Respiratory Assessment
A respiratory assessment is a physical examination carried out to assess ventilation. It involves processes such as depth, rate, and the pattern of respiratory activity. The successful use of respiratory techniques lies in an accurate assessment that relies on the health care professional recognizing normal abdominal and thoracic movement. Normal thoracic movements involve the diaphragm contracting during inspiration. Following the contractions, abdominal organs are forced to move forward and downward, widening the space in the chest cavity. The ribs move upward and outward simultaneously, while the sternum moves upwards to help the lungs expand transversely. During expiration, the diaphragm moves upwards as it relaxes while the ribs and sternum move back to their default relaxed position and the abdominal organs move back to their original position. The techniques used in respiratory assessment rely on this information as the default measure to detect any respiratory changes.
A necessary capability for all clinicians, particularly the nurses, is the capacity to conduct and record a complete respiratory examination. The included components are initial evaluation, history recording, observation, palpation, rhythm, auscultation and further inquiries. An original notification impression allows for instant analysis of disease severity, and effective treatment initiatives at this stage may justify incitement. A thorough history of patients will be evoked after this (Toney-Butler & Unison-Pace, 2019). The patient’s clinical test follows, which includes review, palpation, auscultation, and percussion. At this point, the readiness of a gentle, pleasant, quiet, private environment for investigation and appropriate patient placement must be considered. Inspection is a detailed visual examination, while palpation includes collecting information using the hand (Toney-Butler & Unison-Pace, 2019). The last step is auscultation and percussion. Although percussion hits the chest to assess the condition of the soft tissue, socialinvolves listening to and analyzing sound propagation through a stethoscope through the chest wall. Finally, more inquiries might be required to verify or deny presumed prognoses.
Inspection is an involving technique. It is completed with reasoning skills and eyes. It starts with the basic greeting and carries on unimpeded throughout the whole process of collecting data. And before the first important question of the fully clothed patient is being questioned, the examination starts with careful monitoring. Particularly, the health practitioner should consider the nature of the facial structure of the individual in response to human behaviors and the clinician’s questions (Pasterkamp & Zielinski, 2019). Useful assessment capabilities are used to investigate the action and growth of sternocleidomastoid muscles, the use of pursed lips during expiration, the existence of shoulder girdle fastening related to the use of these accessory muscles, the use of other accessory ventilation muscles, the level of sensitivity, the appearance of jugular venous distention, and the blasting of nasal alae (Pasterkamp & Zielinski, 2019). A supportive smile by the clinician can not only be useful in determining neurological activity, but tooth examination at that time can also show severe pyorrhea that alerts the clinician to a dental issue that may be a potential site for pneumonia bacteria.
As the inspection progresses, one may assume a primary pulmonary mechanism that consequentially creates changes in central nervous system activity by determining the level of consciousness and the suitability of behavior. Breathing acidosis and brain metastases from primary lung carcinoma are pleasant instances (Madigan, 2020). The dressing of the patient may provide an indicator of profession or activity while hygiene and being well kept can be linked to the cognitive ability with which the individual may adopt a health care program (Madigan, 2020). In this case, a drooping shirt pocket with an open pack of cigarettes may be a significant sign of the likelihood of a chest issue. An initial assessment of the ventilatory pattern is done long before during the data collection process. The breath volume, rate, effort used in breathing and rate should be taken into consideration. For instance, although medical records indicate that resting adults breathe 20 times per minute, most people breathe 12 times in a minute (Kelly, 2018). Other patterns such as tidal volumes and ventilatory patterns may change in disease. The ventilatory assessment pattern during history taking increases efficiency and allows the clinician to process data earlier. However, it is not a pathway for the patient to change their way of breathing and alter data.
The next step of the test is palpation. The clinician should put the palm of each hand on the top portion of both hemithoraces with the patient undressed, softly but firmly push the hand inferior to just below the twelfth rib. This process is repeated as the clinician moves anteriorly, laterally and subsequently; searches for rib nodules deformities, and tenderness areas (Joshi, 2011). The clinician then inquires from the patient about the parts that have the most pain if they have a history of chest discomforts. He or she should palpate the region with firmness to establish how this procedure reproduces the symptoms of the patient in a bid to evoke tenderness (Madigan, 2020). The clinician should pay special attention to costochondral junctions in repair patients.
Palpation is also critical for aeration evaluation. The rhythm, synchrony, and duration of a breath may be delicately measured. This is achieved by observing the subject afterwards, bringing the palms of the physician together at the midline at the point of the tenth bone, with the hands gripping the lateral rib cage. All visual and sensory measurements are made during the respiration of the tidal volume and during the inhalation of deep energy. Thumbs distinguish from the latter by approximately three centimeters. Part of the chest exam’s palpatory component is to determine trachea location (Meredith & Massey, 2011). This is achieved better when the clinician stands behind the client and gently massaging the anterior lower neck just above the jugular notch by softly pushing the fingers between the lateral tracheal wall and the sternocleidomastoid muscle’s medial part. Contrasting from one hand to the other, the clinician makes an estimation of the direction of the trachea whether the midline or divergence is far from the centrist location (Kelly, 2018). Tactile awareness of vibrations emitted to the thorax surface when upper airway noises are produced by breathing or talking is a conventional yet disrespectful technique called tactile or vocal fremitus. Egophony is both more delicate and more precise.
The percussion technique aims at producing sounds when the clinician hits the patient’s chest wall. Tapping lightly on these wall produces a myriad of sounds, which are determined by the amount of air in the lungs. Hitting the wall gently makes the underlying tissues and the chest wall move, producing palpable vibrations and audible sounds (Madigan, 2020). These sounds help the clinician to determine whether the chest cavity is filled with solid material, air, or fluid. This assessment is usually done when the patient is in a supine position during the anterior chest percussion and in a sitting position when assessing the posterior chest (Isaacs, 2015). The clinician places the first part of their middle finger on the patient’s skin while striking the skin with the end of the middle finger of the other hand. The health practitioner works from the chest downwards while listening and comparing sounds from the right and left sides.
For normal lung tissue, there are resonant sounds that are characterized by a low pitch and hollow sounds. On bones, there are extremely dull or flat sounds while dull sounds are heard on organs such as the liver or the heart. In cases where solid or fluid tissues replace lung tissues that contain air, resonance is replaced with dullness as in the case with conditions such as pleural infusions, pneumonia, or tumors (Benbassat & Baumal, 2010). Hyper-resonant sounds are heard in very thin persons, children, COPD patients, people with lungs hyperinflated with air, in cases of serious asthmatic attacks, and may be a sign of pneumothorax. Drum-like sounds, also known as tympanic sounds are heard over the stomach but may be heard at the chest as an indication of excessive air. Percussion is a useful skill that can be used to recognize the underlying lung pathology (Benbassat & Baumal, 2010). The health practitioner performing this examination should be attentive to listen to not only the sound but also the frequency and intensity of the vibrations that are produced. This is important for one to make a detained interpretation.
The data that the clinician gathers during the first three stages guides them on what to listen for during auscultation to aid in making the right diagnosis. The stethoscope is an important instrument in this technique, and is used to selectively filter sounds rather than making the sounds significantly louder (Proctor, 2020). The arms of the patient should be crossed anteriorly when the posterior thorax is being assessed to laterally move the scapulas as much as possible. The process should be performed during deep forceful inspiration, tidal ventilation, and forceful expiration. The intensity of the breath sounds is directly associated with flow rates. When the sound is louder, the flow rate becomes greater (Sarkar et al., 2015). The bronchial sounds of breath can either be regular or unnatural. Once they are noticed on the periphery, where vesicular breath sounds are ordinarily heard, the clinician may assert that the airways to the lung units are receptive but that the lung units are loaded with liquid-like substance themselves (Sarkar et al., 2015). The bronchial air noises become noisy as this happens without pleural fluid. As convergence becomes combined with pleural effusion, the bronchial breath noises become apparent but also very decreasing in strength.
The respiratory assessment techniques rely on the effectiveness of the clinician to carry out a detailed assessment. This is done through inspection where the clinician looks out for signs of underlying conditions to find out underlying issues. This technique is most effective when the clinician examines the patent wholly considering other factors such as dressing and lifestyle. The clinician then palpates the body to assess ventilation and locate any deformities, areas of tenderness and nodules. Percussions are then done to establish lung pathology. It is done to determine whether the chest cavity is filled with air, fluid or solid material. The last technique, auscultation, is done in reference to the data collected from the earlier techniques. This enables the clinician to know what to listen to. This respiratory assessment is effective in assessing the state of the chest cavity.
References
Benbassat, J., & Baumal, R. (2010). Narrative review: should teaching of the respiratory physical
examination be restricted only to signs with proven reliability and validity?. Journal of general internal medicine, 25(8), 865-872.
Isaacs, D. (2015). The respiratory examination. Journal of Paediatrics and Child Health, 51(8), 749-750. https://doi.org/10.1111/jpc.12959
Joshi, J. (2011). Physical examination of respiratory system. NCCP Textbook of Respiratory Medicine, 1-1. https://doi.org/10.5005/jp/books/11207_1
Kelly, C. (2018, March 26). Respiratory rate 1: Why measurement and recording are crucial. Nursing Times. https://www.nursingtimes.net/clinical-archive/respiratory-clinical-archive/respiratory-rate-1-why-measurement-and-recording-are-crucial-26-03-2018/
Madigan, N. (2020, June 29). Respiratory assessment for nurses. Health Times. https://healthtimes.com.au/hub/respiratory/53/practice/nc1/respiratory-assessment-for-nurses/1539/
Meredith, T., & Massey, D. (2011). Respiratory assessment 2: More key skills to improve
care. British Journal of Cardiac Nursing, 6(2), 63-68.
Pasterkamp, H., & Zielinski, D. (2019). The history and physical examination. In Kendig’s Disorders of the Respiratory Tract in Children (pp. 2-25). Content Repository Only!
Proctor, J. (2020, June 1). How to perform chest auscultation and interpret the findings. Nursing Times. https://www.nursingtimes.net/clinical-archive/assessment-skills/how-to-perform-chest-auscultation-and-interpret-the-findings-06-01-2020/.
Toney-Butler TJ, Unison-Pace WJ. Nursing Admission Assessment and Examination. [Updated
2019 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493211/
Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015). Auscultation of the respiratory
system. Annals of thoracic medicine, 10(3), 158–168. https://doi.org/10.4103/1817-1737.160831