A THOROUGH respiratory assessment consists of inspection, palpation, percussion, and auscultation in conjunction with a comprehensive health history. Use a systematic approach to do a visual inspection and hands-on assessment of your patient's back and chest. Compare findings between left and right so the patient serves as his own control.
If possible, have him sit up. Uncover his chest and inspect the shape and configuration. Normally, the thorax is symmetrical and the anterior-posterior diameter is less than the transverse diameter. (Equal diameters may signal chronic obstructive pulmonary disease in an adult.) Note any structural deformity such as a pigeon chest (sternal protrusion) or funnel chest (lower sternal indentation).
Note his breathing. Respirations should be even, unlabored, and regular at a rate of 12 to 20 breaths per minute. Normally, inspiration is half as long as expiration and chest expansion is symmetrical. If your patient appears anxious or exhibits nasal flaring, cyanosis of the lips and mouth, intercostal retraction, or use of accessory muscles, he may be in respiratory distress.
Starting your assessment on his back may help him relax. Proceed as shown in the following photos.
Starting at the back
Hand position for percussion
For a right-handed nurse: Press the distal interphalangeal joint of your hyperextended left middle finger (the pleximeter) on the patient's skin. (Don't touch him with any other part of your hand, which could damp vibrations.) Next, position the partially flexed middle finger of your right hand (the plexor) very close above the distal interphalangeal joint of the pleximeter. Using your fingertip, not the pad, strike the pleximeter using a quick, sharp, relaxed wrist motion. Use the lightest percussion that produces a clear note and percuss twice in one location before proceeding.
Bickley, L.: Bates Guide to Physical Examination and History Taking
, 8th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2002.
Jarvis, C.: Physical Examination and Health Assessment
, 3rd edition. Philadelphia, Pa., W.B. Saunders Co., 2000.