ADVANCE PULMONARY ASSESSMENT

I. Learning Objectives

1. Conduct a health history pertaining to Respiratory system.

2. Identify anatomic landmarks in identifying underlying structures and the location of physical
findings.
3. Inspect the thorax for pattern of respiration, skin, symmetry and the use of accessory
muscles.
4. Auscultate the anterior and posterior thorax for normal breath sounds and adventitious
sounds.
5. Describe the findings
6. Document the findings

II. Overview of the Respiratory System

The assessment of the respiratory system includes assessing the thorax, lungs, ventilatory function and
oxygenation of the body.  Focused assessment techniques will be applied intensively in this system:
inspect level of consciousness, agitation, skin color, clubbing fingers, shortness of breath, use of
accessory muscles, position and alignment of the spine; auscultate breathing sounds; palpate position of
the trachea, subcutaneous emphysema; percuss to assess the underlying structure of the chest.

With an understanding of the basic structures and primary functions of the respiratory system, the
nurse collects subjective and objective data to perform a focused respiratory assessment.

Anatomy and Physiology

The pulmonary system consists of the thorax, conducting airways, respiratory airways, and pulmonary
blood and lymph supply. The primary functions of the pulmonary system are ventilation and
respiration. Ventilation is the movement of air in and out of the lungs. Respiration is the process of gas
exchange by means of movement of oxygen from the atmosphere into the bloodstream and movement
of carbon dioxide from the bloodstream into the atmosphere. The anatomic structures that constitute
the pulmonary system are intimately related to function, and structural abnormalities can readily
translate into pulmonary disorders. An applicable knowledge of anatomy and physiology is imperative in
caring for the patient with pulmonary dysfunction.
 III. The Patient
 Geriatric – Elderly (geriatrics) starts from the age of 65 years old
 Neonates or newborns (birth to 1 month)
 Infants (1 month to 1 year)
 Children (1 year through 12 years)
 Adolescents (13 years through 17 years of age )

ADVANCE GENERAL ASSESSMENT ON PULMONARY SYSTEM

PART I HISTORY TAKING COMMENTS/NOTES

Identify the data Age Geriatric/ adult/pedia
Sex
Occupation Exposure to environmental hazard

Source of the History Patient

Wife/ Husband
Guardian/ Parent/ Siblings
Chief Complaint Why patient needing medical help:

“ How are you today, not feeling well

today. Do you have any dyspnea/
shortness of breath (SOB)? Dyspnea is a indicating that the
“ Tell me about it.” patient is having an oxygenation
Onset, duration, frequency, timing, problem
position, severity, does affect your ADL’s,
does it triggers when you feel anxious,
relieving factors, aside from SOB any
symptoms like cough, chest pain, wheezing

“ Do you a cough?”
“Describe your cough”
Onset, duration, frequency, timing, cough Presence of cough indicates
pattern presence of infection
“ Are you coughing out some phlegm?”-
duration and frequency
“ How much?” (amount) “What color of
your phlegm?” ( ask about consistency of
the phlegm), “It has any odor.” “ Any Sputum production is associated
 Hemoptysis?” “ What treatment did you
do?”
“Do you have CP when coughing.?”
“Where do you feel the pain? Describe it to
me? From 1-10 how will you rate it?
Use PQRST method in assessing the pain
Type of cough, associated symptoms with
cough like presence of phlegm or sputum,
hemoptysis, CP and wheezing
with a cough. If a patient
produces sputum frequently in
large amounts, it usually suggests
a problem.
Hemoptysis is the coughing up of
blood from the lungs. The blood
can be frank blood or streaks of
blood in the sputum. If a patient
is experiencing or has
experienced hemoptysis, attempt
to assess the volume of blood. Try
to find out if the blood may be
originating from a source other
than the lung.

A patient may experience chest

pain with breathing. Also, systems
other than the respiratory system
can cause chest pain.
Cardiovascular problems can be a
cause of the chest pain
Present Illness PQRST
Sign and symptoms

Past Medical History Childhood Illnesses- frequent respiratory

infections, ear infections, allergies,
asthma, scarlet fever

Past Illnesses- frequent respiratory

infection, copd, asthma, pneumonia, TB,
lung cancer, PE, pneumothorax,
scleroderma, cor- pulmonale , et al

Past Trauma/ Injury- stab on wound on

chest
Past Surgery: Thoracotomy, Lobectomy
Allergies and type of reactions
Immunizations: TB, Pneumonia, COVID and
Flu vaccines
Medications History: Current medication,
use of OTC drugs

Personal & Social History Tobacco User: present and past

Type of tobacco
How Long? How much/ day
 Do you use Vape?
Did you try to Quit?
Exposure to second hand smoke?

Substance abuse: past and present

Type:
Last intake:

Alcohol Use: present and past

Type of Alcohol:
How long? How much per day? Last
intake of Alcohol? Did you try to quit?
When?
O2 dependent? How many liters
Do you have Sleep apnea?
Do you have bpap/ cpap machine at night?
LIFE SPAN CONSIDERATION
Depending on the age and capability of the
child, subjective data may also need to be
retrieved from a parent and/or legal
guardian.

PEDIATRIC

Is your child up-to-date with

recommended immunizations?
Is your child experiencing any cold
symptoms (such as runny nose, cough, or
nasal congestion)?
How is your child’s appetite? Is there any
decrease or change recently in appetite or
wet diapers?
Does your child have any hospitalization
history related to respiratory illness?
Did your child have any history of frequent
ear infections as an infant?

OLDER ADULT

Have you noticed a change in your

breathing?
Do you get short of breath with activities
that you did not before?
Can you describe your energy level? Is
there any change from previous?
PART II PHYSICAL EXAMINATION

General Appearance Weight

Height
BMI
Level of Consciousness

Speech-

Asses the nose, mouth, and throat. The

nose is in the middle of the face; if an
imaginary line were drawn down the
middle, both sides of nose should be
symmetrical; observe for swelling,
drainage, or bleeding; to observe the
mouth and throat, have the older child
hold his or her mouth wide open and
move the tongue from side to side; with
the infant or toddler, use a tongue blade
to see the mouth and throat; observe
the mucous membranes for color,
moisture, and any patchy areas that
might indicate infection; observe the
number and condition of the child’s
teeth.

Chest and Lungs

Chest measurements are done on infants

and children to determine normal growth
rate.

 How to measure the chest. Take

the measurement at the nipple level
with a tape measure; observe for
chest size, shape, movement of the
chest with breathing, and any
retractions.
 Adolescents. In the older school-age
child or adolescent, note evidence
of breast development.
 Assess respiratory
characteristics. Evaluate respiratory
rate, rhythm, and depth; report any
noisy or grunting respirations.
Vital Signs Respiratory Rate
Heart Rate The vital signs may be taken by the
Blood Pressure nurse or delegated to unlicensed
Temperature assistive personnel such as a
Oxygen Saturation nursing assistant or medical
assistant. Evaluate the respiratory
rate and pulse oximetry readings to
verify the patient is stable before
proceeding with the physical exam.
The normal range of a respiratory
rate for an adult is 12-20 breaths
per minute at rest, and the normal
range for oxygen saturation of the
blood is 94–98% (SpO₂)
Bradypnea is less than 12 breaths
per minute, and tachypnea is
greater than 20 breaths per minute.

INSPECTION

INSPECT FINDINGS
 Position the patient in a sitti ng
position if possible. Be sure and  Patients in respiratory distress may have an anxious
remove the clothing or lift the gown. expression, pursed lips, and/or nasal flaring.
 The arms are slightly away from the  The anteroposterior (AP) diameter of the thorax
body (abducted). should be approximately 1/2 of the lateral diameter.
 Upon inspection, you are looking at
the shape of the thorax.
Look at the movement of the thorax.

 Use of accessory muscles and work of

breathing
 Use of accessory breathing muscles while
at rest is a sign of respiratory distress.
Accessory muscles include scalenes,
sternocleidomastoid muscle, and
intercostal muscles. Lifting the sides of the
nostrils could indicate excessive breathing
 effort.
***FOR PEDIATRIC PATIENT
 Check for flaring nostrils, which could
indicate breathing problems.
 Look for retractions or bulging of the
muscles between the ribs, which suggest
difficulty getting enough air.
 Shape and symmetry of the chest,
anteroposterior to lateral diameter
 Respirations for rate (1 minute), depth,
rhythm pattern
 Skin color of lips, face, hands (clubbing
fingers)
 O2 saturation with a pulse oximeter
 Observe the breathing pattern, including
the rhythm, effort, and use of accessory
muscles.
 Observe the depth of respiration and note
if the respiration is shallow or deep.
 Observe pattern of expiration and patient
position.
 Observe the patient’s color in their lips,
face, hands, and feet.
 Ratio of AP to Lateral diameter
 Asymmetrical chest expansion may indicate
conditions such as pneumothorax, rib fracture,
severe pneumonia, or atelectasis.
 With hypoxemia, cyanosis of the extremities or
around the mouth may be noted.
 Breathing effort should be nonlabored and in a
regular rhythm.
 Pursed-lip breathing, nasal flaring, audible
breathing, intercostal retractions, anxiety, and use
of accessory muscles are signs of respiratory
difficulty. Inspiration should last half as long as
expiration unless the patient is active, in which case
the inspiration-expiration ratio increases to 1:1.
 Patients who experience difficulty expelling air, such
as those with emphysema, may have prolonged
expiration cycles. Some patients may experience
difficulty with breathing specifically when lying
down. This symptom is known as orthopnea.
 Additionally, patients who are experiencing
significant breathing difficulty may experience most
relief while in a “tripod” position. This can be
achieved by having the patient sit at the side of the
bed with legs dangling toward the floor. The patient
can then rest their arms on an overbed table to
allow for maximum lung expansion. This position
mimics the same position you might take at the end
of running a race when you lean over and place your
hands on your knees to “catch your breath.”
 Patients with light skin tones should be pink in color.
For those with darker skin tones, assess for pallor on
the palms, conjunctivae, or inner aspect of the lower

 Inspect the chest for symmetry and
configuration.
 Observe the anterior-posterior diameter
of the patient’s chest and compare to the
transverse diameter.
 Older patients may have changes in their
anatomy, such as kyphosis, an outward
curvature of the spine.
 Inspect the fingers for clubbing if the
patient has a history of chronic respiratory
disease. Clubbing is a bulbous
enlargement of the tips of the fingers due
to chronic hypoxia.  prominent. A patient may have a barrel chest as
PALPATION
PALPATE
Lightly palpate the thoracic area anteriorly and
posteriorly. During palpation, you are looking
for pain, tenderness, abnormalities, pulsations,
lesions, masses or abnormal movement.
Note the expansion of the chest. You may use
palpation to check for chest expansion when it
is diffi cult to observe the expansion or when
you suspect asymmetry.
To palpate for chest expansion posteriorly
lip. Cyanosis is a bluish discoloration of the skin, lips,
and nail beds, which may indicate decreased
perfusion and oxygenation. Pallor is the loss of
color, or paleness of the skin or mucous membranes
and usually the result of reduced blood flow,
oxygenation, or decreased number of red blood
cells.
 The trachea should be midline, and the clavicles
should be symmetrical.
 The expected anteroposterior-transverse ratio
should be 1:2. A patient with a 1:1 ratio is described
as barrel-chested. This ratio is often seen in patients
with chronic obstructive pulmonary disease due to
hyperinflation of the lungs.
 A barrel chest is an increase in the size of the chest
from front to back. This is an anterior-posterior
increase. The sternal angle becomes more
they age and also with respiratory diseases like
chronic obstructive pulmonary disease (COPD).
 A funnel chest is noted when a patient has a
depression in the lower portion of the sternum.
This may cause a person to have a murmur if there
is compression of the heart or the great vessels.
 A pigeon chest is when the sternum is displaced
and protrudes. The ribs next to the sternum at the
xiphoid process are depressed.
FINDINGS
 Crepitus feels like a popping or crackling sensation
when the skin is palpated and is a sign of air
trapped under the subcutaneous tissues.
1. Count the ribs or the intercostal spaces next
to the spine to the intersection of  Unequal expansion can occur with pneumonia,
approximately the 10th rib. thoracic trauma, such as fractured ribs, or
2. Place your thumb at this intersection gently pneumothorax.
on the left and right side of the spine.
3. Loosely place your opened hand pointed
outward to the side or the posterior axillary
line.
4. Have the patient take a deep breath while
you note the movement of your hand.
5. You are looking for the symmetrical
movement of your hands. The distant
should only be about 1 inch between the
thumbs on inspiration.
To palpate for chest expansion anteriorly

1. Place your thumbs at the costal margin at

the xiphoid process.
2. Loosely place your opened hand pointed
outward to the side or the anterior axillary
line.
3. Have the patient take a deep breath while
you note the movement of your hand.
4. You are looking for symmetrical movement
of your hands.
5. The distant should only be about 1 inch
between the thumbs on inspiration.
Next, palpate for tactile fremitus. Fremitus is
the vibration transmitted through the chest
wall when a patient speaks. Tactile is the sense
of touch. So tactile fremitus is check for
fremitus using touch.

PERCUSSION

PERCUSS FINDINGS

The technique of percussion is best accomplished

by the following approach:
 Press the distal phalanx of the middle
finger firmly on the area to be percussed
and raise the second and fourth fingers off
the chest surface; otherwise, both sound
and tactile vibrations will be blunted.
 Use a quick, sharp wrist motion (like a
catcher throwing a baseball to second
base) to strike the finger in contact with
Sounds to monitor for include:
 A short and high-pitched or very dull sound over
muscle or bone. This suggests respiratory
consolidation.
 A loud, long, low-pitched and hollow sound over the
lungs or stomach that may suggest bronchitis.
 A dull, thudding sound over large organs such as the
liver. This may also be a sign of consolidation.
 A loud, low-pitched sound over the stomach that can
 indicate pneumothorax or emphysema.
the chest wall with the tip of the third  A high-pitched drum sound is heard when the chest is
finger of the other hand. The best expanded. This suggests excess air, often due to a
percussion site is between the proximal collapsed lung.
and distal interphalangeal joints. The
novice quickly learns to trim the fingernail
to prevent personal discomfort of minor
abrasions and lacerations.
 If the sound and the vibrations produced
seem suboptimal, make sure that the finger
placed directly on the thorax is making very
firm direct contact with the chest wall. If
not, few vibrations and little sound will be
produced.
 Percuss the posterior, lateral, and anterior
chest wall in such a manner that the long
axis of the percussed finger is roughly
parallel to the ribs. Compare one side to
the other.
 Over each area, begin percussion superiorly
and extend inferiorly to identify the level of
the diaphragm during quiet (tidal volume)
breathing. Note the position of the
diaphragm. Then ask the patient to inhale
fully and "hold it"; continue to percuss
inferiorly to determine the new level of the
diaphragm, now during forced maximal
inspiration. Then, don"t forget to tell the
patient to "breathe normally." The
difference between the two levels is known
as diaphragmatic excursion and should
equal 2 to 3 cm.

AUSCULTATION

AUSCULTATE FINDING

 Using the diaphragm of the stethoscope,  Listen through the entire respiratory cycle because
listen to the movement of air through the different sounds may be heard on inspiration and
airways during inspiration and expiration. expiration
Instruct the patient to take deep breaths
through their mouth
 As you move across the different lung
fields, the sounds produced by airflow vary
 depending on the area you are auscultating
because the size of the airways change.
 Correct placement of the stethoscope
during auscultation of lung sounds is
important to obtain a quality assessment.
The stethoscope should not be performed
over clothes or hair because these may
create inaccurate sounds from friction. The
best position to listen to lung sounds is with
the patient sitting upright; however, if the
patient is acutely ill or unable to sit upright,
turn them side to side in a lying position.
 Avoid listening over bones, such as the
 This side-to-side pattern allows you to compare
scapulae or clavicles or over the female
sounds in symmetrical lung fields.
breasts to ensure you are hearing adequate
sound transmission. Listen to sounds from
side to side rather than down one side and
then down the other side.

 It is important upon auscultation to have

awareness of expected breath sounds in EXPECTED BREATH SOUNDS
various anatomical locations.
Bronchial breath sounds are heard over the trachea and
larynx and are high-pitched and loud.

Broncho vesicular sounds are medium-pitched and heard

over the major bronchi.

Vesicular breath sounds are heard over the lung surfaces,

are lower-pitched, and often described as soft, rustling
sounds.

 Adventitious lung sounds are sounds heard ADVENTITIOUS LUNG SOUNDS

in addition to normal breath sounds. They
most often indicate an airway problem or
disease, such as accumulation of mucus or
fluids in the airways, obstruction,
inflammation, or infection. These sounds
include rales/crackles, rhonchi/wheezes,
stridor, and pleural rub:
Fine crackles, also called rales, are popping or crackling
sounds heard on inspiration that occur in association with
conditions that cause fluid to accumulate within the
alveolar and interstitial spaces, such as heart failure or
pneumonia. The sound is similar to that produced by
rubbing strands of hair together close to your ear.

Wheezes are whistling-type noises produced during

expiration (and sometimes inspiration) when air is forced
through airways narrowed by bronchoconstriction or
associated mucosal edema. For example, patients with
asthma commonly have wheezing.

Stridor is heard only on inspiration. It is associated with

mechanical obstruction at the level of the trachea/upper
airway.

Pleural rub may be heard on either inspiration or

expiration and sounds like the rubbing together of leather.
A pleural rub is heard when there is inflammation of the
lung pleura, resulting in friction as the surfaces rub against
each other
LIFE SPAN CONSIDERATION

CHILDREN

The respiratory rate in children less than 12 months of age can range from 30-60 breaths per minute, depending
on whether the infant is asleep or active.
Infants have irregular or periodic newborn breathing in the first few weeks of life; therefore, it is important to
count the respirations for a full minute. During this time, you may notice periods of apnea lasting up to 10
seconds. This is not abnormal unless the infant is showing other signs of distress. Signs of respiratory distress in
infants and children include nasal flaring and sternal or intercostal retractions.
Up to three months of age, infants are considered “obligate” nose-breathers, meaning their breathing is primarily
through the nose.
The anteroposterior-transverse ratio is typically 1:1 until the thoracic muscles are fully developed around six years
of age.

OLDER ADULTS

As the adult person ages, the cartilage and muscle support of the thorax becomes weakened and less flexible,
resulting in a decrease in chest expansion. Older adults may also have weakened respiratory muscles, and
breathing may become more shallow. The anteroposterior-transverse ratio may be 1:1 if there is significant
curvature of the spine (kyphosis).
 Assessment Findings
Work of breathing effortless
Regular breathing pattern
Respiratory rate within normal
range for age
Inspection Chest expansion symmetrical
Absence of cyanosis or pallor
Absence of accessory muscle use,
retractions, and/or nasal flaring
Anteroposterior: transverse
diameter ratio 1:2
No pain or tenderness with
Palpation palpation. Skin warm and dry; no
crepitus or masses
Clear, low-pitched, hollow sound in
Percussion
normal lung tissue
Bronchovesicular and vesicular
sounds heard over appropriate
Auscultation areas
Absence of adventitious lung sounds
*CRITICAL
CONDITIONS to report
immediately
Abnormal findings
Labored breathing
Irregular rhythm
Increased or decreased respiratory
rate
Accessory muscle use, pursed-lip
breathing, nasal flaring (infants),
and/or retractions
Presence of cyanosis or pallor
Asymmetrical chest expansion
Clubbing of fingernails
Pain or tenderness with palpation,
crepitus, palpable masses, or lumps
Dull sounds heard with high-density
areas, such as pneumonia or
atelectasis
Diminished lung sounds
Adventitious lung sounds, such as
fine crackles/rales, wheezing,
stridor, or pleural rub
Decreased oxygen saturation
<92%[13]
Pain
Worsening dyspnea
Decreased level of consciousness,
restlessness, anxiousness, and/or
irritability
 Documentation of Assessment Findings

Denies shortness of breath or chest pain

no use of accessory muscles

Symmetrical chest wall movement

Clear breath sounds in all lung fields

O2 saturation of 98% room air.

Related Laboratory Values and Diagnostic Findings

A spirometry test (pulmonary function test), have the patient inhale and exhale through a device to
check the lung capacity. It can be used to diagnose asthma and chronic obstructive pulmonary disease.

A chest X-ray is used to view the structure inside of the chest and is a useful test to diagnose
pneumonia. A computerized tomography (CT) scan may also be used to identify respiratory problems
that an X-ray cannot detect.  

Bronchoscopy is an invasive procedure that a fiberscope is inserted into the patient’s airway to examine
bronchi. It can be used to retrieve tissues in the airway (biopsy) to diagnose lung cancer or to treat
airway blockage or obstruction due to foreign objects.

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