Christy Bowen; Bridget Carey; Jessica Palozie; Maren Reinholdt

Learning Objectives

By the end of this section, you will be able to:

Describe the components of an upper respiratory airway assessment
Describe the components of a lower respiratory airway assessment
Summarize the cues to recognize and analyze in both upper and lower airway assessment

Respiratory assessment is important for all patients, even in the absence of known respiratory problems. Initial assessment looks at the patient’s overall appearance, observing for pallor, cyanosis, or sweating. Vital signs are evaluated and help reflect the efficiency of the respiratory system by monitoring the respiratory rate and oxygen saturation. Changes in respiratory rate, capnography, and level of respiratory effort can be early signs of other systemic problems, whereas drops in oxygen saturation may be later signs of systemic problems. This section will explore the assessment of the upper and lower respiratory airway system.

Subjective assessment involves focused questions to elicit information about a patient’s current symptoms and concerns, including:

Have you ever been diagnosed with a respiratory condition, such as asthma, COPD, pneumonia, or allergies?
Are you short of breath with activity?
Does shortness of breath or difficulty breathing interfere with your ability to perform activities of daily living?
Do you use supplemental oxygen?
Do you use home respiratory equipment like CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), nebulizer devices, or a ventilator?
Are you currently taking any medications, herbs, or supplements for respiratory concerns?
Have you noticed any changes with your breathing?
Have you had any feelings of breathlessness (dyspnea)?
Do you have a cough?
Do you smoke or vape?

Upper Respiratory Airway Assessment

An upper respiratory airway assessment builds on the initial results of vital signs and level of consciousness. Determine the patient’s respiratory rate. Then, consider if the patient’s breathing pattern is regular or irregular and observe the approximate duration of inspiration compared with expiration. Note the level of effort and observe for accessory muscle usage. Before using a stethoscope, note if the patient’s breathing is audible, and identify the characteristics of any sounds that are present.

Observe the patient’s position to obtain important cues about their respiratory status. A patient may breathe easily in any position, or they may struggle more when they are not upright. Similarly, the patient’s activity level and ability to speak offers significant information. One patient may be able to walk and exert themself with no significant change in respiratory effort. Another patient may experience visible breathlessness when trying to speak and have limitations on their activity level.

Observe the patient’s nose and mouth. Assess for the presence of mucus, drainage, bleeding, and any signs of trauma. Inspection of the patient’s oral cavity looks at dental status and evaluates the gums and tongue for swelling, color, moisture level, and open areas. Assess for the presence of a cough. Important information to note includes frequency, severity, sound, and any production of sputum or blood.

Evaluate the patient’s chest for symmetry and shape. The trachea should be midline; clavicles should be symmetrical. Chest wall movement during inspiration and expiration should be equal. Compare the anterior-posterior diameter of the chest to the transverse diameter (Figure 11.9). A ratio of 1:2, where the front-to-back distance is about half of the side-to-side distance, is expected. Palpate the patient’s chest to look for injuries, swelling, masses, and pain. Palpation can also identify the presence of any sensation or sounds associated with air trapped in the tissues. Listen for any adventitious lung sounds, which are breath sounds other than a clear sound of air.

Photographs showing comparison of chest with normal anterior/posterior diameter to barrel chest.

Figure 11.9 Comparison of (a) chest with normal anterior/posterior diameter to a (b) barrel chest. Barrel chest is a common clinical finding a nurse may visually observe in a patient with a disease called chronic obstructive pulmonary disease (COPD). (credit: “Figure 8.9” by NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health/Chippewa Valley Technical College, CC BY 4.0)

Unfolding Case Study

COVID Complications: Part 1

The nurse is assessing a sixty-two-year-old man who presents to the ED and reports he has had increasing difficulty in breathing and shortness of breath the past four days. The patient is accompanied by his wife. The patient states he was exposed to COVID one week ago.

PMH	Patient is recently retired from working as a manager in a health-care facility. He has diabetes managed with oral hyperglycemic agents, CABG ten years ago with two coronary artery grafts, and developed community acquired pneumonia. He has HTN controlled with medication. The patient has received his pneumococcal, influenza, and COVID vaccine six months ago. Family History Father has a history of a heart attack, tobacco use, HTN, DM, and passed away at age sixty. Mother died of breast cancer at age fifty-eight. He has three grown children who all live out of town. One brother died of a heart attack ten years ago. Social History Patient lives at home with wife. Past history of tobacco abuse and quit four years ago. He states he has three to four drinks/week socially. Patient states he retired early due to stress at work. Current Medication Atorvastatin 40 mg once daily Losartan 100 mg twice daily, takes in the a.m. Carvedilol 50 mg twice a day Baby ASA once daily Liraglutide 10 mg daily Acetaminophen 500mg 2 tabs for temperature > 100.7 No Known Allergies
Nursing Notes	1930: Triage Assessment Patient presents with dyspnea and shortness of breath (SOB), which increases when talking, and a dry, nonproductive cough. Patient’s O₂ saturation is 90 percent on room air. Patient has elevated BP, HR, and RR. Skin is warm and dry to the touch. Patient is slightly restless and anxious and reports fatigue. He is asking if he has COVID. He does not want to be admitted to the hospital but is cooperative. He is alert and oriented to person, place, and time. Lung sounds with bilateral diminished breath sounds and scattered crackles in bilateral bases. He is restless and fidgety. He tries to sit at edge of cart, moving self frequently. Patient reports he “just retired.” He did not take his medications yet today. The provider orders his usual meds and nurse administers.
Flow Chart	1930: Triage Assessment Blood pressure: 170/92 Heart rate: 110 Respiratory rate: 30 Temperature: 101.2 Oxygen saturation: 90% room air Pain: no pain Weight: 190 lbs Height: 5 ft. 9 in 02/20/23, 00:00 Physical Examination HEENT: Pupils equal and reactive to light, mucous membranes dry, no thyroid enlargement. Lymphatic: Lymphatic nodes were not swollen or enlarged Respiratory: Increased agitation, increased vital signs, increasing effort to breathe. Lung sounds with diminished bases and mid lung field, with increasing crackles from baseline. Dry nonproductive cough. Cardiovascular: Tachycardia, repeat ABG demonstrating respiratory acidosis with lower pH, decreased PO₂, and increased PCO₂ from baseline. Abdomen: Soft, denies pain by nodding no, not distended, bowel sounds present all four quadrants Musculoskeletal: Weak, bodily fidgeting has decreased. Not following all commands to move extremities. Skin: Pale, moist Mental Assessment Increased agitation and onset of confusion.
Flow Chart	2/20/24, 0:00 Blood pressure, 182/92 Heart rate, 108 Respiratory rate, 30 Temperature, 101.1 Oxygen saturation, 90% room air Pain, denies pain 02/20/2024, 04:00 Assessment Blood pressure, 150/88 Heart rate, 100 Respiratory rate, 30 Temperature, 101.0 Oxygen saturation, 88% room air Pain, denies pain ABG: pH, 7.31 PCO₂, 55 mmHg PO₂, 60 mmHg HCO₃, 30 mEq/L 2/20/2024, 08:00 Increased agitation, increased vital signs, increasing effort to breathe. Dry nonproductive cough. Lung sounds with diminished bases and mid lung field, with increasing crackles from baseline. tachycardia, repeat ABG demonstrating respiratory acidosis with lower pH, decreased PO₂, and increased PCO₂ from baseline. Weak, bodily fidgeting has decreased. Not following all commands to move extremities. Physical Examination: HEENT: Pupils equal and reactive to light, mucous membranes dry, no thyroid enlargement. Lymphatic: Lymphatic nodes were not swollen or enlarged Respiratory: Increased agitation, increased VS, increasing effort to breathe. Lung sounds with diminished bases and mid lung field, with increasing crackles from baseline Cardiovascular: Tachycardia, repeat ABG demonstrating respiratory acidosis with lower pH, decreased PO₂, and increased PCO₂ from baseline. Abdomen: Soft, denies pain by nodding no, not distended, bowel sounds present all four quadrants Musculoskeletal: Weak, bodily fidgeting has decreased. Not following all commands to move extremities. Skin: Warm and moist
Lab Results	2/19/24, 20:00 WBC, 14.3 x10E3/u C-reactive protein, 4.0 mg/L Hgb, 14 g/dL Hct, 44% INR, 1.0 BUN, 10 mg/dL Creatinine, 0.09 mg/dL Lactic acid, 3 mmol/L Na, 146 mEq/L K+, 3.8 mEq/L Cl, 100 mEq/L Rapid PCR COVID test, positive RT-PCR COVID antigen test, pending Pulse oximetry, 90% RA ABG: pH, 7.31 PCO₂, 55 mmHg PO₂, 60 mmHg HCO₃, 30 mEq/L BS, 108 mg/dL Blood cultures ×3, pending 02/20/24, 0630 Lactic acid, 3 mmol/L Na, 139 mEq/L K+, 3.8 mEq/L Cl, 98 mEq/L WBC, 14 cells/mm³ Blood cultures ×3, pending ABG: pH, 7.31 PCO₂, 55 mmHg PO₂, 60 mmHg HCO₃, 30 mEq/L BS, 110 mg/dL
Diagnostic Tests/Imaging Results	2/19/24, 2030 CXR: unilateral base pneumonia with parapneumonia pleural effusions
Provider’s Orders	2/19/24, 2030 CXR stat ABG prior to O2 O2 at 3 LPM via NC Start IV ½ NS @ 75cc/hr EKG Blood cultures × 3 Sputum for C&S Place in contact and droplet isolation Bedrest with BRP with assist Continue meds patient is currently taking: Atorvastatin 40 mg once daily Losartan 100 mg twice daily, takes in the a.m. Carvedilol 50 mg twice a day Baby ASA once daily Admit to telemetry with continuous pulse oximetry. Albuterol nebulizer X1 administer by respiratory therapy Pulmonary Consult Infection Control Consult Acetaminophen 500 mg 2 tabs for temperature > 100.7 Repeat labs in a.m.: CBC with differential Hgb Hct Lactic acid Electrolytes Repeat CXR ABG Lipid Profile BS 02/20/24, 12:00 Transfer to ICU Critical care consult for hemodynamic compromise
	02/19/24, 20:30 Interventions Use appropriate PPI for positive covid CXR result: Pneumonia O₂ 2L nasal canula IV started left antecubital, #20 gauge of ½ NS, rate of 75 ml/hr Administered home meds as ordered: Atorvastatin 40 mg once daily Losartan 100 mg twice daily, takes in the a.m. Carvedilol 50 mg twice a day Baby ASA once daily Acetaminophen 500 mg 2 tabs for fever. Liraglutide 10 mg daily First set of blood cultures drawn Cefazolin 1.5 mg IV started per order Reassess VS: B/P, HR, RR, temperature, O₂ saturation Albuterol nebulizer X1 administer by respiratory therapy Acetaminophen 500 mg 2 tabs for temperature > 100.7

1.

After assessing the patient, the nurse determines the patient’s presentation is due to [Option 1] resulting in a new symptom of [Option 2]. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

Option 1	Option 2
Panic attack	Increased SOB and fever
Medication side effects	Irritability
Asthma	Cough
Respiratory infection	Wheezing
Depression	Respiratory rate 30

2.

Once the nurse has reviewed the relevant patient information, which assessment finding(s) are most consistent with the associated disease process?

Assessment Finding	Respiratory Infection	COPD	Pneumothorax
Pain in chest and intense chest pain that is worse with movement
Temperature: 101.2
Tracheal deviation
Subcutaneous emphysema
Barrel-shaped chest

Lower Respiratory Airway Assessment

A lower respiratory airway assessment focuses on auscultation of lung sounds during inspiration and expiration. Ideally, lung auscultation is performed with the patient in the upright position. If an injury or serious illness prevents the patient from sitting up, turn them to the side. Using the diaphragm of the stethoscope, systematically move the stethoscope side to side across all lung fields (Figure 11.10); this allows the nurse to compare lung sounds at the same level on both sides.

Photographs showing respiratory auscultation pattern anterior and respiratory ascultation pattern posterior.

Figure 11.10 Anterior and posterior auscultation areas of the lungs should be auscultated following a systematic pattern. (modifications of credit: “Figure 10.5 Anterior Auscultation Areas” and “Figure 10.6 Posterior Auscultation Areas” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)

Normal lung sounds vary based on the part of the lung field being auscultated:

The bronchial breath sounds are high-pitched, loud sounds heard over the trachea and larynx.
The bronchovesicular breath sounds are medium-pitched and heard over the major bronchi.
The vesicular breath sounds are lower-pitched sounds heard over the lung surfaces; they are often described as soft, rustling sounds.

Adventitious lung sounds can indicate airway diseases and problems. The presence of mucus or fluids changes the way air flows through the passageways, resulting in abnormal lung sounds. Obstruction, inflammation, and infection can also cause adventitious lung sounds. Examples include the following:

Popping or crackling sounds heard on inspiration as collapsed airways reopen are called fine crackles or rales. This occurs with conditions such as heart failure or pneumonia, when fluid accumulates within the alveoli and other lung spaces or when airways collapse. Crackles may be fine or coarse. Fine crackles are soft and higher pitched. Coarse crackles are loud and lower pitched.
Whistling-type noises produced during expiration (and sometimes inspiration) are called wheezes. Wheezes occur when air travels through airways narrowed by constriction or swelling.
Coarse, loud sounds that occur due to constriction in the larger airways due to mucus or fluid are called rhonchi.
Heard only on inspiration, stridor is harsh, high-pitched, and is often loud enough to hear without a stethoscope. Stridor occurs when the upper airway is narrowed, and airflow is obstructed. Stridor is a potentially life-threatening emergency.
Caused by inflamed lung surfaces rubbing against each other, rub has a grating sound.

Link to Learning

This video gives examples of abnormal breath sounds such as crackles, rales, wheezes, rhonchi, and others.

Cues to Recognize and Analyze for Upper and Lower Airway Assessment

A thorough respiratory assessment provides important information that may indicate the patient requires immediate intervention. Even with normal vital signs, respiratory problems can be present. Before using a stethoscope or obtaining vital signs, the nurse first observes for potential signs of distress. Respiratory compromise can present as changes in level of consciousness. Both hypoxemia (low blood levels of oxygen) and hypercapnia can cause a decreased level of consciousness, irritability, anxiousness, restlessness, or confusion.

Subtle changes in the rate of breathing can be a sign of deteriorating condition; accurate assessment of respiratory rate is necessary. Normal breathing is regular and has a rate of twelve to twenty breaths per minute and regular. By contrast, bradypnea is less than twelve breaths per minute, and tachypnea is greater than twenty breaths per minute. Oxygen saturation is also assessed; the normal range is 94 to 100 percent (SpO2). Increased heart rate and blood pressure can also occur when someone is struggling to breathe.

Clinical Safety and Procedures (QSEN)

Safety: The Challenges of Pulse Oximetry Monitoring

Measuring oxygen saturation, or pulse oximetry, is commonly used as a part of a routine assessment. These devices can provide helpful, noninvasive information about blood oxygen saturation. Recent research shows, however, that pulse oximeters can be less accurate in patients with darker skin pigmentation, or even colored fingernail polish, which may overestimate their oxygen saturation when their actual oxygen levels may be less than 80 percent. This inaccuracy can mask hypoxemia and result in lower oxygen supplementation and poor patient outcomes. It is also challenging to measure oxygen saturation of patients with poor perfusion or fluid volume deficit. Because an accurate representation of oxygenation is difficult to obtain, awareness of how this measurement bias can contribute to race-based disparities in care is essential. Ongoing study is needed, especially in the context of models that use data from electronic health records and artificial intelligence to identify and predict outcomes. Patients, clinicians, and manufacturers are all affected parties.

(Feldman & Lane-Fall, 2021

End-tidal carbon dioxide (EtCO₂) monitoring, or capnography, is a noninvasive way to measure exhaled carbon dioxide and provide information about ventilation. Capnography can alert clinicians to abnormally elevated or decreased carbon dioxide levels that may require intervention. Capnography can detect respiratory depression earlier than pulse oximetry. Commonly used during anesthesia and in settings requiring intubation, it is now gaining favor in other settings. In spontaneously breathing patients, capnography can be helpful in circumstances including:

assessing for hypoventilation in patients who are unconscious, unresponsive, or receiving sedation
assessing seizing or critically ill patients
identifying treatment response during acute respiratory distress
identifying the efficacy of CPR and the possible return of spontaneous circulation during cardiac resuscitation (Krauss et al., 2022).

During physical assessment with inspection, the nurse notes changes in appearance that can indicate respiratory distress, such as pallor and cyanosis. The patient’s position and posture can offer information about respiratory status. Many patients who are struggling to breathe will be unable to tolerate lying flat. They will naturally move their body into a tripod position, an upright position with hands braced on knees or a table (Figure 11.11). This position maximizes the space available for the lungs to expand.

Man sitting on stool, bent over slightly with hands on thighs.

Figure 11.11 The tripod position eases the work of breathing by optimizing the space available in the thoracic cavity for lung expansion. (credit: “Figure 13.18 Tripod Position” by Nic Ashman/Chippewa Valley Technical College, CC BY 4.0)

The nurse should closely observe the patient’s breathing pattern, including the rhythm, effort, and use of accessory muscles. Normal breathing is subtle and can be almost imperceptible. Audible breathing, nasal flaring, and pursed lip breathing are signs of respiratory difficulty; pursed lip breathing increases the amount of carbon dioxide exhaled so that more oxygen can be inhaled. Stridor indicates a narrowed or obstructed upper airway and requires urgent evaluation. Abnormal breathing may be labored, irregular, or unusually shallow or deep. Normally, inspiration is about half as long as expiration; when expiration is prolonged, it can be reflective of lung problems, such as emphysema. Anatomical structures should be symmetrical; if the trachea is not midline, it can be a sign of decreased lung volume (i.e., from a tumor) or fluid accumulation.

A patient with labored breathing may experience shortness of breath with exertion. In patients with serious lung problems, speaking can be difficult due to shortness of breath. The patient may only be able to speak in short sentences, phrases, or single words. In severe cases of respiratory distress, patients may be unable to speak (Reyes et al., 2022). Other indicators of labored breathing can include diaphoresis and accessory muscle usage. Accessory muscles are found in the upper back, neck, abdomen, and between the ribs.

Real RN Stories

Nurse: Emily, RN
Years in Practice: One
Clinical Setting: Inpatient medical unit
Geographic Location: Rural Northwest Community Hospital

As a newly licensed RN, Emily was working on an inpatient medical unit. One of Emily’s patients was an older person who had been admitted with pneumonia. The doctors did not yet know what type of pneumonia the patient had and were doing more diagnostic studies.

At the start of her shift, Emily entered the patient’s room to do a set of vital signs. The patient was alert and able to answer her questions, the patient’s temperature was normal, and the patient’s blood pressure was a little bit high.

She put the pulse oximeter on the patient’s finger and waited. At first, it had no reading! Then, it displayed a reading of 73 percent, but that went away, and the machine read no result. Emily asked the charge nurse to come into the room to help her troubleshoot the equipment.

As the charge nurse entered the room, together they immediately looked at the patient. The charge nurse asked Emily, “Has the patient been breathing like this the whole time?” The charge nurse—who had years of experience—was able to immediately identify labored breathing. Now that Emily looked more closely at the patient and timed the respirations, she realized that the respiratory rate was about thirty breaths per minute, the patient appeared pale and stressed, and intercostal muscle usage was present. The charge nurse immediately placed a non-rebreather mask on the patient and called the medical team. The patient needed to be transferred to the intensive care unit for closer monitoring and to receive more oxygen therapy.

Palpation of the chest can evaluate potential areas of injury or complications related to a procedure. A popping or crackling sensation when the skin is palpated, crepitus is a sign of air trapped under the subcutaneous tissues. This can occur when air trapped in the pleural space moves into the subcutaneous tissue and becomes trapped there. Inspect the fingers for clubbing, a bulbous enlargement of the tips of the fingers due to chronic hypoxia. It often occurs in chronic respiratory diseases, such as COPD, as well as other conditions that cause chronic low oxygen levels or malabsorption (Figure 11.12).

Hand showing clubbing in tips of fingers.

Figure 11.12 Clubbing is a bulbous enlargement of the tips of the fingers due to chronic hypoxia. (modification of “Showing bilateral grade III clubbing with cyanosis of the extremities” by Twayana et al./BMC Research Notes, CC BY 4.0)

Auscultation identifies adventitious lung sounds, including crackles and wheezes. The nurse analyzes the presence of adventitious lung sounds as well as how they may have changed. Adventitious lung sounds can occur in different lung fields and can also change in volume.

11.2 Upper and Lower Respiratory Assessment