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PHOTO GUIDE

Assessing respiratory status

MEHTA, MARJAANA RN, APN, C, MSN

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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

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Figure:
1. Stand behind your patient and inspect his back for any deformities, such as kyphosis (convex curvature) or scoliosis (lateral curvature) of the spine. To palpate for symmetric lung expansion, place your hands on his back with your thumbs at the level of T9 or T10, then slide them medially to pinch a small skin fold between your thumbs, as shown. Ask him to inhale deeply and note if your thumbs move apart symmetrically.
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Figure:
2. Feel for fremitus by placing the ball of your palms or the ulnar edge of your hands on the right and left sides of his upper back. Ask him to say “99” to generate vibrations and note whether they're symmetrical, moving your hands down and from the center to the periphery. Next, gently palpate his back with your fingers, noting any tenderness, masses, lesions, temperature changes, or crepitus—a coarse, crackling sensation that's palpable over the skin.
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Figure:
3. To measure diaphragmatic excursion, ask your patient to inhale and hold it. Percuss from the lower edge of his right scapula down toward the diaphragm (see Hand Position for Percussion). When the note changes from resonant to dull, you've located your first landmark. Tell him to breathe, then mark the landmark with a washable pen. Ask him to exhale and hold it, then repeat the process in full expiration. When the sound changes from resonant to dull, tell him to breathe. Mark this landmark.Measure the distance between the marks to determine diaphragmatic excursion, normally 5 to 6 cm in adults. Repeat these steps on your patient's other side and compare. Because the diaphragm is usually higher on the right because of displacement by the liver, the measurement may be greater on the left.
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Figure:
4. Have your patient breathe deeply through his mouth. Using the diaphragm of your stethoscope, auscultate his lung sounds starting at the apices at C7 to the bases at approximately T10 and laterally from the axilla down to approximately the eighth rib. Decreased or absent lung sounds may indicate obstruction of the bronchial tree.Listen for adventitious lung sounds. Crackles are distinct, noncontinuous sounds defined as “fine” (sound like popping) and “coarse” (sound like bubbling or gurgling and usually clear or decrease after coughing). Sibilant wheezes—high-pitched musical or whistling sounds—are commonly heard in patients with asthma, typically during or at the end of expiration. Sonorous wheezes, heard throughout inspiration and expiration, may be caused by airway secretions or bronchoconstriction.

Up-front assessments

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Figure:
5. Have your patient lie supine, and percuss his anterior and lateral chest as shown. (Percuss the areas of auscultation shown in step 6.) Use a systematic approach and compare resonance from one side to the other. Dullness over the diaphragm, liver, and other visceral organs is normal but over the lungs may indicate a mass or consolidation. Hyperresonance over the lungs indicates hyperinflation. You'll note flatness over muscle or bone.
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Figure:
6. If possible, have your patient sit up and breathe deeply through his mouth. Place the diaphragm of your stethoscope above the supraclavicular notch and medial to the cricoid cartilage. Listen to his breath sounds at the areas indicated, down to the sixth rib.• Tracheal sounds, heard over the trachea, are high-pitched, loud, harsh, and hollow sounding, with inspiration and expiration of equal duration.• Bronchial sounds occur in the right and left bronchi just above the clavicles on each side of the sternum, above the manubrium and between the scapulae. They're high-pitched, blowing, and muffled, with expiration sounding slightly longer than inspiration.• Bronchovesicular sounds are audible just below the clavicles on either side of the sternum and over the upper third of the anterior chest near the sternum. The sounds of inspiration and expiration are equally long.• Vesicular sounds, heard over most of the lung fields, are soft, low-pitched, and described as rustling or breezy. The sound of inspiration is three times longer than that of expiration.

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.

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Figure

SELECTED REFERENCES

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.
      © 2003 Lippincott Williams & Wilkins, Inc.