DR D Y PATIL COLLEGE OF NURSING PIMPRI, PUNE-18

ASSIGNMENT
ON
RESPIRATORY
ASSESMENT

SUBMITTED TO: SUBMITTED BY:

MR. UTKARSH SIR MR.ROHIT THETE

(NURSE PRECEPTOR) 1ST YEAR NPCC

DR D Y PATIL HOSPITAL DR D Y PATIL COLLEGE

AND RESEARCH CENTER. OF NURSING.

SUBMITTED ON:
 RESPIRATORY ASSESSMENT

INTRODUCTION

A prompt initial assessment allows immediate evaluation of severity of illness

and appropriate treatment measures may warrant instigation at this point.
Following this, a comprehensive patient history will be elicited. Clinical
examination of the patient follows and involves inspection, palpation,
percussion and auscultation. At this point, consideration must be given to
preparation of a light, warm, quiet, private environment for examination and
suitable patient positioning. Inspection is a comprehensive visual assessment,
while palpation involves using touch to gather information. The next stages are
percussion and auscultation. While percussion is striking the chest to determine
the state of underlying tissues, auscultation entails listening to and interpreting
sound transmission through the chest wall via a stethoscope.

DEFINITION

The respiratory system is a biological system consisting of specific organs

and structures used for gas exchange. The anatomy of a typical respiratory
system is the respiratory tract. The tract is divided into an upper and a lower
respiratory tract. The upper tract includes the nose, nasal cavities, sinuses,
pharynx and the part of the larynx above the vocal folds. The lowertract
includes the lower part of the larynx, the trachea, bronchi, bronchioles and the
alveoli
ANATOMY PHYSIOLOGY OF RESPIRATORY TRACT
The respiratory tract can also be divided into a conducting zone and
a respiratory zone, based on the distinction of transporting gases
or exchangingthem. The conducting zone includes structures outside of the
lungs – the nose, pharynx, larynx, and trachea, and structures inside the lungs –
the bronchi, bronchioles, and terminal bronchioles.

The respiratory tract is divided into the upper airways and lower airways. The
upper airways or upper respiratory tract includes the nose and nasal
passages, paranasal sinuses, the pharynx, and the portion of the larynx above
the vocal folds(cords). The lower airways or lower respiratory tract includes the
portion of the larynx below the vocal folds, trachea, bronchi and bronchioles.
The lungs can be included in the lower respiratory tract or as separate entity and
include the respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli

Upper respiratory tract

The upper respiratory tract, can refer to the parts of the respiratory system lying
above the sternal angle (outside of the thorax), above the vocal folds, or above
the cricoid cartilage.The larynx is sometimes included in both the upper and
lower airways. The larynx is also called the voice box and has the associated
cartilage that produces sound. The tract consists of the nasal
cavity and paranasal sinuses, the pharynx.

1. NASAL CAVITY

The nose formed from both bone and cartilage. The nasal bone forms the
bridge, and the remainder of the nose is composed of the cartilage and
connective tissue. Each opening of the nose on the face (nostrils or nares) leads
to a cavity( vestibule). The vestibule is lined anteriorly with skin and hair that
filter foreign objects and prevent them from being inhaled. The posterior
vestibule is lined with a mucous membrane, composed of columnar epithelial
cells, and goblet cells that secrete mucous. The mucous membrane extends
throughout the airways, and cilia (hair liked-projection) propel mucous to the
pharynx for elimination by swallowing or coughing.

2. PHARYNX
The pharynx is a funnel-shaped tube that extends from the nose to the larynx. It
can be divided into three sections,
 The nasopharynx is located above the margin of the soft palate and receives
air from the nasal cavity. From the ear , the Eustachian tubes open into the
nasopharynx. The pharyngeal tonsils (called adenoids when enlarged) are
located on the posterior wall of the nasopharynx.
 The oropharynx serves both respiration and digestion. It receives air from the
nasopharynx and food from the oral cavity. Palatine (facial) tonsils are
located along the sides of the posterior mouth, and the lingual tonsils are
located at the base of the tongue.
 The laryngopharynx (hypopharynx) , located below the base of the tongue, is
the most inferior portion of the pharynx. It connects the larynx and serves
both respiration and digestion.

3. LARYNX:

The larynx is commonly called the voice box. It connects the upper (pharynx)
and lower (trachea) airways. The larynx lies just anterior to the upper
esophagus. Nine cartilages from the larynx: three large unpaired cartilages
(epiglottis, thyroid, cricoid) and three smaller paired cartilages (arytenoids,
coriculate, cuneiform). The cartilages are attached to the hyoid bone above and
below the trachea by muscles and ligaments, all of which prevent the larynx
from collapse during inspiration and swallowing.

Lower respiratory tract

The lower respiratory tract or lower airway is derived from the
developing foregut and consists of the trachea, bronchi (primary, secondary and
tertiary), bronchioles (including terminal and respiratory),
and lungs (including alveoli). It also sometimes includes the larynx.

The lower respiratory tract is also called the respiratory tree or tracheobronchial
tree, to describe the branching structure of airways supplying air to the lungs,
and includes the trachea, bronchi and bronchioles.

 trachea
 main bronchus (diameter approximately 1 – 1.4 cm in adults)
 lobar bronchus (diameter approximately 1 cm)
 segmental bronchus (diameter 4.5 to 13 mm)
 subsegmental bronchus (diameter 1 to 6 mm)
 conducting bronchiole
 terminal bronchiole
 respiratory bronchiole
 alveolar duct
 alveolar sac
 alveolus

1. TRACHEA:

The trachea (windpipe) extends from the larynx to the level of the seventh
thoracic vertebra, which it divides into two main (primary) bronchi. The point at
which the trachea divides is called the carina. The trachea is a flexible, muscular
2- cm- long air passage with C-shaped cartilaginous rings.

2. BRONCHI AND BRONCHIOLES:

The right main stem bronchus is shorter and wider, extending more vertically
downward than the left main stem bronchus. Thus foreign bodies are more
likely to lodge there than the left main stem bronchus. The segmental and sub-
segmental bronchi are subdivisions of the main bronchi and spread in a
inverted, tree-like formation through each lung. Cartilage surrounds the airway
in the bronchi, but the bronchioles (the final pathway to the alveoli) contain no
cartilage and thus can collapse and trap air during active exhalation.

3. LUNGS

The lungs lie within the thoracic cavity on either side of the heart. They are
cone-shaped, with the apex above the first rib and the base resting on the
diaphragm. Each lung is divided into superior and inferior lobes by an oblique
fissure. The right lung is further divided by a horizontal fissure, which creates a
middle lobe. The right lung, therefore, has three lobes; the left lobe has only
two. In addition to these 5 lobes, which are visible externally , each lungs can be
subdivided into about 10 smaller units (broncho-pulmonary segments).
LUNG VOLUMES

The volume of air that move in and out with each breath is called the tidal
volume. During quite breathing , tidal volume is about 500 ml. The amount of
air inhaled, beyond the tidal volume is called the inspiratory reserved volume;
the extra air that can be exhaled after a forced breath is called the expiratory
reserved volume.

ALVEOLI:

The lung parenchyma, which consist of millions of alveolar units, is the

working area of the lung tissue. At birth the person has approximately 24
million alveoli; by the age 8 years, a person has 300 million. The total working
alveolar surface area is approximately 750 to 860 square feet.The blood supply
flowing towards the alveoli comes from the right ventricle of the heart.

4. THORAX:

The bony thorax provide protection to the heart, lungs, and great vessels. The
outer shell of the thorax is made up of 12 pairs of ribs. The ribs connect
posteriorly to the transverse processes of the thoracic vertebrae of the spine.
Anteriorly, the first seven pairs of ribs are attached to the sternum by cartilage .
The 8th, 9th , an 10th ribs are attached to each other by costal cartilage.

5. DIAPHRAGM:

The diaphragm is the primary muscle of breathing and serves as the lower
boundary of the thorax. The diaphragm is dome-shaped in the relaxed position,
with central muscular attachments to the xiphoid process of the sternum and the
lower ribs.

6. PLEURAE:

The pleurae are serous membranes that enclose the lung in a double wall sac.
The visceral pleura covers the lung and the fissures between the lobes of the
lung. The parietal pleura covers the inside of each hemithorax, the mediastinum
and the top of the diaphragm. Normally, no space exists between the pleurae:
the pleural space is a potential space between the two layers of pleura.

FUNCTION OF RESPIRATORY SYSTEM:

The respiratory system enhances gas exchange. Inspiration brings oxygen- rich
air into the alveoli. The upper and lower airways filter and humidify inspired
air. Gas exchange between the air ad the blood occurs in the alveolus. Oxygen
diffuses into the blood, and co2 diffuses from the blood into the alveolar air.
The co2-enriched air is removed from the body during expiration. The large
number and large surfaces area of alveoli are necessary to meet both resting and
exercise exchange requirements. The thorax ad diaphragm alter pressures in the
thorax to drive air movement.

1. Inhalation and Exhalation

The respiratory system aids in breathing, also called pulmonary ventilation. In

pulmonary ventilation, air is inhaled through the nasal and oral cavities (the
nose and mouth). It moves through the pharynx, larynx, and trachea into the
lungs. Then air is exhaled, flowing back through the same pathway. Changes to
the volume and air pressure in the lungs trigger pulmonary ventilation. During
normal inhalation, the diaphragm and external intercostal muscles contract and
the ribcage elevates. As the volume of the lungs increases, air pressure drops
and air rushes in. During normal exhalation, the muscles relax. The lungs
become smaller, the air pressure rises, and air is expelled.

2. External Respiration (Exchanges Gases Between the Lungs and the

Bloodstream)

Inside the lungs, oxygen is exchanged for carbon dioxide waste through the
process called external respiration. This respiratory process takes place through
hundreds of millions of microscopic sacs called alveoli. Oxygen from inhaled
air diffuses from the alveoli into pulmonary capillaries surrounding them. It
binds to hemoglobin molecules in red blood cells, and is pumped through the
bloodstream. Meanwhile, carbon dioxide from deoxygenated blood diffuses
from the capillaries into the alveoli, and is expelled through exhalation.
3. Internal Respiration( Exchanges Gases Between the Bloodstream and
Body Tissues )

The bloodstream delivers oxygen to cells and removes waste carbon dioxide
through internal respiration, another key function of the respiratory system. In
this respiratory process, red blood cells carry oxygen absorbed from the lungs
around the body, through the vasculature. When oxygenated blood reaches the
narrow capillaries, the red blood cells release the oxygen. It diffuses through the

capillary walls into body tissues. Meanwhile, carbon dioxide diffuses from the
tissues into red blood cells and plasma. The deoxygenated blood carries the
carbon dioxide back to the lungs for release.

4. Air Vibrating the Vocal Cords Creates Sound

Phonation is the creation of sound by structures in the upper respiratory tract of

the respiratory system. During exhalation, air passes from the lungs through the
larynx, or “voice box.” When we speak, muscles in the larynx move the
arytenoid cartilages. The arytenoid cartilages push the vocal cords, or vocal
folds, together. When the cords are pushed together, air passing between them
makes them vibrate, creating sound. Greater tension in the vocal cords creates
more rapid vibrations and higher-pitched sounds. Lesser tension causes slower
vibration and a lower pitch.

5. Olfaction, or Smelling, Is a Chemical Sensation

The process of olfaction begins with olfactory fibers that line the nasal cavities
inside the nose. As air enters the cavities, some chemicals in the air bind to and
activate nervous system receptors on the cilia. This stimulus sends a signal to
the brain: neurons take the signal from the nasal cavities through openings in
the ethmoid bone, and then to the olfactory bulbs. The signal then travels from
the olfactory bulbs, along cranial nerve 1, to the olfactory area of the cerebral
cortex.

6. Regulation of acid-base balance:

The lungs through gas exchange, have a key role in regulating the acid-base
balance of the body. Pulmonary disorders that change the CO2 level in the
blood cause either respiratory academia or respiratory alkalemia . Insufficient
ventilation causes hypercapnia, a respiratory academia caused by retention of
excessive amounts of CO2. Hyperventilation, conversely, causes hypocapnia, a
respiratory alkalemia caused by the low amounts of CO2 in the blood. The
effectiveness of ventilation is best measured by the PCO2 in the arterial blood.

PURPOSES

 To ascertain the respiratory status of the patient.

 To confirm data obtained in the nursing history.
 To obtain data that will help established nursing diagnosis and plan of
care.
 To evaluate the physiologic outcome of health care and thus the progress
of the client’s health problem.
 To make clinical judgements about a client’s health status.
 To identify areas for health promotion and disease prevention.

PREPARING THE ENVIRONMENT

 It is important to prepare the environment before starting the assessment.

 The time for the physical assessment should be convenient to both the
client and the nurse.
 The environment needs to be well lighted and the equipment should be
organized for efficient use.
 The room should be warm enough to be comfortable for the client.

PREPARATION OF THE PATIENT

 Greet patient.
 Explain assessment techniques.
 Quiet ,well light examination.
 Wash hands.
 Introduce yourself.
 Confirm the patients details.
 Explain to the patient that you are going to perform a lung examination.
 Position the patient’s at 45˚.
 Ask if the patient has any pain before you begin.
 ASSESSMENT OF RESPIRATORY SYSTEM

1. HISTORY COLLECTION

INTRODUCTION

History taking is the foundation of clinical medicine. In the context of

respiratory system assessment, history allows healthcare professionals to
understand the nature, onset, duration, and progression of symptoms affecting
the lungs and airways. It helps clinicians formulate an initial diagnosis, decide
on investigations, and initiate management even before physical examination or
imaging. Properly structured respiratory history taking can help detect
conditions such as asthma, tuberculosis, chronic obstructive pulmonary disease
(COPD), pneumonia, lung cancer, and other pulmonary disorders.

OBJECTIVES OF RESPIRATORY HISTORY TAKING

 To identify respiratory symptoms and understand their characteristics.

 To establish the likely onset and triggers of respiratory complaints.
 To correlate environmental, occupational, personal, and family factors
with lung conditions.
 To assist in narrowing down differential diagnoses.
 To guide the clinician towards relevant investigations and immediate
interventions.
 To assess the impact of the illness on the patient’s quality of life and
functional status.

IMPORTANCE OF HISTORY IN RESPIRATORY ASSESSMENT

History taking is especially vital in respiratory medicine because many

respiratory diseases present with overlapping symptoms such as cough and
breathlessness. Without proper context, these complaints can be misleading. For
example, a dry cough may be due to an upper respiratory tract infection, post-
nasal drip, or even interstitial lung disease. A patient’s occupation, habits, and
exposure history may be crucial to identifying causes of chronic bronchitis or
occupational asthma. Therefore, a thorough and structured respiratory history
helps in evaluating the risk factors, chronicity, and seriousness of illness.

1.DEMOGRAPHIC DATA

Demographic data provides background information that can influence the

development, diagnosis, and management of respiratory disorders. This section
sets the context for the rest of the history.

Key Elements:

 Name and Age: Certain diseases are age-specific (e.g., bronchiolitis in

infants, COPD in elderly).
 Sex: Some respiratory diseases like asthma may have different
prevalence rates between males and females.
 Occupation: Exposure to dust, chemicals, or allergens (e.g., coal miners,
factory workers) is critical.
 Residence: Living in urban, polluted, or overcrowded areas increases the
risk of TB and asthma.
 Socioeconomic Status: Poor housing, nutrition, and access to healthcare
can predispose individuals to respiratory infections.

2. Chief Complaints

The chief complaint (CC) is the first symptom or group of symptoms that leads
the patient to seek medical attention. In respiratory cases, chief complaints
typically relate to abnormalities in breathing and oxygen exchange.

Common Respiratory Chief Complaints:

1. Cough
2. Shortness of Breath (Dyspnea)
3. Chest Pain
4. Wheezing
5. Sputum Production
6. Hemoptysis
7. Fever with Respiratory Symptoms
8. Fatigue and Reduced Exercise Tolerance
Each complaint must be clearly documented, ideally using the patient’s own
words. If multiple complaints are present, they should be recorded in order of
severity or duration.

3. Present History of Illness (HOPI)

The Present History of Illness provides a detailed analysis of the symptoms

mentioned in the chief complaints. This is the most critical section of the
respiratory history and must be approached systematically.

1 Onset

 Refers to when the symptom first appeared.

 Can be sudden (e.g., pneumothorax, pulmonary embolism) or gradual
(e.g., tuberculosis, COPD).
 Understanding onset helps in differentiating between acute and chronic
illnesses.

2 Duration

 Describes how long the patient has experienced symptoms.

 Acute (<3 weeks): Infections, allergic reactions.
 Subacute (3–8 weeks): Post-infectious cough, resolving pneumonia.
 Chronic (>8 weeks): Asthma, COPD, bronchiectasis, interstitial lung
diseases.

3 Progression

 Describes whether the symptoms are improving, worsening, or

fluctuating.
 Progressive worsening (e.g., increasing breathlessness) may indicate
advancing disease.
 Episodic symptoms (e.g., in asthma) may be triggered by environmental
factors.

4 Character of Symptoms

Cough:

 Dry Cough: Seen in viral infections, asthma, GERD.

  Productive Cough: May indicate infection or chronic disease. Important
to assess:
o Color: Yellow/green (infection), white (non-infectious), red
(hemoptysis).
o Consistency: Frothy, thick, foul-smelling.

Breathlessness (Dyspnea):

 Evaluate using a dyspnea scale (mild, moderate, severe).

 Determine if it occurs at rest or with activity.
 Assess for orthopnea (difficulty breathing while lying flat) or PND
(awakens at night due to dyspnea).

Chest Pain:

 Pleuritic Pain: Sharp, worsens with inspiration or coughing.

 Non-Pleuritic Pain: Dull, pressure-like, may radiate (consider cardiac
origin).

5 Associated Symptoms

 Fever: May suggest infection (pneumonia, TB).

 Night Sweats: Classically associated with tuberculosis.
 Weight Loss: Seen in chronic infections, malignancies.
 Wheezing: High-pitched sound from airway narrowing.
 Clubbing: Sign of chronic hypoxia; observed in bronchiectasis, lung
cancer.

6 Aggravating and Relieving Factors

 Aggravating: Dust, cold air, allergens, exercise, lying flat.

 Relieving: Rest, sitting upright, use of bronchodilators or medications.

4. PAST HISTORY OF ILLNESS

The examiner must comprehensively explore the patient’s prior respiratory

conditions, focusing on whether symptoms such as cough, shortness of breath,
chest pain, or wheezing have occurred before. It's critical to understand the
timeline, severity, and any treatments undertaken.
  Symptom recurrence: Determine if respiratory symptoms are acute,
chronic, or episodic. Chronic cough lasting more than eight weeks may
suggest conditions like chronic bronchitis or tuberculosis.
 Treatment history: Record all past treatments including use of
antibiotics, bronchodilators, corticosteroids, or oxygen therapy. Check if
the patient adhered to these treatments and the outcome.
 Hospital admissions: Note any previous hospitalizations due to
respiratory illness, including ICU admissions for severe exacerbations
such as asthma attacks or pneumonia.
 Complications: Identify any history of respiratory failure, lung abscess,
or hemoptysis.
 Impact on daily life: Assess how past respiratory illnesses affected
physical activity, work, and quality of life.

Common diseases related to past history:

 Asthma: Chronic inflammatory disease causing airway hyper-

responsiveness, wheezing, and breathlessness, often beginning in
childhood or early adulthood. Symptoms may flare due to allergens,
exercise, or infections.
 Chronic Obstructive Pulmonary Disease (COPD): Progressive airflow
obstruction mainly caused by long-term smoking. Symptoms include
persistent cough with sputum, exertional dyspnea, and frequent
exacerbations.
 Pneumonia: Acute infection causing lung inflammation and
consolidation, presenting with cough, fever, chest pain, and sputum
production. Recurrent pneumonia may indicate underlying lung disease
or immunodeficiency.
 Tuberculosis (TB): Infectious disease caused by Mycobacterium
tuberculosis, presenting with chronic cough, night sweats, weight loss,
and sometimes hemoptysis. Previous TB treatment or latent TB history is
vital to record.
 Diabetes Mellitus (DM): Chronic hyperglycemia impairs immune
function, making patients more susceptible to respiratory infections such
as pneumonia and tuberculosis. Diabetic patients also have delayed
wound healing and increased risk of complications post lung surgery.
 Hypertension (HTN): High blood pressure can be associated with
cardiovascular diseases that impact respiratory status through heart failure
 or pulmonary edema. It’s important to know if the patient is on
antihypertensive medications that may affect respiratory function.
 Thyroid disorders: Both hypothyroidism and hyperthyroidism can
influence respiratory function. Hypothyroidism may cause
hypoventilation and pleural effusion, while hyperthyroidism can cause
muscle weakness including respiratory muscles, leading to dyspnea

5. PAST SURGICAL HISTORY

Obtaining a history of prior surgeries related to the respiratory tract or chest is

essential as it can influence current respiratory function and management.

 Lung resections: Includes lobectomy, segmentectomy, or

pneumonectomy often performed for lung cancer, tuberculosis sequelae,
or severe localized infections. Post-surgical lung capacity and function
should be assessed.
 Bronchoscopy: A diagnostic or therapeutic procedure involving direct
visualization of airways. Prior bronchoscopic biopsies or foreign body
removals should be noted.
 Thoracotomy and chest tube insertions: Surgeries to manage pleural
effusion, pneumothorax, or chest trauma. Presence of surgical scars or
chest tubes can indicate previous severe lung disease or injury.
 Tracheostomy: Surgical opening in the trachea to bypass upper airway
obstruction or for prolonged mechanical ventilation. This history suggests
significant airway or respiratory muscle dysfunction.

The presence of these surgeries might predispose patients to postoperative

complications such as restrictive lung disease or recurrent infections.

6. FAMILY HISTORY

Family history can provide clues about inherited or environmental risks for
respiratory diseases:

 Asthma: Often runs in families due to genetic predisposition; family

members with asthma increase the patient’s risk of developing allergic
airway disease.
 COPD: Though mainly linked to smoking, familial cases can occur due
to genetic factors like alpha-1 antitrypsin deficiency.
  Tuberculosis: Family members with active TB indicate possible shared
exposure, necessitating screening and preventive therapy.
 Pneumonia and other infections: Repeated infections in family
members may suggest immune deficiencies or poor living conditions.
 Other inherited lung conditions: Such as cystic fibrosis (genetic
disorder causing thick mucus and recurrent infections) or primary ciliary
dyskinesia
 Diabetes Mellitus: Increases risk for infections including pulmonary
infections.
 Hypertension: Family history often indicates genetic predisposition to
cardiovascular diseases which affect lung function indirectly.
 Thyroid disorders: May be inherited, influencing respiratory health via
metabolic effects.

7.PERSONAL HISTORY

Lifestyle

 Smoking: Includes cigarettes, cigars, pipes, electronic cigarettes, and

hookah. Assess frequency, duration, and recent smoking status. Smoking
causes chronic inflammation, airway obstruction, and lung cancer.
 Tobacco chewing: Chewing tobacco is common in many populations
and is a significant risk factor for oral cancers and respiratory irritation.
Chewed tobacco releases carcinogens and irritants which can contribute
to chronic bronchitis and increase risk for upper airway malignancies.
 Alcohol: Excessive use increases vulnerability to respiratory infections
by impairing immunity and cough reflex.

8.SOCIAL HISTORY

Social history is the assessment of the patient’s living conditions and social
environment, which influences respiratory health:

 Living environment: Includes housing quality, ventilation,

overcrowding, and exposure to indoor pollutants like biomass smoke
from cooking with wood, cow dung, or coal, which increases risk of
chronic bronchitis and pneumonia.
  Socioeconomic status: Impacts access to healthcare, nutrition, education
about disease prevention, and ability to afford treatment. Poor
socioeconomic conditions are associated with higher rates of tuberculosis
and respiratory infections.
 Exposure to secondhand smoke: Non-smokers living with smokers
have higher risk of asthma, bronchitis, and lung cancer.
 Physical activity: Sedentary lifestyle can worsen respiratory and
cardiovascular health.
 Diet and nutrition: Poor nutrition impairs immune function, increasing
infection risk.

9.OCCUPATIONAL HISTORY

Certain occupations expose individuals to hazardous airborne particles that

increase the risk of respiratory diseases:

• Coal Mining: Miners inhale coal dust particles leading to Coal Workers’
Pneumoconiosis (CWP), or “black lung disease.” This is a progressive
fibrotic lung disease causing breathlessness, chronic cough, and reduced
lung function.

 Asbestos Work: Exposure to asbestos fibers can cause asbestosis (lung

fibrosis), pleural plaques, and increase risk of mesothelioma and lung
carcinoma. Symptoms include progressive dyspnea and chest pain.
 Farming: Exposure to moldy hay, grain dust, pesticides, and animal dander
can lead to Farmer’s Lung or Hypersensitivity Pneumonitis, an immune-
mediated inflammation causing cough, breathlessness, fever, and fatigue.
 Other high-risk jobs include construction workers exposed to silica dust
(silicosis), textile workers exposed to cotton dust (byssinosis), and those
exposed to chemical fumes or gases
 RESPIRATORY SYSTEM PHYSICAL
EXAMINATION

The Possible Short Cases in Clinic Exam are:

1- COPD & Asthma. 2- Bronchiectesis.

3- Pleural Effusion. 4- Pneumothorax.
5- Pneumonia. 6- Interstitial Lung Disease (ILD).

Chest Examination Means - Examination On Chest From Front OR From

the Back. Respiratory Examination Means - Chest Examination & General
Examination Related to Respiratory System.

 CHEST EXAMINATION FROM THE BACK:

IN CHEST EXAMINATION FROM THE BACK PATIENT HAS TO BE IN SETTING

POSITION

1.INSPECTION
1- Scars:

Look at the Chest From the Both Axilla For Any Scar Such as:
A- Small Axillary Scar - Indicate Chest Tube Insertion.
B- Large Axillary Scar (Lateral Thoracotomy Scar) - indicates Lobectomy
or Pneumonectomy.
2.Chest Deformity:
Check the Chest From the Back and Observe If There is Any
Deformity Like:
A- Scoliosis.
B- Kyphosis.
C- Kypho-Scoliosis.

Other Chest Deformity From Front are:

- Pectus Carinatum (Pigeon Chest)
- Pectus Excavatum (Funnel Chest)
- Barrel Chest (Increase Antero-Posterior Diameter Of Chest).

3.Chest Movement:
Ask the Patient to Breath From His Mouth and Observe the Chest From
the Back to Check Chest Movement During Inspiration & Expiration.

Differential Diagnosis of Bilateral Differential Diagnosis of Unilateral

Decrease Chest Movement Decrease Chest Movement
-Asthma. -Pleural Effusion (Lower Zone).
-COPD. -Pneumothorax (Upper Zone).
-Bronchiectesis. -Lung Collapse.
-Interstitial Lung Disease (ILD). -Lobar-Pneumonia.
-Broncho-Pneumonia. -Pneumonectomy or Lobectomy.
4.OTHERS (S S):

Superficial Dilated Vein - Indicate Superior Vena Cava Obstruction in

Case of Apical Lung Tumor. Symmetry of The Chest - Bulging Or
Retraction
- Bulging Indicate - Pleural Effusion & Pneumothorax.
- Retraction Indicate - Lung Collapse & Lung Fibrosis.

2.PALPATION

1- Chest Expansion:

Put The Palms of Your Both Hands On the Chest From the Back in Three
Areas (1, 2, 3) as in the Picture, Start From Area (1) , Then Ask the Patient
to Breath From His Mouth and Check the Expansion of the Chest in Both
Sides in Area (1) ,, Do the Same
 2-Tactile Vocal Fremitus (TVF):
Use Ulnar Border of Your Hand and Put it On the Chest From the Back
On Intercostal Space in Order According to the Numbers in The Picture
,, and Ask the Patient to Say 44 In Each Area

(in English Say Ninety Nine) You are Going to Feel Simple Vibration
(Transmitted Sound),

*Don’t Forget To Follow the Numbers in the Picture and Compare

Between Both Lungs:

Differential Diagnosis of Decrease Differential Diagnosis of Increase

Tactile Vocal Fremitus Tactile Vocal Fremitus
- Asthma. - Consolidation in Pneumonia.
- COPD.
- Lung Fibrosis.
- Pleural Effusion.
- Pneumothorax.

Note:
Ask Permission From the Doctor to Palpate Tracheal Position, Because It is
Useful In Case of Shifted Mediastinum as in - Massive Pleural Effusion,
Tension Pneumothorax, Lung Collapse, Pneumonectomy
3.PERCUSSION

Put the Palm of Your Left Hand on Intercostal Space of the Chest From the
Back in Order According to the Numbers in The Picture ,, and Use The
Middle Finger of Your Right Hand and Tap it On Distal Interphalangeal
Joint of Your Left Hand.

Listen to the Sound that Will Occur Due to Percussion Which May Be:

- Resonant - Means - Normal.

- Hyper-Resonant (Tympanic) - Means - Pneumothorax OR Obstructive

Lung Diseases (Asthma, COPD, Broncheictesis).

- Dull - Means - Consolidation (Pneumonia).

- Stony Dull - Means - Pleural Effusion
4- AUSCULTATION

1- AIR ENTRY:

Put Your Stethoscope On the Chest From the Back On Intercostal Space
in Order According to the

Numbers in The Picture ,, and Ask the Patient to Breath From His
Mouth ,, Then Auscultate;;

and Check If the Air Entry Equal in Both Lungs OR If there is Any
Decrease of Air Entry:

Differential Diagnosis of Bilateral Differential Diagnosis of Unilateral

Air Entry Decrease Air Entry Decrease
- Asthma. - Pleural Effusion.
- COPD. - Pneumothorax.
- Bronchiectesis. - Lung Collapse.
- Interstitial Lung Disease. - Pneumonectomy or Lobectomy.
2- TYPE OF BREATHING:

*Harsh Vesicular Breathing - Means - Normal (Inspiration More Than

Expiration).

*Broncho-Vesicular Breathing - Means - Obstructive Lung

Diseases
(Expiration More Than Inspiration) as in Asthma, COPD,
Bronchiectesis.
*Bronchial Breathing - Means - Consolidation of Pneumonia (Gap
Between Inspiration & Expiration
 CHEST EXAMINATION FROM THE FRONT:

In Chest Examination From The Front Patient Has To Be Laying In

Supine Position (Flat Or 45 Degree).
Introduce Your Self,, Stand On The Right Side Of The Patient &
Take Permission From The Patient For Examination & Exposure

1- INSPECTION

*First Stand at the End of the Bed and Check the Symmetry of Chest From
Both Sides;
- Bulging Indicate – Pleural Effusion & Pneumothorax.
- Retraction Indicate – Lung Collapse & Lung Fibrosis.

*Now Do Inspection For:

1- Scars:

*Look at the Chest From the Both Axilla For Any Scar Such as:
A- Small Axillary Scar - Indicate Chest Tube Insertion.
B- Large Axillary Scar (Lateral Thoracotomy Scar) - indicates Lobectomy or
Pneumonectomy.
C- Mid-Line Sternotomy Scar - Indicate Open Heart Surgery, (Valve
Replacement OR Coronary Artery Bypass Graft “CABG”).
D- Left Infra-Clavicular Scar - indicates Pacemaker or Implantable Cardiac
Defibrillator (ICD).
E- Left Infra-Mammary Scar - indicates Valvotomy of Mitral Stenosis.
*Then Look at the Chest From Front For Any
2-Chest Deformity
Check the Chest From Front and Observe if There is Any Deformity Like:
A- Pectus Carinatum (Pigeon Chest) - Bulging of Sternum (Due to
Childhood Asthma OR Rickets).

B- Pectus Excavatum (Funnel Chest) - Depression of Sternum.

C- Barrel Chest (Increase Antero-Posterior Diameter Of Chest) in COPD.

Then Check the Chest From the Back and Observe If There is Any
Deformity Like:
A- Scoliosis.
B- Kyphosis.
C- Kypho-Scoliosis.
3-CHEST MOVEMENT:
Ask the Patient to Breath From His Mouth and Observe the Chest From the
Front to Check Chest Movement During Inspiration & Expiration.

4-OTHERS:
Superficial Dilated Vein - Indicate Superior Vena Cava Obstructon in Case of
Apical Lung Tumor. Gyneacomastia, Cauthery Mark.

2- PALPATION

1.Chest Expansion:
Put The Palms of Your Both Hands On the Chest From the Front in Three
Areas (1, 2, 3) as in the Picture, Start From Area (1) , Then Ask the
Patient to Breath From His Mouth and Check the Expansion of the Chest
in Both Sides in Area (1) ,, Do the Same Thing in Area (2) , Then Area

(3):
1-Tactile Vocal Fremitus (TVF):

First Use the Tip of Your Fingers and Put Them in Supra-Clavicular Area
[Number 1 as in thePicture], Then Ask the Patient to Say 44, and Feel the
Vibration, After That Use Ulnar Border of Your Hand and Put it On the Chest
From the Front On Intercostal Space in Order According to the Numbers in
The Picture Starting From Number 2 Until Number 6, and Ask the Patient to
Say 44 In Each Area (in English Say Ninety Nine) You are Going to Feel
Simple Vibration (Transmitted Sound),

*Don’t Forget To Follow the Numbers in the Picture and Compare

Between Both Lungs

3-Tracheal Position:

First Say to the Examiner; (I Would Like to Examine Mediastinal

Structures By Examining Tracheal Position) and Ask the Patient to Sit,

Then Put Your Index Finger On the Medial End of the Right Clavicle and
Put Your Ring Finger On the
 Medial End of the Left Clavicle as in the Picture,
Then Use Your Middle Finger and Try to Palpate the Trachea as in the
Picture and Check If It Centralized OR Not,(Normally the Distance
Between the Index Finger and Middle Finger is Equal to the Distance
Between Ring Finger and Middle Finger - Equi-Distance).

3- PERCUSSION
Put the Palm of Your Left Hand on Intercostal Space of the Chest From the
Front in Order According to the Numbers in The Picture,, and Use The Middle
Finger of Your Right Hand and Tap It On Distal Interphalangeal Joint of Your
Left Hand.

Listen to the Sound that Will Occur Due to Percussion Which May Be:

- Resonant - Means - Normal.

- Hyper-Resonant (Tympanic) - Means - Pneumothorax OR Obstructive Lung

Diseases (Asthma, COPD, Brochiectesis).

- Dull - Means - Consolidation (Pneumonia).

- Stony Dull - Means - Pleural Effusion.

4-AUSCULTATION

1. Air Entery:
Put Your Stethoscope On the Chest From the Front On Intercostal Space in
Order According to the
Numbers in The Picture ,, and Ask the Patient to Breath From His Mouth ,,
Then Auscultate;;
and Check If the Air Entry Equal in Both Lungs OR If there is Any Decrease
of Air Entry:

2. Type of Breathing:
Harsh Vesicular Breathing, Broncho-Vesicular Breathing & Bronchial
Breathing.
*as Mentioned Before.

3. Added Sound:
Rhonchi & Crackles.
*as Mentioned Before.

4. Vocal Resonance:
Similar to Tactile Vocal Fremitus But By Using Stethoscope, Put it in
Same Areas of Intercostal Space in Order According to Numbers in
The Picture ,, and Ask Patient to Say (44) in Each Area.

*Finally: Cover the Patient and Thank The Patient

CONCLUSION

A thorough assessment of the respiratory system is essential in identifying early

signs of respiratory dysfunction and guiding appropriate clinical interventions.
By systematically collecting a patient's history, evaluating signs and symptoms,
and performing a focused physical examination—inspection, palpation,
percussion, and auscultation—healthcare professionals can detect conditions
such as asthma, pneumonia, chronic obstructive pulmonary disease (COPD),
and pulmonary edema. Recognizing abnormal sounds like wheezes, rhonchi, or
crackles, along with interpreting breathing patterns, can aid in accurate
diagnosis and timely treatment. Comprehensive respiratory assessment not only
supports diagnostic accuracy but also enhances patient outcomes by ensuring
individualized care and monitoring of disease progression or improvement.

BIBLIOGRAPHY

1. Bickley, L. S. (2020). Bates’ Guide to Physical Examination and History

Taking (13th ed.). Wolters Kluwer.
2. Jarvis, C. (2020). Physical Examination and Health Assessment (8th ed.).
Elsevier.
3. Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2023).
Medical-Surgical Nursing: Assessment and Management of Clinical
Problems (11th ed.). Elsevier.
4. Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2019).
Mosby’s Guide to Physical Examination (8th ed.). Elsevier.