VERY USEFUL CONTENT IN HEALTH ASSESSMENT UNIT FOR NURSING STUDENTS

1. Respiratory Assessment
By:
V. Prasanthy,
M.Sc Nursing,
Medical Surgical Nursing.

2. Inspection
General conditions:
Consciousness: In severe hypoxia, resulting in
chronic pulmonary heart failure, the patient may be
in the form of stupor. (Stupor is an alteration of
consciousness marked by decreased responsiveness to
environmental stimuli and absence of spontaneous
movement.)

3. Posture of the patient: Patients with respiratory
diseases can show three postures.
Active posture : Indicates consciousness of
patient is preserved.
Passive posture: It is typical for patients with
severe toxic CNS disorders
Forced position : It is used by patients to ease
their condition in symptoms of dyspnea, chest
pain, coughing or sputum discharge.

4. Passive posture Forced position

5. Inspection of Neck : Distended neck
vein: Denotes increase in intra thoracic
pressure and central venous pressure
seen in chronic lung disease

6. Inspection of Skin :
1. Cyanosis
a)Diffuse cyanosis : Imbalance between
ventilation and perfusion (The passage of fluid
through the circulatory system (blood stream)) results
due to accumulation of CO2 in blood and
reduced Hb.
b)Peripheral cyanosis : Cyanosis seen on
face, neck and extremities.
2. Pallor : It is seen in anemia

7. Erythema nodosum : It is
red coloured nodes seen in
alveolar hyperventilation.

8. Edema : Peripheral and pulmonary edema is
seen in patients with lung disease.

9. Lymphnode enlargement : Swollen lymph
nodes may occur into pulmonary TB,
sarcoidosis, lung tumors (Metastases)
Clubbing of the nails: It is sign of chronic
hypoxia

10. Inspection of Chest
Barrel chest: The chest wall is prominent.
The A-P diameter of the chest is increased
and has barrel-like configuration.

11. Paralytic Chest: The shoulder are sloping,
clavicles are asymmetrical and pronounced
with depressed supra and infra clavicular
fossa.

12. Pigeon Chest : It is due to abnormal skeletal
formation in childhood. The sternum is
displaced anteriorly, increasing the A-P
diameters and the ribs meet at an acute angle
to the sternum

13. Funnel Chest : Characterized by depression is the
lower portion of the sternum, near the xiphoid
process.

14. Abnormalities in respiration, depth and
rythm
Tachypnea : Rapid breathing above 20 breaths per minute.
Bradypnea : It is slow breathing below 16 breaths per minute
Shallow respiration : It is characterized by short inspiratory and
expiratory phases.
Deep respiration : It is characterized by elongation of the inspiratory
and expiratory phases.
Kussmaul respiration : Deep rapid breathing, with marked
respiratory movements accompanied by noisy sound.
Cheyne stokes respiration : Noiseless shallow respiration, quickly
deepens, becomes noisy.

15. Palpation
Palpation is used to assess areas of tenderness,
palpate areas of pain, bruises, or lesions on the
front and back of the chest. Bruises may indicate a
fractured rib, and tenderness between the ribs may
indicate inflamed pleura.
Palpate any abnormal masses or structures on the
front and back of the chest. Abnormal masses or
sinus tracts may point to infections.

16. Palpation
To observe chest wall expansion on the back of the
chest, place palms on the patient's back with fingers
parallel to the ribs and thumbs at the 10th ribs. Move
hands towards each other to raise some skin on either
side of the spine. Instruct the patient to inhale and
observe the movement of the thumbs on the patient's
back. Asymmetry in chest expansion may be due to
disease of lung or pleura.

17. chest wall expansion

18. Palpation
Place the bony parts of the palm around the borders of the
patient's scapulae while he or she says "ninety-nine" or
"one one one" to test for fremitus. Repeat the sequence on
the front of the chest. A decrease in fremitus may be
observed if the patient has a soft voice, obstructed
bronchus, COPD(a chronic inflammatory lung disease that
causes obstructed airflow from the
lungs). , pneumothorax(is a collapsed lung), or other disease
or injuries that may obstruct the vibrations of the larynx.

20. Percussion
Percussion over different body tissues results in five common "notes".
Resonance: Loud and low pitched. Normal lung sound.
Dullness: Medium intensity and pitch. Experienced with fluid.
A dull, muffled sound may replace resonance in conditions
like pneumonia or hemothorax.
Hyper-resonance: Very loud, very low pitch, and longer in duration.
Abnormal.
Hyper-resonance can result from asthma or emphysema
Tympany: Loud and high pitched. Common for percussion over gas-
filled spaces.
Tympany may result in pneumothorax.

21. Auscultation;
During auscultation, deep breaths are taken through the
mouth and abnormal sounds listened. Abnormal sounds
include:
Wheezes: describing a continuous musical sound on
expiration or inspiration. A wheeze is the result of narrowed
airways. Common causes include asthma and emphysema.
Rhonchi: charecterised by low pitched, musical bubbly
sounds heard on inspiration and expiration. Rhonchi are the
result of viscous fluid in the airways.

22. Auscultation
Crackles: Intermittent, non-musical and brief sounds heard
during inspiration only. They may be described as fine (soft,
high-pitched). These are the result of alveoli opening due to
increased air pressure during inspiration.
Stridor: a high-pitched musical breath sound resulting
from turbulent air flow in the larynx or lower in the bronchial
tree. Causes are typically obstructive, including foreign
bodies, epiglottitis, tumors, infection and anaphylaxis.

23. Thank you