To gain an accurate picture of a patient’s respiratory functioning, the nurse must combine knowledge of the anatomy and physiology of the respiratory tract with data from the patient’s assessment. Every patient has a
unique combination of previous medical history, current symptoms, life-style and behavior patterns, and genetic history. The goal is to gather data from the patient’s history, physical assessment, and diagnostic testing to compile a complete picture of the patient’s respiratory functioning.

Many respiratory problems begin with similar symptoms. Clarifying the nature of these symptoms narrows the possible problems and directs the remainder of the assessment and examination. Some common presentations
of respiratory problems include cough, sputum production, nasal secretions, dyspnea (difficult breathing), wheezing, and pain. Each presentation requires further questioning to ascertain the nature of the symptom and how it affects the patient’s functioning.

The patient’s prior medical history contains important clues when assessing the respiratory system. A thorough listing of previous illnesses, surgeries, and their respective dates should be recorded. Questions should include the presence of general conditions, such as hypertension, heart disease, and diabetes. Systemic symptoms such as weight loss, night sweats, and fatigue provide valuable information.

Take the time to list all the medications the patient is taking: prescription, nonprescription, herbal remedies, and nutritional supplements. Nurses should obtain a detailed history of all medications for breathing problems including the method of administration and schedule or symptoms that initiate the use of as-needed medications. For example, if a patient with asthma uses an inhaler, it would be important to note if the medication is
used for relief of particular symptoms (as needed) or on a scheduled basis. Also note the frequency of as-needed medications and for what symptoms the patient decides to use these mediations. Nonprescription medications taken for breathing difficulties may include antihistamines, decongestants, nasal sprays, cough and allergy medications, inhalants, herbs, vitamins, and home remedies.

Specific patient responses about respiratory symptoms provide details that can direct further questioning and examination. The patient should be asked about any history of asthma, bronchitis, pneumonia, sinusitis, tuberculosis (TB), allergies, or frequent colds during the assessment. Further clarification should be obtained about allergic conditions, such as asthma, eczema, and hay fever, as well as specific allergies to dust, mold, pollen, animal dander, foods, trees, or grass. If the patient has a history of asthma, the nurse should inquire about gastroesophageal reflux disease, heartburn, and indigestion. Allergies also may be associated with asthma. Treatment for allergies, such as desensitization, should be listed with associated dates of treatment.

Any prior surgery to the upper or lower respiratory tract and the dates of surgery should be listed in the assessment. Family history of respiratory and other problems (e.g., emphysema, cystic fibrosis, lung cancer, and asthma) is important because there may be a genetic link in these conditions. The patient should be asked about recent travel and the countries that were visited, as TB is very common in Asian and Latin American countries. TB is also common among household members of an infected person, so it is important to ask about family illnesses. List the dates of the last chest radiograph, TB (Mantoux or PPD) test, vaccinations for influenza, tuberculosis, and pneumococcus, and pulmonary function tests, if appropriate.

One of the most important areas to cover in a respiratory assessment is the smoking history of the patient and his significant others. Questioning should include the use of any tobacco products, such as cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, and marijuana products. Although a patient may state that he or she does not smoke, always ask
about smoking in the past. A nonjudgmental attitude about smoking should be maintained to minimize the patient’s guilt and encourage honesty. For cigarette smokers, the number of years the patient has been smoking should be ascertained and multiplied by the number of packs per day to obtain the number of “pack-years.”

If the patient has already quit using tobacco products, the date(s) should be noted. Also, ask the patient whether anyone in the home has exposed the patient to secondhand or passive smoke. There is increasing evidence that passive smoke exposure increases the risk of asthma in children and lung cancer in nonsmoking adults. Other sources of smoke exposure include wood stoves, kerosene heaters, and fireplaces.

Reviewing the patient’s dietary history provides valuable information about their appetite, nutritional status, eating patterns, and food allergies. Measure and weigh the patient to obtain an accurate height and weight. Review his daily dietary and fluid intake. Patients with dyspnea tend to eat smaller meals because of difficulty catching their breath when eating. Chronic dyspnea may lead to inadequate food intake, increased calorie expenditure, weight loss, and nutritional deficiencies.

Food additives have been linked to allergies and asthma. Beer, wine, restaurant salads, and many processed fruits and vegetables contain sulfites as preservatives. Sulfites may produce allergic responses in sensitive individuals, such as sneezing, urticaria (hives), shortness of breath and wheezing, chest pain or tightness, and rhinitis (excessive clear mucus from nose or “runny nose”). Tartrazine, a component of the Food, Drug,
and Cosmetic Act (FD&C) Yellow No. 5, is a food additive that has been linked to allergic responses. This is a coloring agent used in many processed foods.

Ask about daily fluid intake. Adequate fluid intake (six 8-oz glasses per day) is necessary for liquefying and mobilizing secretions. The daily fluid requirements of a patient can be calculated by taking his or her weight in pounds, dividing the number in half, and changing the units of measurement to ounces. For example, a woman who weighs 150 pounds should have a daily fluid intake of 75 ounces. Caffeinated and alcoholic beverages have a mild diuretic effect and extra fluids are needed to compensate for this effect. The type, amount, and frequency of alcohol intake should be determined. Excessive alcohol intake has been associated with the increased incidence of head and neck cancers.

Occupational history requires careful questioning during the assessment. The patient’s job(s) and date(s) of employment should be listed. Exposure to industrial fumes, chemicals, and dust may damage the respiratory tract. Dust from coal, stone, silicone, and asbestos may cause toxic lung injury. The classic case of occupational dust exposure and resultant disease is coal dust and black lung disease. Other occupations that involve exposure to toxic substances are jobs in dry cleaning, beauty salons, insect control, farming, and painting. Hobbies such as furniture refinishing, model airplane building, and woodworking also may expose the patient to noxious fumes or particles.

Finally, other sources of respiratory problems include pets (e.g., birds, cats), time spent in the armed forces (e.g., Agent Orange exposure, Gulf War syndrome), and exposure to certain farm products (e.g., moldy wheat and hay).

The nose and nostrils should be inspected, keeping in mind the underlying structures. The symmetry of the bony part of the nose (upper
third) and the cartilaginous part (lower two thirds) should be noted. The patient’s head should be tilted back 15° to 30°, and the position should be stabilized by putting a hand on the patient’s forehead to prevent sudden changes of position. Using a penlight and a nasal speculum, the interior of the nose, or nasal vestibule, should be inspected while not touching the septum, as it is very sensitive. The outermost portion should be skin with fine hairs followed by mucous membranes, which are normally pink and moist. The mucosa may be reddened during infection or pale during allergic reactions. The nasal septum should be inspected for deviation or perforation. The middle and lower turbinates should be visible as well. The third turbinate will not be visible because of its anatomic location. The patency of each side of the nose should be assessed by pressing on one nares to block airflow, asking the patient to inhale through the other nares, and repeating on the other side. An alcohol wipe or essence of peppermint is used to assess whether the sense of smell is intact while the patient closes his eyes and is asked to identify the smell. This determines whether the first cranial nerve, the olfactory nerve, is intact.

Two of the four pairs of sinuses in the head, the frontal and the maxillary, are accessible for examination (see Figure 2-3). Swelling and tenderness over these sinuses is checked by palpating the area. Using the thumbs, the nurse should press firmly but gently up on the cheekbones to assess the maxillary sinuses and up on the brow bone to assess the frontal sinuses. Pain or tenderness in these areas may indicate infection (sinusitis).

Transillumination is another technique that may be used to assess the sinuses. It is an assessment technique used to evaluate the translucency of the sinuses using an outside light source. In a darkened room, a penlight is placed under the brow bone to assess the frontal sinus. A dim, red glow on the forehead indicates a normally air-filled frontal sinus. Lack of this glow may indicate a fluid or mucous-filled sinus. The same technique can be used to assess the maxillary sinuses. With the patient’s mouth opened and head tilted back, the light should be placed downward just under the inner aspect of the eye. A dim glow should be visible in the mouth on the hard palate. Although transillumination is not a definitive test, it may be
helpful in conjunction with other findings in the physical examination and history for deciding whether radiographs or computed tomography (CT scan) are needed.

The examination begins by assessing the lips for cyanosis or pallor, sores, ulcers, cracks, or nodules. Look for signs of peripheral cyanosis on the lips that may indicate poor oxygenation. Sores or ulcers may be present with a herpes infection. Cracks in the corners of the mouth (cheilitis) may indicate nutritional deficiencies. The teeth, the quality of the dental hygiene, and the presence of dentures and other dental appliances should be noted. The patient should remove the dentures, if they are present. A penlight and tongue blade should be used to check the gums for soreness or redness that may indicate poorly fitting dentures, gingivitis, or aphthous ulcers (canker sores). Check the mucous membranes of the mouth for pallor. Because the tongue may interfere with a thorough examination, a dry 4 × 4 gauze should be used to hold the tongue and gently move it side to side to examine the mouth. The mucous membranes lining the oral cavity should be moist, and their color may vary from coral pink in light-skinned people to a brownish-pink tone in darker-skinned people. Any redness, especially along the gum line, white patches (leukoplakia), ulcerations, sores, or growths should be noted.

The tongue should have pinkish papillae and be without redness or white patches. A shiny surface also is an abnormal finding on the tongue and may indicate nutritional deficiencies. With the tongue wrapped in gauze, the tongue should be moved side to side in order to examine the base of the tongue and the floor of the mouth. This is especially important for people at high risk for oral cancers, such as patients who smoke, have a history of high alcohol intake, and chew tobacco. Any redness, leukoplakia, or ulcerations should be noted.

The posterior oropharynx is visualized with a tongue blade and a penlight. While gently pressing on the middle of the tongue (not too far back, as this may cause gagging), the palate, uvula, tonsils, and posterior oropharynx should be inspected. The color and symmetry from one side to the other should be noted. Abnormal findings include swelling, exudate,
and ulceration. Enlargement of the tonsils is an abnormal finding in the adult, because tonsils should be small to nonexistent in adults. Push gently down on the tongue and have the patient say “ahhhh” or yawn to elevate the soft palate and allow visualization of the posterior oropharynx. Asymmetric elevation of the soft palate and the uvula indicates a problem with the 10th cranial nerve.

Inspect the neck for alignment, symmetry, nodules, or masses. Palpate the lymph nodes in the neck, assessing their size and mobility and whether they are tender (see Figure 2-4). Tender, enlarged lymph nodes usually indicate inflammation, whereas hard, fixed nodes may indicate malignancy. Palpate the trachea gently so as not to stimulate coughing or gagging. The thyroid cartilage (Adam’s apple) and the cricoid cartilage beneath it should be identified. The trachea should be uniform and midline, elevating smoothly during swallowing.

Anatomic landmarks on the thoracic cavity are useful for identifying organs within the thoracic cavity and for labeling abnormal findings (see Figures 2-5 through 2-8). The midsternal line is an imaginary line that runs vertically through the sternum. The midclavicular line runs vertically down the anterior chest wall beginning at the center of each clavicle. The anterior axillary line is another landmark that runs vertically along the anterior aspect of the chest at the anterior fold of the axilla. The posterior axillary line, which also starts at the axilla, extends vertically down the posterior chest. Also remember that each intercostal space is numbered by the rib just above it. Finally, the bases of the lungs are the lowest portions of the lungs. Anteriorly, the base of the lung refers to the lower portion of the lung beginning at the sixth intercostal space at the midclavicular line anteriorly, the eighth space laterally, and the 10th to 12th intercostal spaces posteriorly. The apex of the lung refers to the uppermost portion of the lung located above the clavicle anteriorly.

The chest is examined by following the same stepwise examination: inspection, palpation, percussion, and auscultation. One side of the patient should be compared with the other side to assess physical symmetry and similarity of breath sounds.

The examination begins with the posterior chest, with the patient sitting with his arms folded across his chest. As the chest is uncovered,
take care to cover the unexamined areas, particularly on female patients. If the patient has difficulty sitting up, ask for assistance or roll the patient from side to side for the examination.

Inspection of the chest begins with observing the patient’s breathing, watching for chest expansion, and the use of accessory muscles. The rate, rhythm, and regularity of the ventilations and the length of inspiration and expiration should be noted. Expiration is normally 1.5 times longer than inspiration. Prolonged expiration indicates narrowed airways or difficulty moving air out of the lungs (air trapping), as seen in emphysema. Slight retraction of the intercostal spaces is normal in thin people during quiet breathing, but any more than slight retraction indicates difficulty moving air, which may occur with chronic obstructive pulmonary disease (COPD) or an obstructed airway. Accessory muscles in the neck and shoulders normally are not used during breathing. The use of accessory muscles may indicate respiratory distress.

A normal chest has a lateral (side-to-side) diameter, which is twice as large as the anteroposterior (front-to-back) diameter. The ratio of the lateral to anteroposterior (A-P) diameter may be increased in patients with emphysema or in infants. Some common abnormalities of the chest are seen in Figure 2-9.

Palpation of the thorax provides information about respiratory excursion, tender areas or masses on the chest, and the presence of tactile fremitus. Keeping the patient warm and draped, examine the posterior chest beginning with any areas that the patient reports as problematic. Palpate the chest wall gently with the palm of the hand. Note any painful areas and their anatomic location. Gentle palpation should not normally cause any pain. Note any crepitus, crackling feelings under the skin that indicate subcutaneous pockets of air. This is an abnormal condition but may occur around chest tube insertion sites.