitus

1. Use the ball of the hand or the ulnar surface of the hand. The bone in the hand is more sensitive to vibration.
2. Have the patient repeat the words “ninety-nine.”
3. You can use one hand and check each side, or you can use both hands simultaneously.
4. Check approximately 4 areas on each side starting at the apices of the lung down to about the base of the lungs and out to the posterior axillary line.
5. You are checking for symmetry of fremitus.

Tip # 6 – Percuss the Anterior and Posterior Thorax

Percussion is used to assess the density of the lungs. It is also used to assess the air in the lungs. Percussion of the thorax is another one of those assessment tools you will probably only see in the lab.

To be really good at percussion you have to see it demonstrated. You also have to practice the skill. You can read how to do it over and over and you may get it, but seeing an instructor demonstrate this procedure is the key.

That being said, this article will just provide some notes of percussion you should be familiar with. Those percussion notes include flatness, dullness, resonance, hyperresonance, and tympany.

Flatness

Flat percussion sounds are a high-pitched sound with a soft quality. This sound is heard over dense tissue where there is no air.

Dullness

Dullness usually has a medium pitch. You will hear the dullness when there is a combination of a solid and a fluid-filled area.

Resonance

Resonance sounds are heard over normal lungs. These sounds usually have a low pitch.

Hyperresonance

Hyperresonance sounds are also low-pitched. However, these sounds are lower than resonance sounds. You will hear hyperresonance sounds over hyper-inflated lungs.

Tympany

Tympany sounds are drum-like sounds. A gas-filled area can cause tympanic breath sounds. Also, a pneumothorax can cause tympanic breath sounds.

Tips #7 – Auscultation of the Anterior and Posterior Thorax

The auscultation of the anterior and posterior thorax is one of the most important assessment techniques you can learn.

To become good at auscultation of the thorax, learn a pattern of auscultation that covers all the lobes of the right and left lung.

Also, you must know the difference between normal breath sounds and adventitious breath sounds.

There are many different respiratory auscultation patterns. The one above is a quick way to auscultate all the lobes. You can always add auscultation points if needed. The points above match the anterior and posteriors auscultation points below.  Also, this pattern can be used for palpation and percussion.

To auscultate breath sounds

1. Have the patient sit up if they are able.
2. The lungs can be auscultated with the patient lying down. Ascultate the anterior chest first. Then,  change the patient’s position to auscultate the posterior chest.
3. Have the patient take a deep breath with their mouth open while listening with the diaphragm of the stethoscope.
4. Be sure and listen between the intercostal spaces.
5. Use a pattern to move down the chest anteriorly and posteriorly. (See images below)
6. Following a side to side pattern is more efficient because you can compare sides.
7. Listen for at least one full breath (inspiration and expiration) at each location.
8. Don’t move too fast. Allow the patient to rest if needed.
9. Note the pitch and the intensity of the breath sounds.
10. Note the duration of inspiration and expiration. If you have a hard time hearing the breath sounds ask the patient to take a deeper breath as the patient may be shallow breathing.
11. Breath sounds may be diminished normally when a patient has a thick chest wall or if the patient is obese.

Tip #8 – Auscultation of Breath Sounds

Breath sounds are created when air moves in and out the respiratory tract. When you assess breath sounds you are assessing the pitch, intensity, quality and duration of the inspiration and expiration.

The classification of normal breath sounds includes vesicular, bronchovesicular, bronchial, and tracheal.

Vesicular

Vesicular breath sounds usually are a low-pitched sound and have a soft quality. You will hear vesicular breath sounds from the beginning of inspiration to almost the end of expiration.

Therefore, there is not usually a pause in this breath sound. You can hear vesicular breath sounds throughout the lungs.

Bronchovesicular

Bronchovesicular breath sounds are the inspiration and expiration sounds heard. These breath sounds will have a pause between inspiration and expiration.

They have a moderate pitch. You can usually hear this breath sound over the upper portion of the lungs around the 1st and 2nd intercostal spaces.

Bronchial

Bronchial breath sounds are a high-pitched sound. The expiration period is longer than the inspiration period. You will hear these sounds best next to the trachea.

Tracheal

Breath sounds heard over the trachea are tracheal breath sounds. The tracheal breath sounds are high-pitched and are loud. The sounds are heard equally during inspiration and expiration.

Tip #9 – Auscultation of Adventitious Breath Sounds

Abnormal breath sounds are called “extra” or “adventitious” breath sounds. Adventitious breath sounds include crackles (formerly known as rales), wheezes, rhonchi and friction rubs.

Air flowing by liquid cause crackles (rales).

• Crackles can be fine, medium or coarse.
• Fine crackles are high-pitched crackling or popping sound.
• Coarse crackles are a low-pitched gurgling sound.
• These sounds are usually heard during inspiration.
• Crackles create a dry sound when heard higher in the bronchial tree.
• Crackles create a wet sound when heard lower in the bronchial tree.

Air flowing through constricted airways cause wheezes.

• Wheezes have a high-pitched musical sound.
• High-pitched wheezes are sibilant.
• Low-pitched wheezes are sonorous.
• Heard on inspiration and expiration.
• Wheezes are continuous.
• They are usually bilateral. Wheezes that are unilateral are usually due to an obstruction by a foreign object.

Air flowing over thick secretions cause rhonchi.

• Rhonchi create a low-pitched sound.
• They are usually continuous and prolonged.
• Sibilant or high pitched rhonchi are heard over the smaller bronchi.
• And, sonorous or low pitched rhonchi are heard over the larger bronchi.
• It is sometimes hard to distinguish between crackles and rhonchi. Therefore, have the patient cough. If it disappears, it is usually rhonchi.

Inflammation of the pleural space cause friction rubs.

• A friction rub is not produced inside the airways.
• Also, friction rubs are a dry, rubbing, crackling sound.
• Usually caused by inflammation or loss of pleural fluid.
• You will hear friction rubs during inspiration and expiration.

In conclusion, the tips above will help you with a nursing health assessment of the respiratory system. These skills will also help you with a head-to-toe assessment.

Begin by practicing your auscultation skills. Listen to as many different breath sounds as possible. This includes well people also. Once you have learned to recognize normal breath sounds, you will be able to recognize adventitious breath sounds when you hear them.

The 9 tips above will give you a foundation as you increase your skills of performing not only a respiratory assessment but also a head-to-toe nursing health assessment.

Reference

Bickley LS., Szilagyi PG., (2017). Bates Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA. Wolters Kluwer/Lippincott Williams & Wilkins.

Jarvis C., (2017). Physical Examination & Health Assessment. St Louis, MO. Elsevier Inc.

Mosby’s Medical Dictionary (2017). 10th ed. St Louis, MO. Elsevier Inc.

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