Respiratory Assessment

Action Advice/Diagram/Findings
1 Introduce yourself to the patient and gain consent for examination, wash/sanitize hands.
Assist the patient to lay of the couch (or may sit on the
The patient can lie at either 45o or upright, whichever is
2 edge) and remove all top garments (remember
more comfortable.
dignity).
Is the patient alert, comfortable/distressed, in pain, colour,
breathless or laboured breathing, needing to sit upright, any
General observation of the patient from end of the obvious respiratory noises, accessory muscle use.
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bed.
Medication, inhalers, nebulizer, oxygen, cigarettes in
immediate surroundings.
Clubbing may indicate chronic lung disease, pulmonary
fibrosis, CA lung.
Inspect both hands and fingernails for clubbing, tar
Tremor is a coarse, jerky movement of the wrist, which may
4 staining (smoker), tremor, peripheral cyanosis and
be a sign of carbon dioxide retention due to respiratory
perfusion (CRT).
failure. It may indicate the
severity of the patient’s condition but should be considered
alongside other signs.
Chest infections, asthma exacerbations, hypoxia may cause
tachycardia. A ‘bounding’ pulse may be a sign of carbon
dioxide retention.
Palpate the radial pulse for rate and rhythm, count
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respiratory rate. Normal respiratory rate can vary from 14 to 25 per minute
but this depends on the patient and the condition.
Tachypnoea can generally be suspected at >25 breaths per
minute.
Abnormal facial swelling can be attributed to blockage of the
superior vena cava due to tumour invasion or thrombosis or
could be due to angioedema.

Horner’s syndrome is caused by nerve damage and is

haracterized by a small pupil and drooping of the eyelid.
Inspect face for swelling/angioedema, eyes for This can be caused by tumour growth, stroke or skull
Horner’s syndrome, underneath tongue for cyanosis, fracture.
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oral candida, inside of lower eyelids for conjunctival
pallor, note any nasal discharge (type/colour).
Cyanosis may be sudden in patients with acute problems
such as chest infection or chronic with severe respiratory or
cardiac disease.

Oral candida may indicate immunodeficiency, Conjunctival

pallor may indicate anaemia.
Turn patient head slightly to the left, look for double
pulsation on left side of the neck.
Inspect right internal jugular vein for jugular venous
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pressure.
Estimate the height above the sternal angle in cm (usually
<3-4cm). Raised = HF, fluid overload.
Look for breathing pattern, accessory muscle use, leaning
forward to ease breathing, Cheyne-Stokes breathing, fast,
Inspect the chest, inspecting the breathing pattern,
8 deep breathing. Look for abnormalities of the chest shape,
the chest shape and movement, scars, deformities.
e.g., Barrel chest (COPD), pectus carinatum/excavatum,
scoliosis/kyphosis (restrict chest movement). .

The trachea lies in the mid-line between the suprasternal

notch and the cricoid cartilage. Displacement of the trachea
9 Palpate the trachea.
is an important sign as it may indicate upper lobe fibrosis or
lung collapse/tension pneumothorax.
 Compare expansion – equal rise/fall – do your thumbs move
equally as the patient takes deep breaths?

Palpate for chest expansion anteriorly and

10 posteriorly, comparing both sides. Palpate for
subcutaneous emphysema, tenderness, crepitus.

Percuss the front and back of the chest and axillae, Listen for dull, resonant and
comparing both sides. tympanic sounds over each area
percussed. Dull may = consolidation,
hyper resonant may = hyperinflation.
Percussion may be difficult in women
11 because breast tissue is in the way.

Assess tactile fremitus at the front and back of the
chest and in the axillae, comparing both sides.
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Get the patient to say ‘99’ – whilst they are speaking,
concentrate on the vibration transmitted to your hand. The
vibration should be the same on both sides. Check left and
right clavicle, chest wall and axillae. Vibration is increased
over areas of consolidation (e.g., due to pneumonia).

Decreased vibration indicates pleural effusion or build up of

air inhibiting lung expansion or due to chronic disease e.g.
COPD.
Auscultation over 3rd IC space Left sternal margin. To get a
good overview of heart sounds assessing for any
13 Auscultate ‘Erbs’ Point.
abnormalities e.g. murmurs would require a more in depth
CVS exam.
Auscultate over the front of the chest and in the Use the diaphragm of the stethoscope (the bell is useful if
axillae, comparing the two sides. the patient has a hairy chest).

Ask the patient to breathe in and out briskly if they can and
listen to the sounds generated. Listen for abnormal breath
sounds and adventitial sounds for example:

Crackles – air bubbling through secretions in major bronchi.

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In pulmonary oedema occur mid inspiration. Fine late
crackles suggest pulmonary fibrosis.
Wheeze – imply airway narrowing e.g., in asthma/COPD,
usually louder on expiration. Low pitched – larger airways,
high pitcher – smaller airways
Pleural Rub – creaking sound (like treading on fresh snow),
produced when inflamed parietal and visceral pleural move
over each other can be associated with pleuritic chest pain.
Listen in same areas again – ask the patient to say ‘99’. You
should normally hear muffled sound, it may be more
resonant/increased if there is consolidation or reduced if
Assess vocal fremitus and whispering pectoriloquy at there is pneumothorax or effusion. Both sides should be the
15 the front and back of the chest and in the axillae, same in the normal patient.
comparing the two sides.
Whispering pectoriloquy is assessed by asking the patient to
whisper ‘99’ – you should not hear the words or they should
be muffled. In consolidation, a whisper is heard well.
Inspect/palpate for evidence of peripheral oedema Evidence of pitting oedema – can be suggestive of fluid
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and sacral oedema (if bed bound). retention/heart failure.
17 Complete full set of vital signs and include 12 lead ECG.
 ENT Assessment

Action Advice/Diagram/Findings

1 Examine the face and neck for enlarged lymph nodes.

Palpate using fingertips - symmetrically.

Tender/warm, raised in association with current illness =
infection. Non-tender, stuck down, prolonged appearance = ?
malignant.
Examine external ears looking for redness, swelling, ear
protruding compared to opposite side, discharge (purulent
suggests Ottitis Media, serous suggests Otitits Externa),
behind ears for redness, abscess, tender mastoid
Examine the external ears and oropharynx – ask
2 (mastoiditis).
about ear pain or sore throat.
Oropharynx - redness
Tonsils - swollen/inflamed tonsils, exudate
Uvular - deviation/signs of peritonsillar abscess (quinsy)

3 Wash hands and present/document findings.