ASSESSMENT PHOTO GUIDE

HOW TO PERFORMPldURE-PERFECT

RESPIRATORYASSESSMENT

BY SUSAN APPLING STEVENS, RN, CRNP, MSKATHLEEN LENT BECKER, RN, CRNP, MS

Instructors • Johns Hopkins UniversityAdult Nurse Practitioners • Johns Hopkins Hospital

Baltimore, Maryland

Assessing the respiratory system means knowing whereto look and what to listen for.

This photo guide takes you on a tour of the thoracic landscapeand describes the breath sounds you'll hear.

58 NursingSe, January

iliiam Franklin, age 58, isbrought to the emergencydepartment (ED) com-plaining of shortness ofbreath and fatigue. He alsohas a fever, and his ankles

are swollen.

After examining Mr. Franklin, an EDdoctor makes a diagnosis of pneumoniaand congestive heart failure. He tellsMr. Franklin that he'll be admitted tothe hospital.

If you were the admitting nurse onthe medical/surgical unit, you'd haveto assess Mr. Franklin's respiratory sta-tus to obtain baseline information. Youmight have only a few minutes for arespiratory assessment that includes in-specting the thorax and auscultatingsubtle breath sounds.

How do you meet this challenge? Oneword—preparation. This review ofthoracic landmarks and breath soundswill prepare you to assess patients likeMr, Franklin quickly and accurately,using the same organized approacheach time.

All you need is a stethoscopeThe only equipment you'll need is agood stethoscope witb some basic fea-tures, The earpieces should fit snuglybut comfortably; tbe binaurals shouldbe angled forward, toward your tem-ples, so you get tbe best possible soundtransmission. Make sure the stetho-scope has a sturdy 1-inch bell and aI'/2-inch diaphragm. For respiratoryassessment, you'll use the diaphragm,which works well for high-pitched

sounds, such as breath sounds. You'lluse the bell when listening for low-pitched sounds—certain heart sounds,such as S3, for instance.

Inspection firstBegin your assessment of the patient'srespiratory status with a systematic in-spection. To save time, start your in-spection as you're obtaining a briefhistory and continue it as you auscul-tate breath sounds.

First, observe the patient's respira-tory rate and rhythm and the quality ofhis breathing. If his respiratory rate isless than 8 breaths/minute, check forotber changes in vital signs, a de-creased level of consciousness, and pu-pillary constriction. If tbe rate isgreater than 16 breaths/minute, lookfor signs of labored breathing—the useof accessory neck, shoulder, and ab-dominal muscles; intercostal, subster-nal. or supraclavicular retractions;nasal flaring; and pale or cyanotic nailbeds or mucous membranes. Also, takenote of the patient's posture. He'll mostlikely lean forward when he sits if he'shaving trouble breathing.

The patient's respiratory rhythmshould be regular, witb expirationstaking about twice as long as inspi-rations. A prolonged expiratory phasemay indicate an obstructive pulmo-nary disease, such as asthma or em-physema. When a patient's expirationsare prolonged, you may aiso note la-bored, pursed-lip breathing. Irregularrhythms, sucb as ataxic breathing orCbeyne-Stokes respirations, are usu-ally associated with central nervoussystem or metabolic disorders. Theyrequire immediate intervention.

Next, observe the patient's antero-posterior (AP) and transverse diame-ters. Normally, the transverse diameteris about twice the AP diameter. If theAP diameter is as large as (or almostas large as) the transverse diameter,the patient could bave emphysema. Inan elderly patient, however, sucb alarge AP diameter could be a normalfinding.

As tbe patient breathes, watcb howhis chest moves. On inspiration, thechest should move up and out sym-

metrically, [f one side of the chestdoesn't expand as much as the other,the patient may have atelectasis or anunderlying pulmonary disease. Certainthoracic and spinal deformities—ky-phosis, scoliosis, and pectus excava-tum, for example—may also restrictchest expansion.

Now listen to the patient breathe,without using your stethoscope. Nor-mal respirations are quiet and unla-bored. Labored breathing may beaccompanied by audible wheezes, gur-gling, or stridor (an inspiratory high-pitched crowing). Any of these soundsrequire immediate intervention.

Posterior chest landmarksThe next step in your assessment isauscultating breath sounds. But first,you need to be familiar with certainthoracic landmarks and their underly-ing structures. So lei's take a tour ofthe thoracic landscape.

Starting with the posterior chest, thefirst landmark you'll need to locate isC7 (see Photograph 1.) This is the mostprominent spinous process. You'll findit at the base of tbe neck when thepatient towers his head. From C7. youcan slide your fingers down tbe spinalcolumn, moving froniTl toT12. Eachof tbese spinous processes articulateswitb a rib. Below eacb rib is the cor-responding intercostal space (ICS).

Wbile palpating the posterior chest,be sure you locate the spinous pro-cesses T3 and TIO. You'll need tbesekey landmarks wben auscultating yourpatient's posterior lung fields (see Pbo-tograpb 2). T3 marks the point wheretbe major fissures dividing the upperand lower lung lobes begin. From tbispoint, tbe fissures arc down laterally,bebind the scapulae. Note tbat on tbeposterior chest the tracbea branchesinto the left and right mainstem bronchiat T4. TIO usually marks the lowerborder of the lungs. On inspiration.

KEY LANDMARKS OF THE POSTERIOR CHEST

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KEY LANDMARKS OF THE ANTERIOR CHEST

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though, the lower border descends toT12.

Anterior chest landmarksNow move to tbe anterior chest (seePhotograpb 3). The first importantlandmark bere is the sternal notch, lo-cated at the top of the sternum. Theclavicles extend from the sternal notch.Two or tbree fingerbreadtbs below tbesternal notcb, you'll feel the elevatedridge known as tbe sternal angle. Tbisis where the second rib joins the ster-num.

Locate tbe second rib, then slide yourfinger down to the second ICS. Fromhere you can count up or down to findthe other ribs and ICSs. Don't try tocount the ribs and ICSs by sliding yourfingers down along the sternum. Theribs are too close togetber at the lowersternum. Instead, move your fingersdiagonally away from the sternal angle.

The anterior chest bas two otber im-portant landmarks—the midclavicularlines (MCLs). These imaginary linesbegin at the midpoint of tbe claviclesand run straight down the thorax.

Once you're familiar with tbe ante-rior cbest landmarks, you can readilyidentify the locations of tbe lung lobes.As Pbotograpb 4 sbows. the apices oftbe upper rigbt and left lobes extendjust above tbe clavicles. Keep this inmind during your assessment, and besure to auscultate above the clavicles.Near the sternal angle, the tracbea bi-furcates into the two mainstem bron-chi. Note that the horizontal fissurebetween tbe upper right and middlelobes is located at tbe fourth rib. ontbe MCL. The lower rigbt and left lobesbegin at tbe sixth rib. also on the MCL.

Auscultating the lungsDuring a quick assessment of a medical/surgical patient like Mr. Franklin.you"ll usually go rigbt from inspectionto auscultation, skipping palpation andpercussion. If a patient complains ofpain or has suffered cbest trauma,though, you should palpate for pointtenderness, which may indicate a ribor soft tissue injury.

Before you begin auscultating yourpatient's lungs, have him sit on tbe side

of the bed with his chest exposed. Ifhe can't sit in this position, help himinto the high Fowler's position. Thenask him to lean forward to expand hischest. When he's comfortable, tell himto breathe slowly and deeply throughhis mouth. This will accentuate breathsounds. Explain to him that breathingslowly will prevent byperventilationand dizziness.

As you did during inspection, use tbesame approach every time for auscul-tation. I suggest tbat you start with theposterior chest, going from one side tothe matching area on the other side,checking for symmetrical breathsounds (see Pbotographs5 and6). Thenmove to the anterior chest, againchecking for symmetrical breathsounds.

Here's an auscultation tip: Place tbediaphragm of your stethoscope firmlyagainst the thorax. This creates a sealthat will eliminate most extraneousnoise. If a male patient's chest haircauses too much noise, mat it to thechest with water, then apply yourstethoscope.

Recognizing normal breath soundsNormal breath sounds are caused byair moving tbrougb tbe respiratorytract, Depending on their characteristicsound and their location, normal breatbsounds are classified as broncbial,bronchovesicular. or vesicular. To dis-tinguish among the three, listen closelyto the duration, pitch, and intensity oftbe sound you hear.

You'll auscultate bronchial breathsounds over the largest airway, the tra-

AUSCULTAT ON SEQUENCE

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AUSCULTATING BRONCHIAL ( • ) . BRONCHOVEStCULAR (O),AND VESICULAR (X) BREATH SOUNDS

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chea. On the posterior chest, that will beon botb sides of tbe spinal column fromC7 to T4. On tbe anterior chest, thetrachea extends to about the level of tbesternal angle (see Pbotograpbs 7 and 8).

Bronchial breath sounds are loud andhigh pitched. They may remind you ofwind blowing through a tunnel. You'llhear the inspiratory phase for just ashort time, but tbe expiratory phasewill sound long and loud. That's be-cause the stetboscope picks up only thesound of air coming toward it. Andwben you listen to bronchial sounds,the stethoscope is high on the chest.So on inspiration, air travels only ashort distance down to the stethoscope,but on expiration, air must travel a longway up to It.

If you hear bronchial breath soundsin any other area besides over tbe tra-cbea, suspect consolidation. For ex-ample, if Mr. Franklin bas consolida-tion in his lower right lung lobe, you'dbear bronchial breath sounds instead ofnormal vesicular sounds over tbat area.

Bronchovesicular breath sounds arebeard over the mainstem broncbi. Solisten between the scapulae from T4 toT7 on the posterior chest and from thesternal angle to the fourth ribs on theanterior chest. These sounds have amedium pitch and intensity. With bron-cbovesicular breatb sounds, tbe inspi-ratory and expiratory phases will lastthe same amount of time.

You'll hear vesicular breath soundsover most of the peripheral lung fieldswbere air moves tbrougb small airways.So expect these soft, breezy, low-pitcbed sounds wben you're auscultat-ing away from the trachea and main-stem broncbi. Witb vesicular sounds,inspiration will sound longer than ex-piration. Now air must travel a long wayto reach tbe stethoscope on inspiration,but only a sbort way to reach it onexpiration.

Remember that solid tissue transmitssound better tban air or fluid does. Soover an area of consolidation, breatbsounds (as well as spoken or wbisperedsounds) will be louder tban they sbouldbe. But if there's pus, fluid, or air intbe pleural space, breath sounds willbe quieter tban normal. If a foreignbody or secretions are obstructing abronchus, breath sounds will be di-minisbed or absent over distal lung tis-sue.

IDENTIFYING ABNORMAL BREATH SOUNDS

Type Location Description Cause

Crackles anywhere crackling sound; canbe classified as fine,meflium, or coarse

air passing throughairway containing fluid

Gurgies iargeainways

low-pitched; similar tosnoring

large upper airwaypartially obstructed bythick secretions

Wheezes anywfiere high-pitched, musicalsqueaks

airway narrowed byasthma or partiallyobstructed by tumor orforeign body

Pleuraifrictionrubs

anywhere grating sound infiamed viscerai andparietal pleuraerubbing together

Adventitious breath soundsThe four adventitious breatb sounds arecrackles, gurgles, wheezes, and rubs.Usually, when you hear one of thesebreath sounds, your patient has someform of pulmonary disease.

Crackles (formerly called rales) re-sult from air moving through airwaysthat contain fluid. Typically heard oninspiration, crackles are discretesounds that vary in pitch and intensity.They are classified as fine, medium,or coarse.

Fine crackles are bigb-pitchedsounds heard near tbe end of inspira-tion. To produce a similar sound, holdseveral strands of hair close to your earand roll them between your fingers.Fine crackles can result from fluid insmall airways or small atelectatic areastbat expand when the patient breathesdeeply. You may bear these adventi-tious sounds in a patient who has con-gestive heart failure or pneumonia, likeMr. Franklin. Generally, fine cracklesare first detected in the lung bases.Tbey usually don't clear with coughing,altbougb in some patients they may.

Medium crackles are produced byfluid in sligbtly larger airways—thebronchioles, for instance. They're lowerpitched and coarser than fine crackles.You'll hear them during the middle orlatter part of inspiration. Mediumcrackles won't clear when the patientbreathes deeply and cougbs.

Coarse crackles are loud, bubbling,gurgling sounds, resulting from a largeamount of fluid or exudate in tbe largerupper airways, including the mainstembroncbi and tbe large broncbi. You'llbear these sounds on both inspirationand expiration. Usually, coarse crack-les can't be cleared by breatbing deeply

and coughing. Tbey indicate increasingpulmonary congestion.

Gurgles (formerly called rhoncbi)develop when thick secretions partiallyobstruct air flow tbrougb large upperairways. Loud, coarse, and low-pitched, they sound a lot like snoring.You'll hear gurgles mostly on expira-tion and sometimes on inspiration, too.A patient may be able to clear gurglesby coughing up secretions.

Like gurgles, wheezes occur on ex-piration and sometimes on inspiration.Wheezes are continuous, high-pitched,musical squeaks. You'll hear themwhen air moves rapidly through air-ways narrowed by astbma or partiallyobstructed by a tumor or foreign body.In a patient witb mild astbma, you'llprobably hear bilateral wheezes on ex-piration. But if his condition worsens,you'd hear wheezes on both expirationand inspiration. Unilateral, isolatedwbeezes usually indicate a tumor orforeign body obstruction.

A pleural friction rub, the final ad-ventitious breath sound, has a distinc-tive grating sound. It may remind youof the sound made by rubbing leather.As tbe name indicates, tbese breathsounds are caused by inflamed visceraland parietal pleurae rubbing together.

Reeording your findingsYour respiratory assessment isn't com-plete until you've clearly and conciselydocumented your findings. Describeexactly what you saw and heard. For

instance, you might record the follow-ing information about Mr, Franklin:

Sitting in high Fowler's position,leaning forward on overbed table andbreathing rapidly (28 breaths/minute),using accessory muscles. Mucous mem-branes and skin pale. Chest expansionequal, andAP diameter less than trans-verse. Auscultation reveals bronchialbreath sounds in posterior lower rightlobe. Fine inspiratory crackles heardin lower third of posterior lung fields.Expiratory gurgles scattered through-out anterior and posterior lung fields.

This note gives otber members of tbebealth care team a clear, accurate pic-ture of Mr. Franklin's respiratory sta-tus.

Tuning in to breath soundsRemember, performing a respiratoryassessment takes a fine blend of knowl-edge and skill, If you're just learningto identify breatb sounds, be patient.No one is saying it's easy. But withpractice, you'll learn to perform thisessential part of respiratory assess-ment. Here are some suggestions thatshould help:

Try observing tbe breatbing patternsof friends and family members, thenauscultate tbeir breath sounds. Thiswill help you get used to a broad rangeof normal findings.

Learn from more experiencednurses. After you auscultate a patient'sbreath sounds, have an experiencednurse do tbe same. Then compare yourfindings with hers.

Take advantage of teaching rounds.When a doctor auscultates a patient'sbreatb sounds and comments on bis re-spiratory status, take out your stetho-scope and listen to the patient's breathsounds.

The more you practice, the betteryou'll become at distinguisbing breatbsounds. After a wbile, you'll probablybe able to auscultate these sounds withconfidence in most situations. Fromthen on, it's just a matter of brushingup so you'll always be ready to assesspatients like Mr, Franklin, UI

SELECTED REFERENCESBates. B.: A Guide to Physical Examination. 3rdedition. Philadelphia. J.B. Lippincott Co.. 1987,DeGowin. E.. and DeGowin. R.: Bedside Diag-nostic Examinatkm. •iih edition. New York. Mac-millan Publishing Co., 1981.Matasanos, L,, et al: Health Assessment. St. Louis,C,V. Mosby Co.. 1986.Seidel, H., et al: Mosby's Guide to Physical Ex-amination. St. Louis. C.V. Mosby Co., 1987.

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