Respiratory Assessment

Description #

This unit is designed to help the students and clinically registered nurses develop a better understanding of the skills involved in repiratory assessment.

Learning Objectives #

On completion of this module, you will be able to:

1. Describe the techniques for completing a respiratory assessment.

2. Demonstrate the concepts of oxygen supply and demand.

3. Undertake a comprehensive assessment of a patient with respiratory failure.

4. Identify normal and abnormal clinical findings including physical assessment findings, lab and diagnostic results.

Introduction #

The respiratory system provides the body with two primary functions: Ventilation and External gas exchange. Ventilation is the process of moving air into and out of the lungs. External gas exchange is the movement of oxygen from the lungs into the blood and the movement of carbon dioxide into the lungs from the blood. Internal gas exchange occurs between the capillaries and the cells. The respiratory system works closely with the cardiac system, and together they make the cardiopulmonary system. When present, a disease process may affect both systems.

To understand the respiratory status of your patient, you must perform a comprehensive assessment. This is achieved through communication, inspection, and auscultation. In addition, there are several adjuncts to assessment such as the use of pulse oximetry, arterial blood gases, and chest radiographs, which will be mentioned briefly in this unit. One of the most important tools you can use during your assessment is your knowledge of what is ‘normal’ for your patient, based on their medical and admitting history. As your skills develop, you will be able to perform many aspects of your assessment simultaneously. Ideally, the respiratory assessment should take place with the patient sitting upright, allowing access to the anterior, lateral, and posterior aspects of the chest. As well, the chest should be bare.

Communication #

Communication will usually be the first step of your assessment. By asking the patient how they are, you will gain a sense of their ease of breathing with their answer. A patient who cannot speak in full sentences, or who coughs excessively while speaking may have respiratory compromise. For detailed information, ask your patient about the onset, duration, and severity of associated signs and symptoms of respiratory disease, such as shortness of breath, cough, and sputum production. 

Communication will usually be the first step of your assessment. By asking the patient how they are, you will gain a sense of their ease of breathing with their answer. A patient who cannot speak in full sentences, or who coughs excessively while speaking may have respiratory compromise. For detailed information, ask your patient about the onset, duration, and severity of associated signs and symptoms of respiratory disease, such as shortness of breath, cough, and sputum production.

Shortness of breath (dyspnea) is a subjective feeling of breathlessness, and is common with cardiopulmonary disease.  Dyspnea often worsens with exertion and improves with rest, and patients who are dyspneic are often anxious.

Cough is one of the most frequent symptoms in patients with respiratory disease. Cough typically occurs when the cough receptors of the larger airways are stimulated by inflammation, secretions, or noxious materials. Assessment of the patient’s ability to cough effectively is important, as it can indicate if the patient is having trouble clearing the lungs of sputum. A cough may be described as productive, where lots of sputum is present; weak, when the patient has a hard time clearing their sputum; or strong, where the patient clears sputum easily. A strong cough may also be called an effective cough.

Sputum refers to the production of secretions from the lungs. A small amount of sputum is normal, and is part of the lungs’ natural defense system. Sputum is carried to the upper airway by tiny cilia (tiny waving hairs on cells lining the airway). When sputum production becomes excessive, is thick, or colored, it is a sign of respiratory disease. Sputum can be described as mucoid when it is clear and thick, purulent when it is yellow or green from pus, and copious when it is present in large amounts. 

When assessing a patient’s cough, make note of the following:

·   Regularity of the cough

·   Length of time required to cough

·   Presence or absence of pain with coughing

·   Distinctive sounds of coughing

·   Strength of cough

·   Sputum production with coughing

Communication leads easily into and overlaps with the next step of your respiratory assessment, which is a detailed inspection.

Inspection #

Inspection

Inspection focuses on a visual examination of patient position and of the head, neck, and chest areas. Patient position is an indication of their ease of breathing – a patient who appears comfortable is likely not in respiratory distress. A patient in distress will often appear restless, want to sit up, and might lean forward – this helps to stabilize the accessory muscles of breathing. 

Assessment of a patient’s level of consciousness is an important part of your assessment. The conscious patient should be evaluated for orientation to person, time and place. Altered consciousness may occur when poorly oxygenated blood is delivered to the brain. A patient with acute or advancing respiratory illness and resulting hypoxemia (low blood oxygen level) may become restless, confused, and disoriented. If hypoxemia worsens, the patient may become unconscious. 

During your inspection you need to assess whether your patient has a normal respiratory rate; about 12 to 20 breaths per minutes. A fast respiratory rate, or tachypnea, is a common finding in a patient with cardiopulmonary disease.  Tachypnea is almost always seen in a patient with acute hypoxemia.  Bradypnea, or an abnormally slow respiratory rate, is not common, but might be seen in a patient who is hypothermic, with some CNS disorders, and in late stages of respiratory distress. As well, you should note the depth of breaths – whether they are normal, deep, or shallow, and whether they are regular or irregular in pattern. Remember to relate your findings as to what is considered ‘normal’ for this patient, and to note changes from that ‘normal’. 

The color of a patient’s skin and oral mucosa (the mucus membrane lining of the mouth) gives information about their respiratory status. A stable patient will usually have skin and mucosa that is slightly pink (color will vary with ethnicity). A patient with hypoxemia may have skin and mucosa that is pale and/or cyanotic.  Cyanosis is a blue coloration of the skin and mucous membranes due to the presence of deoxygenated hemoglobin in blood vessels. Cyanosis is most noticeable when the oxygen saturation of the blood falls below 85%, but this level can vary when other conditions are present, such as anemia, where patients may not appear cyanotic with low blood oxygen levels. Some patients with chronic respiratory disease may have chronic hypoxemia, in which case a degree of cyanosis may be ‘normal’ for them. However, it is important to know what is ‘normal’ for your patient, and then to monitor them for changes. 

When breathing requires extra effort, the accessory muscles are used to stabilize the thorax, and to assist in ventilation. The accessory muscles of breathing include the sternocleidomastoid, scalene, pectoralis major, trapezius, intercostals, and abdominal muscles. Some accessory muscle use is normal with activities such as singing, talking, coughing, and exercising. More pronounced use of these muscles may signal acute respiratory distress, diaphragmatic weakness, or fatigue. When a patient has a high work of breathing, you will likely see retractions. A retraction is when the skin around bony structures sinks inwards with inspiration. Retractions can be intercostal (inward movement of the rib interspaces), suprasternal, or supraclavicular. All are an indication of a high work of breathing, and require monitoring and medical attention.  Another indication of a high work of breathing is nasal flaring, an outward movement of the external nares with inspiration, seen when a patient has a hard time breathing in. Another important parameter to evaluate during chest inspection is the breathing pattern, as it can provide important clues regarding the underlying respiratory disease. 

Patients who breathe with a prolonged expiration usually have inflammation in the airways (such as with asthma or COPD). Some patients with prolonged exhalation may exhibit pursed lip breathing, which is a means of increasing airway pressure to keep the bronchioles open and prevent air trapping during exhalation. A patient who has a narrowed upper airway may breathe with a prolonged inspiration, such as with an inflamed epiglottis or tumor in the upper airway. The upper airway tends to narrow more during inspiratory efforts, making gas flow into the lungs more difficult. Patients who have a loss of lung volume (such as with atelectasis or pneumothorax) may have shallow breaths; the greater the loss of lung volume, the quicker the breaths. Without treatment, patients with very shallow breaths and tachypnea and who are using accessory muscles to breathe will eventually become very tired, and may go into respiratory failure or respiratory arrest.

Paradoxical breathing (inward motion of the abdomen during inspiration) is an abnormal breathing pattern seen in patients with diaphragm fatigue. It is often seen in patients with neuromuscular disorders. When seen in a patient without a neuromuscular disorder, it indicates significant respiratory distress and impending respiratory failure.

Lastly, you should examine the degree of symmetry of the chest wall with breathing. Normally, both sides of the chest expand evenly with each inspiratory effort. Unilateral chest diseases, such as pneumothorax or pneumonia, may result in better expansion of the healthy side of the chest compared to the diseased side. Some patients with COPD may have an increase in the anteroposterior diameter of the chest, referred to barrel chest. As well, some patients may have congenital deformities of the chest that are important to be aware of, such as scoliosis (lateral curvature of the spine) or kyphosis (anteroposterior curvature of the spine).

The next step of your assessment will likely be auscultation of the bare chest with a stethoscope. 

Anatomy of the Respiratory System #

Important Landmarks and Underlying Anatomy

Auscultation #

Auscultation

Adjuncts to Basic Respiratory Assessment #

Adjuncts to Basic Respiratory Assessment

There are several adjuncts to a basic respiratory assessment, which include the use of pulse oximetry, chest radiographs, and arterial blood gases.

Pulse oximetry is an easy, painless, non-invasive method to continuously monitor SpO2 (O₂ Saturation measured by pulse oximetry). The pulse oximeter is attached to a patient with a finger or ear probe. Beams of red and infrared light pass through the tissue from a transmitter to a receiver. The receiving sensor measures the amount of light absorbed by the oxygenated and deoxygenated hemoglobin in pulsatile (arterial) blood.  An oximeter will also monitor a patient’s heart rate by counting the pulsations, and give an indication of signal strength. Pulse oximeters are a useful tool in assessing oxygenation, but have many limitations. It is important to know how to check for accuracy. All pulse oximeters have an indicator of signal strength. This may be a bar graph, an audible tone, a waveform, and a flashing green/amber/red light, LED lights or some other indicator to show how strong the receiving signal is.  If the signal strength is poor, measurements are likely inaccurate. Use your patient assessment skills to check the accuracy of a pulse oximeter. If the SpO2 reading does not match the patient’s clinical picture, you may want to confirm accuracy by measuring with a different oximeter or by checking an arterial blood gas for a more definitive SaO2.

Chest Radiographs are an important tool in the evaluation of the respiratory status or your patient, especially when there is a change in their condition from what is normal for them. Radiographs are typically obtained in two projections, frontal (back to front or front to back) and lateral (side to side), and it is important to know the position of the patient when the radiograph was taken to be able to review it properly. The first and most important step in evaluating the chest radiograph is evaluation of the patient information. Before looking at the image itself, it is essential that you evaluate the identification on the film. The questions that you should ask yourself are: Is this my patient? (Correct name, correct birth date, correct identification number) and Is this the film that I want to evaluate? (correct date and time). Evaluation of radiographs require multiple steps which are beyond the scope of this discussion – any formal evaluation of a chest radiograph should be performed by a physician, and for intimate detail, by a radiologist.

An arterial blood gas (ABG) is a blood test that is performed specifically on arterial blood, to determine the concentrations of carbon dioxide, oxygen and bicarbonate, as well as the pH of the blood. It is used mainly to determine gas exchange levels in the blood related to lung function. Arterial blood gases are typically performed by respiratory therapists, lab technicians, and physicians.

Video: Auscultation #

Cyber Patient contains animated interactive material for e-education.

Cyber Patient Module

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