We’re just cookin’ right along with the Ultimate Guide to the Nursing Head to Toe Assessment!
If you missed any of the last posts, you can find them here:
Today we’re talking about how to do a super-duper-fantastically-thorough respiratory assessment. To make your life easy peasy, I have broken the assessment down into 5 simple steps:
1. Ask questions
If you need a review of the four primary nursing assessment techniques (inspection, palpation, auscultation, and percussion), click here. I will cover each of these techniques below as they relate to the respiratory system.
Make sure you download your FREE Respiratory Assessment Cheat Sheet. Take it to clinical so you never have to stress over the respiratory assessment again!
Okay, friend, let’s dive in!
1. Focus your assessment by asking questions
When doing a respiratory assessment, you will first want to ask these questions:
1. Are you having any chest pain or have you had chest pain recently? Chest pain is serious, and it is important to alert the RN to this.
2. Are you having shortness of breath or have you had shortness of breath recently?
3. Have you had a cough lately? Is it productive? If so, what color and consistency is the sputum?
4. Do you use oxygen, CPAP, or BiPAP?
If the patient responds with yes to any of these questions (except number 4), make sure to ask when the problem started, what leads up to it, what (if anything) relieves it, and if they have taken any medications for it.
Inspection is everything that you see or notice about the patient without actually touching them, such as respiratory effort and chest expansion symmetry.The primary things you will want to notice are:
1. Chest movement: Is it symmetrical? Is one side expanding more than the other? Is one part of the rib cage expanding or collapsing unevenly?
2. How fast are they breathing? Count their respirations for a full minute. This gives you their respiratory rate.
3. Is their inhale and exhale equal duration or is one longer than the other? Exhalation is typically about twice as long as inhalation. This is known as respiratory rhythm.
4. Are they elevating their shoulders, chest or tummy in order to breathe? This indicates accessory muscles use and labored breathing.
Palpation for the respiratory system can be used to locate painful areas, crackles under the skin that are caused by a leak in the lung (crepitus) as well as to feel the symmetry of the rib cage. Move the tips of your fingers or palm of your hand up and down over the patients chest, pressing and lifting as you go. Notice any lumps, bumps, tenderness, or abnormal sounds.
Bust out that stethoscope, girlfriend! (Yeah, you’re legit, you get to use your stethoscope!)
Auscultation means that you’re listening to the patient’s body, typically using your stethoscope. This will help you identify areas with less air movement than others, as well as crackles, wheezes, rhonchi, stridor, pleural rub and the location of their breath sounds.
When listening to the patient’s chest, make sure your stethoscope is on! Don’t worry, I quickly learned how to rotate the bell of the stethoscope unnoticed too. “Oh good, he didn’t see me. SCORE! Oh shoot, how many respirations was that again?” #NursingSchoolProbs
Place your stethoscope in 8 places in the front and 10 places on the back, moving in a Z-block pattern. Press the stethoscope firmly on the patients chest, and have them take deep breaths through their mouth. Listen for a full respiratory cycle (one inhalation and one exhalation) at each placement. It is really important to listen for a full respiratory cycle because abnormal sounds may only appear during either inhalation or exhalation.
Here are the placements in the front of the chest. The Z-block pattern is the quickest way to make sure you hit all of the right placements.
Follow the same pattern on the back, adding two more places at the base of the lungs.
5. Percuss (You know it’s all about that bass)
Percussion involves tapping your fingers along the patients body in order to identify denser or gas filled areas.Place your non dominant hand’s middle finger on the patients chest and tap the knuckle closest to the finger nail with the middle finger of your dominant hand. Percuss in a Z-block pattern just like you did with your stethoscope, except you will percuss in 10 places in the front of the rib cage and 18 places in the back.
The front should look something like this:
I have found this technique to be especially helpful to determine if the patient has fluid in the lungs, which will cause a dull sound with very little echo. In a healthy patient, percussion should sound hollow and have a low-pitch (resonant) sound, you know, like that bass!
Did you grab your FREE Cheat Sheet yet? Do that now so you’re prepared for clinical this week!
Okay, now that we’re virtual BFFs, let’s get real! Comment below and tell me how many times you have forgotten to turn on your stethoscope. My record is 4. 🙂
Comerford, K. C., & Hodgson, B. E. (2013). Assessment made incredibly easy. Ambler, PA: Lippincott Williams & Wilkins.