Place the diaphragm of the stethoscope on the back and listen for breath sounds during inspiration and expiration. Move systematically down the back, listening in the same areas on both sides. • Breath sounds should be equal, clear, and vesicular (like a light breeze) on both sides - Note any adventitious sounds such as wheezes, crackles, decreased breath sounds - Compare findings to normal breath sounds - Note any areas of diminished or absent breath sounds - Ask patient to cough - note transmission of voice sounds - Auscultate anterior chest in a similar manner - Note any abnormalities in breath sounds or adventitious sounds

1. .

2. ‫‪Respiratory system‬‬
‫&‬
‫‪Respiratory ASSessment‬‬
‫د ‪‬جيهان‪‬عبد‪‬ال‬
‫حكيم‪‬يونس‬
‫مدرس التمريض الباطني والجراحي‬
‫والحالت الحرجة‬

3. • Assessment of Respiratory System
Outline
• part I : assessment of respiratory function:
– history
– physical examination:
• inspection
• percussion
• palpation
• auscultation
– laboratory tests:
• pulmonary function studies
• arterial blood gases
• sputum studies
• pleural fluid analysis
• part II: assessment of respiratory structure:
• pulse oximetry
• chest –x- ray
• computed tomography for chest
• magnetic resonrnce imaging
• bronchoscopy

4. Respiratory System Functions
1. supplies the body with oxygen and
disposes of carbon dioxide
2. filters inspired air
3. produces sound
4. contains receptors for smell
5. rids the body of some excess water and
heat
6. helps regulate blood pH
7. Gase exchange

5. Respiration
• Respiration – four distinct processes
must happen
– Pulmonary ventilation – moving air into and
out of the lungs
– External respiration – gas exchange between
the lungs and the blood
– Transport – transport of oxygen and carbon
dioxide between the lungs and tissues
– Internal respiration – gas exchange between
systemic blood vessels and tissues

6. Anatomy and physiology
• The respiratory tract extends from the nose
to the alveoli and includes not only the air-
conducting passages also but the blood
supply
• The primary purpose of the respiratory
system is gas exchange, which involves the
transfer of oxygen and carbon dioxide
between the atmosphere and the blood.
• The respiratory system is divided into two
parts: the upper respiratory tract and the
lower respiratory tract

7. Components of the Upper
Respiratory Tract
Figure 10.2

8. The upper respiratory tract includes
• The nose
• pharynx
• adenoids
• tonsils
• epiglottis
• larynx,
• and trachea.

9. Upper Respiratory Tract
Functions
 Passageway for respiration
 Receptors for smell
 Filters incoming air to filter larger
foreign material
 Moistens and warms incoming air

10. Components of the Lower
Respiratory Tract
Figure 10.3

11. The lower respiratory tract consists of
• the bronchi,
• Bronchioles
• alveolar ducts
• and alveoli
• all lower airway structures are
contained within the lungs.

12. Lower Respiratory Tract
 Functions:
 Larynx: maintains an open airway, routes
food and air appropriately, assists in
sound production
 Trachea: transports air to and from lungs
 Bronchi: branch into lungs
 Lungs: transport air to alveoli for gas
exchange

13. lung
• The right lung is divided into three
lobes (upper, middle, and lower)
• the left lung into two lobes (upper and
lower)
• The structures of the chest wall
• (ribs, pleura, muscles of respiration)
are also essential

16. Physiology of Respiration
• Ventilation. Ventilation involves inspiration
(movement ofair into the lungs) and expiration
(movement of air out of the lungs). Air moves in and
out of the lungs because intrathoracic pressure
changes in relation to pressure at the airway
opening.
• Contraction of the diaphragm and intercostal
muscles increases chest dimensions, thereby
decreasing intrathoracic pressure. Gas flows from
an area of higher pressure (atmospheric) to one of
lower pressure (intrathoracic)

17. Assessment of respiratory
Part I: Assessment of respiratory function
[1] history:
1) medical history:
 Is there pt's history of lung disease
 Cardiac or neuromuscular disease.
2) Surgical history of any operation:
- is there a history for any surgical operation?

18. 3) Past medical history: -
 Is there past pulmonary diseases?
 History of heart problem?
 Childhood illness exposure to TB,?
 Diabetes? kidney disease, liver disease? Or
hypertension
 cancer or T.B?

19. 4) Family history:
 is there a History of lung disease, COPD, cardiac
disease ,diabetes, kidney disease, liver disease,
hypertension, cancer, T.B, or Others ?
5) Smoking History:
 Is there smoking history? If there is smoking
history ? is it current or in the past?
 environmental exposure to dust, chemicals,
asbestos, air pollution

20. 6 present complaint:
Chest pain
Cough
dyspnea

21. Cough
• Type
– dry, productive
• Onset
• Duration
• Pattern
– activities, time of day, weather
• Severity
– effect on ADLs
• Wheezing
• Associated symptoms
• Treatment and effectiveness

22. sputum
• amount
• color
• presence of blood (hemoptysis)
• odor
• consistency

23. :Physical Examination] 2[
[1] Posterior Chest: Inspect, Palpate,
Percuss, and Auscultate
• Preparation before procedure:

24. Position/
Lighting/
Draping
• Position –
• patient should sit upright on the examination table.
• The patient's hands should remain at their sides.
• When the back is examined the patient is usually
asked to move their arms forward (hug themself
position)
• Lighting - adjusted so that it is ideal.
• Draping - the chest should be fully exposed.
Exposure time should be minimized.

25. Surface markings of the lobes of the lung:
(a) anterior, (b) posterior, (c) right lateral and (d) left lateral.
(UL, upper lobe; ML, middle lobe; LL, lower lobe).
ul
ll Ul
ml
a
ul
ml
ll
b ll

27. 1) Inspiction:
1. Inspect posterior thorax:
1. Assess shape and symmetry. Note rate and rhythm
of respiration, movement of chest wall with deep
inspiration and full expiration, and signs of distress.
2. Estimate the anteroposterior diameter.
Respirations are quiet, effortless, and regular, 12–20
breaths per minute. Thorax rises and falls with
respiratory cycle.
Ribs slope across and down, without movement or
bulging in the intercostals spaces
3.Observe for abnormalities

30. II. Palpation.
 place thumbs close to client’s spine
and spread hands over thorax. Note
divergence of thumbs, feel for
range and symmetry of movement
during deep inhalation and full
exhalation.
 Place ulnar aspect of your open
hand at right apex of lung and place
the hand at each location .
 Instruct client to say “99” and
palpate for tactile fremitus
(vibrations created by sound
waves). Note areas of increased or

31. Palpation
Tactile fremitus •
is vibration felt by palpation. Place your open palms
against the upper portion of the anterior chest, making
sure that the fingers do not touch the chest. Ask the
patient to repeat the phrase “ninety-nine” or another
resonant phrase while you systematically move your
palms over the chest from the central airways to each
lung’s periphery.You should feel vibration of equally
intensity on both sides of the chest. Examine the
posterior thorax in a similar manner. The fremitus should
be felt more strongly in the upper chest with little or no
fremitus being felt in the lower chest

32. • Move hands from side to side, from right to left, with
client repeating the words with the same intensity
every time you place your hands on the back.
• Thumbs should separate an equal distance (3–5 cm)
and in the same direction during thoracic expansion
and meet in the midline on expiration. Posterior
thorax is free from tenderness, lesions, and
pulsations.
• Fremitus is equal on both sides of thorax, strongest
at the level of trachea.
• Examine the body part that may be tender or painful

33. Note the following characteristics:
 Pulsations, Temperature of the tissue
 Presence of lumps or tumors,Swelling
 Texture of the skin
 Moisture or dryness of the skin
 Tenderness or pain, Distensions
 If a lump, nodule, or tumor is located: Feel for the
size, shape, and consistency; attempt to move it with
the Fingers.

34. (III) Using Percussion:
 Start at lung apices. Move
hands from side to side
across the top of each
shoulder.
 Note sound produced from
each percussion strike .
 Continue downward and
posterolateral every other
intercostal space.

35.  Note intensity, pitch, duration
 -Air-filled lungs create a resonant sound.
Identify contralateral sound; bones (e.g., ribs
or spine, create a flat sound).
 - Thorax is more resonant in children and
thin adults.

36. Note these sounds:
Flat: Soft intensity, high pitch, short duration
Dull: Medium intensity, medium pitch, medium
duration
Dull sound is created in solid or fluid-filled
structures (e.g., pneumonia, pleural effusion,
or tumors). Pleural fluid sinks to lowest part
of pleural space (posteriorly in a supine
client).

37.  Resonant: Loud intensity, low pitch, long
duration
 Hyperresonant: very loud intensity, lower
pitched; longer duration
 Hyperresonance in adults occurs in
pneumothorax, emphysema, or asthma.
 Tympany: Loud intensity, lower pitched with
musical quality, longer duration

40. (IV) Auscultation:
 - Auscultate posterior and lateral surfaces.
 Place diaphragm of stethoscope on right
lung apex. Instruct client to inhale and exhale
deeply and slowly when the stethoscope is
felt on the back. Repeat on left lung apex.
 Move downward every other intercostal
space and auscultate, placing stethoscope in
the same position on both sides.

41. Auscultation
• To assess breath sounds, ask the
patient to breathe in and out slowly and
deeply through the mouth.
• Begin at the apex of each lung and
downward between intercostal
spaces . Listen with the diaphragm
portion of the stethoscope.

43. • Normal breath sounds
Observe:
• Pitch
• Intensity
• Quality
• Duration

44.  Auscultate the lateral aspect by placing the
stethoscope directly below the right axilla,
instructing the client to breathe only through
the mouth and to inhale and exhale deeply
and slowly. Proceed downward, every other
intercostal space on the same side.
 Repeat on left side. Posterior sounds:
bronchovesicular and vesicular sounds;
lateral: vesicular sounds.

45. Normal Breath Sounds
• Bronchial: Heard over the trachea and mainstem bronchi (2nd-4th
intercostal spaces either side of the sternum anteriorly and 3rd-6th
intercostal spaces along the vertebrae posteriorly). The sounds are
described as tubular and harsh. Also known as tracheal breath
sounds.
• Bronchovesicular: Heard over the major bronchi below the clavicles in
the upper of the chest anteriorly. Bronchovesicular sounds heard over
the peripheral lung denote pathology. The sounds are described as
medium-pitched and continuous throughout inspiration and
expiration.
• Vesicular: Heard over the peripheral lung. Described as soft and low-
pitched. Best heard on inspiration.
• Diminished: Heard with shallow breathing; normal in obese patients
with excessive adipose tissue and during pregnancy. Can also

46. Normal auscultatory
sound

47. Anterior Chest: Inspect, Palpate, Percuss, and
Auscultate
(I) inspection
 Place client in a sitting or supine position.
 Instruct client to inhale deeply and exhale fully.
Inspect anterior thorax for:
a. Symmetry and depth of movement
b. Rhythm of respirations
c. Slope of ribs and musculoskeletal deformities
Scapula at same height. Thorax rises and falls in
unison with respiratory cycle

49. (II). Palpation:
 Place finger pads on right apex, above
the clavicle. Proceed downward to
each rib and intercostal space and
note tenderness, pulsation, masses,
and crepitance. Repeat on left side.
 Palpate for tactile
 Note that fremitus is usually decreased
or absent over the precordium.

50. ).Assessing chest expansion in expiration (left) and inspiration (right
.Percussion over the anterior chest Direct percussion of the clavicles for
disease in the lung apices

51. (III) percussion:
 Symmetrically percuss anterior
surface
 Percuss 2–3 strikes along right
lung apex, repeat on left lung
apex.
 Proceed downward, percussing
in every other intercostal space
going from right to left in same
position on both sides. Displace
breast tissue as necessary.

52.  Assess in each thoracic area:
 Resonant-lung field
 Cardiac dullness: third to fifth intercostal spaces
left of sternum.
 Liver dullness: place your pleximeter finger parallel
to upper border of expected liver dullness in right
midclavicular line; percuss downward. - Gastric air
bubble: repeat procedure performed for liver
dullness on left side. Resonant sound over lung
tissue (hyperresonance in children and thin adults).

54.  (IV) Auscultate anterior surface:

55. • -Note about sounds:
• Their presence and location.
• Type of sounds
• Pulses, heart sounds, lung sounds, and
bowel sounds)
• Duration and intervals between sounds

56. Pitch of
Intensity of
Normal expirator
Duration of sound Expiratory Location
Sound y
sound
sound
1-vesicular Inspiratory sound
sound lasts longer Relatively Over the lung (both
soft
than expiratory low lung)
one
2- In the 1s1 & 2nd
bronchvesicul Inspiratory &
intercostals
ar sound expiratory
intermediate intermediate space anterior
sounds are
& between
equal
scapula
3- Bronchial Expiratory sound
sound lasts longer Relatively
loud Over manubrium
than high
Inspiratory one
4- tracheal Inspiratory &
sound expiratory Relatively Over the trachea
very loud
sound are about high in the neck.
equal

57. 1-Crackles Soft, high pitched Secondary to fluid in the air ways,
discontinuous popping sounds or alveoli or to opening or collapse
occur during inspiration of alveoli
2-Crackles in Same as above Associated with obstructive;
early pulmonary disease;fine crackles
inspiration associated with bronchitis, or
Pneumonia
3-Crackles in Same as above Associated with restrictive
late Pulmonary disease
Inspiration
4-Wheezing or Deep, low, pitched rumbling Caused by air moving through
bronchi sound during narrowed trachio bronchial passage
expiration may be from secretion or tumor
5-Sibilant Continues, musical, high-pitched Caused by narrow bronchioles &
wheezes whistle like sound during associated with broncho spasm ,
inspiration & expiration asthma, build up of secretion.
6- Pleural Harsh, crackling sound likes two Secondary to inflammation & loss of
friction rub pieces of leather rubber together. lubricating pleural fluid
Heard during inspiration alone or
during both inspiration &
expiration may subside when
patient Holds breath.

58. [3] laboratory tests:
pulmonary function studies:
 Pulmonary function studies provide
information about the volume, pattern, and
rates of air flow involved in respiratory
function.
 to determine the need for mechanical
ventilation.

59. Uses:
 Pulmonary function tests are used to
diagnose specific types of lung
abnormalities and to assess the risk of
respiratory complications. They are
also used to monitor the course of
pulmonary diseases
 Evaluate the effectiveness of
prescribed medications, and

61. Arterial blood gas analysis:
 - ABGs analysis is an essential test in diagnosing &
monitoring patient with respiratory disorder,
because it gives direct information about ventilatory
function.
 Blood gas results are reported in millimeters of
mercury(mmHg).
 Arterial blood gas studies aid in assessing the
ability of the lungs to provide adequate oxygen and
remove carbon dioxide and the ability of the kidneys
to reabsorb or excrete bicarbonate ions to maintain
normal body pH

62. Normal ABG ranges are:
 PaO2 (partial pressure of O2 in arterial blood) is 80-l00 mmHg.
 PaCO2 (partial pressure of CO2 in arterial blood) is 35-45
mmHg.
 The arterial oxygen tension (PaO2) indicates the degree of
oxygenation of the blood, and the arterial carbon dioxide
tension (PaCO2) indicates the adequacy of alveolar ventilation.
 SaO2 saturation of O2 in arterial blood is greater than 94 % or
95 %.
 pH → Hydrogen ion concentration or degree of acid base
balance 7.35-7.45

63. :Pleural fluid analysis •

64. Part II assessment of respiratory structure
• (1) pulse oximetery
 Pulse oximetrey is a
noninvasive method of
continuously monitoring the
oxygen saturation of
hemoglobin (SpO2 or SaO2).
 A probe or sensor is
attached to the fingertip ,
forehead, earlobe, or bridge
of the nose.

65. (2) Chest X-Ray
 Chest radiography, is one of the most frequently performed
radiologic diagnostic studies. This study yields information about the
pulmonary, cardiac, and skeletal systems.
 X-rays penetrate air easily; areas filled with air appear dark or black
on x-ray film.
 Bones appear near-white on the film because x-rays cannot
penetrate them to reach the film.
 Organs and tissues appear as shades of gray because they absorb
more x-ray than air but less than bone.
 A routine chest x-ray includes a posteroanterior and lateral view.
Films may be taken on full inspiration and on full expiration to detect
a pneumothorax.

66.  Chest films can indicate the following alterations and diseases:
 Lesions (tumors, cysts, masses) in the lung tissue, chest wall,
bony thorax or heart
 Inflammation of lung tissue (pneumonia, atelectasis,
abscesses, tuberculosis); pleura (pleuritis); and pericardium
(pericarditis)
 Fluid accumulation in the lung tissue (pulmonary edema,
hemothorax); (pleural effusion); and (pericardial effusion)
 Bone deformities and fractures of the rib and sternum
 Air accumulation in the lungs (chronic obstructive
 pulmonary disease, emphysema), and pleura
 (pneumothorax)
 Diaphragmatic hernia

67. (3) Computed Tomography for thorax:
• - CT of the thorax is an imaging method in which the
lungs are scanned in successive layers by a narrow-
beam x-ray.
• CT may be used to define pulmonary nodules and
small tumors adjacent to pleural surfaces that are
not visible on routine chest x-ray, and to
demonstrate mediastinal abnormalities and hilar
adenopathy, which are difficult to visualize with
other techniques. Contrast agents are useful when
evaluating the mediastinum and its contents.

68. • (4) Magnetic Resonance Imaging
- MRIs are similar to CT scans except that magnetic
fields and radiofrequency signals are used instead of
a narrow-beam x-ray.
• MRI uses a magnet and radio waves to produce an
energy field that can be displayed as an image.
- Chest MRI scanning is performed to assist in
diagnosing abnormalities of cardiovascular and
pulmonary structures.

69. • (5) Bronchoscopy
- This procedure provides direct visualization of the
larynx, trachea, and bronchial tree by means of
either a rigid or a flexible bronchoscope.
- The purpose of the procedure is both diagnostic and
therapeutic. The rigid bronchoscope allows
visualization of the larger airways, including the
lobar, segmental, and subsegmental bronchi, while
maintaining effective gas exchange.