The respiratory system
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The Respiratory System. Jean M. Wilson, BSN, RN, CCE. Assessment of the Chest and Lungs. Equipment needed: Tape measure Stethoscope Blanket or drape Ruler. A & P. Position of the Patient:

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The Respiratory System

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The Respiratory System

Jean M. Wilson, BSN, RN, CCE

Assessment of the Chest and Lungs

  • Equipment needed:

    Tape measure


    Blanket or drape


A & P

  • Position of the Patient:

    Sitting = best; Allows for inspection of both the back and the chest for: the 3 S’s





  • Landmarks:



    Intercostal spaces (ICS)

    Midclavicular lines

    Axillary lines

Landmarks Continued

Midsternal line


Xiphoid process

Anterior Chest

  • Lungs:

    Right upper lobe Left upper lobe

    Right middle lobe Left lower lobe

    Right lower lobe

Posterior Chest

  • Vertebral line

  • Right and left lobes

  • Scapula

  • Scapula line


  • Anteroposterior Diameter = half of the transverse diameter

  • Unexpected findings:

    Barrel chest

    Pigeon chest

    Funnel chest



  • Assess the patient’s;

    Lips: color, pursed lips

    Nails: clubbing, cyanosis

    Nares: flaring

    Oxygen saturation

    Breath: odor

    Patients overall color


  • Expected:

    Rhythm and pattern: even & easy with no distress

    Repiration rate: 12-20 breaths per minute

    Ratio of HR/RR: 1 to 4


  • Unexpected:

    Shortness of Breath (SOB)



    Use of accessory muscles


Patterns of Respirations

  • Normal: regular 12-20 per minute

  • Bradypnea: slow, < 12

  • Tachypena: fast, > 20

  • Hyperpnea (hyperventilation) faster, >20 and deep

  • Sighing: sigh/deep breath

Patterns of Respirations

  • Air trapping: increase difference in the air getting out

  • Cheyne Stokes: increase in depth with periods of apnea

  • Kussmauls: rapid, deep, and labored

  • Biots: apnea and disorganized breathing

Patterns of Respirations

  • Ataxic: irregular, with varying depths


  • Two types of breath sounds; normal and abnormal

  • Normal are called; bronchial, bronchial vesicular, and vesicular

  • Abnormal are also called; adventitious


  • Review the proper use of the stethoscope

Normal Breath Sounds

  • Bronchial: trachea, anterior only, and high pitch

  • Bronchovesicular: main bronchus, anterior and posterior, medium pitch

  • Vesicular: heard over most of the lung fields, bases, low pitch

Adventicious Breath Sounds

  • Crackles: fine, medium, and coarse

    Fine: not cleared by coughing, heard at the end of inspiration

    Medium: lower, moist, heard during inspiration, not cleared by cough

    Coarse: loud, bubbly, heard on inspiration, can be cleared by coughing

Adventicious Breath Sounds

  • Wheezes: musical note, squeaky, heard on inspiration or expiration

  • Rhonci: sunorous wheeze, loud, low, inspiration or expiration, coughing may clear, due to mucous accumulation

  • Stridor: bark, no air exchange

  • Pleural friction rub: rubbing, dry, grating sound, inspiration or expiration, anterior


  • Pulsations

  • Tenderness

  • Bulges

  • Depressions

  • Unusual movement

  • Unusual positions

Thoracic Expansion

  • Stand behind the patient

  • Place palms lightly on patient’s back with thumbs at the 10th rib

  • Have patient breathe & watch thumbs with each breath

  • Symmetric expantions should be seen

  • Repeat anteriorly under the xiphoid process


  • Midline

  • Palpate gently with index finger about suprasternal notch

  • A slight deviation to the right is normal

  • Should be non-tender

  • Pulsations = abnormal

Chest Percussion

  • Direct:

  • Indirect:

  • Percuss all areas anteriorly and posteriorly

Percussion Tones

  • Resonant: low pitch, hollow, loud, long

  • Flat: soft, extremely dull, short, high pitch

  • Dull: medium, medium-high pitch, thudlike

  • Tympanic: loud, high pitch, drumlike

  • Hyperresonant: very loud, very low pitch, long, booming sound

Vocal Resonance

  • Have patient recite numbers or words as you listen to all lung fields (99)

  • Muffled sound should be heard


  • Cancer

  • Infections: upper respiratory, sputum production

  • Asthma

  • Chronic Obstructive Pulmonary Disease (COPD)

Abnormalities Continued

  • Emphysema

  • Pneumonai

  • Barrel Chest

  • Productive (sputum)/non-productive coughing

  • Long expirations

Cough Descriptions

  • Dry

  • Moist

  • Non-productive

  • Productive: assess sputum color; yellow, green, rust, clear, purrulent, blood streaked, thick(viscous) or thin


  • Assess:



    Regularity; certain time of day or activities

    Postural changes


    Environmental/work related issues


Schilling, J. A. et al (2007). Health

assessment made incredibly visual!

Philadelphia: Lippincott, Williams,

& Williams.

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