Upon completion of this chapter, the nurse will:
1. Outline the areas to include when assessing the respiratory system
2. Identify appropriate questions to assess the respiratory system
3. Analyze approaches to gather more information about the respiratory system
THE RESPIRATORY SYSTEM
As a review, the respiratory system is divided into the upper and lower tracts. The parts of the upper respiratory tract include:
Part of the trachea
The major purpose of the upper respiratory tract is to moisten and warm inspired air. The sinuses:
Decrease the weight of the skull bones
Add resonance to the voice
Protect delicate facial structures
Produce mucus as part of the immune system
The pharynx is a part of both the respiratory and gastrointestinal systems. For the respiratory system, the pharynx:
The main functions of the larynx are:
The trachea serves as a connection between the upper and lower respiratory tracts.
The lower respiratory tract consists of the connections from the trachea, the bronchi, and the lungs.
Because the respiratory system includes two sets of structures, the assessment should be divided into two parts. This assessment can be challenging. You will not be able to visualize:
Nasal drainage, color, and consistency
Edematous sinus areas
Chest drainage, color, and consistency
Nurses traditionally use a stethoscope to listen for lung sounds. You will not be able to do this when providing telephonic care. What will be audible is the presence of a cough and the “noisiness” of breath sounds. The receiver on the telephone will serve as your “virtual” stethoscope. As with all major body system assessments, determine first if the patient is experiencing any particular respiratory problem. If so, focus on that area first. If not, complete a general assessment of this system.
QUESTIONS TO ASSESS THE RESPIRATORY SYSTEM
Have you noticed or experienced any changes in your breathing?
If so, please describe the changes.
How many pillows do you need or use to sleep and breathe comfortably?
Has there been a change in the number of pillows you use?
Have you ever been diagnosed with a respiratory problem?
If so, what is the problem?
Do you breathe through your nose?
Have you experienced any nasal stuffiness or congestion?
Are you experiencing any nasal drainage?
If so, what is the color of the drainage?
Is there any particular pattern to your sneezing?
Do you breathe through your mouth?
If so, what is the primary reason for mouth-breathing?
Have you noticed any changes in your ability to swallow?
Have you noticed any changes in your voice quality?
If so, describe the changes.
Have you been experiencing a cough? (You will also be able to hear if the patient is coughing.)
If so, how long have you had the cough?
What causes the cough to occur?
What make the cough better?
Are you coughing up any phlegm?
Describe the color of the phlegm.
What does the cough sound like?
Does the cough cause you any pain?
If so, describe the pain: quality, location, intensity, and precipitating factors.
Do you ever wake up from sleep coughing?
If so, what do you do you to stop coughing?
Do you have or have been diagnosed with allergies?
To what are you allergic?
Have you been prescribed medication to treat the allergies?
How frequent do you experience respiratory effects from the allergies?
Are you exposed to items in your work or home environment that affect your breathing or cause you to cough?
Do you smoke?
How much do you smoke? (Packs per day)
When did you start smoking? (Pack years)
Have you attempted smoking cessation?
If so, when was the last time you stopped smoking?
Do you use any other inhalants such as marijuana, vaping, glue, or spray paint?
If so, how frequently do you use these inhalants?
Do you receive an annual influenza vaccination?
Have you ever received a vaccination for pneumonia? (appropriate for clients over the age of 65)
Have you noticed if your shirts or blouses are more snug across your chest?
Have you noticed any changes in your fingernails?
Are the tips of your fingers becoming thicker?
Are the nails growing over the tips of the fingers?
What is the color of your nail beds? Pink, pale, white-pale blue?
ASSESSING THE RESPIRATORY SYSTEM BY LISTENING
A great deal of information about the client’s respiratory system can be collected by listening to the client talk/respond to questions. Assess for:
Shortness of breath
Can the client complete a sentence without having to stop and take a breath?
Ask the client to walk to another part of the room. Listen to their ability to breath and talk while walking.
After walking, ask if the client if he or she feels short of breath. You will be able to hear or determine this by the client’s ability to talk, walk, or breathe.
Does the client feel the need to sit down after walking a short distance?
Does the client’s voice sound clear?
Does the client sound “congested” or the voice has a “nasal” quality?
Is the client “clearing the throat” while talking?
Ask the client to take a deep breath in through the nose and exhale through the mouth.
Are there any audible lung sounds?
Does the action of taking a deep breath in and out cause the client to cough?
ADDITIONAL ASSESSMENT QUESTIONS
Depending on the responses from the general assessment, you may want to collect additional data to determine if the client is experiencing a specific health problem. Questions to help with this data collection include the following:
New onset shortness of breath
Do you feel like you can’t catch your breath?
Has this ever happened before?
What did you do to help it in the past?
If this is new, suggest the client seek immediate medical attention.
Have you ever had a nosebleed?
What did you do to control the bleeding?
Are you experiencing that now?
If so, instruct to pinch the bridge of the nose and lean the head back against the back of a chair.
If the bleeding does not stop or slow down, suggest the client seek immediate medical attention.
What color is your phlegm?
Have you coughed up this color of phlegm before?
Is there blood in your phlegm?
If the client says the phlegm is dark in color or red, suggest that medical attention be sought immediately.
How long has your voice sounded hoarse or raspy?
Has this ever happened to you before?
What did you do to make the sound of your voice better?
Are you experiencing any other symptoms like upper chest pain or swelling of the neck, face, or arms?
If pain or edema of the neck, face, or arms is present, suggest the client seek immediate medical attention.
ALGORITHM FOR ASSESSING THE RESPIRATORY SYSTEM
Assess for other symptoms to include fever, cough, headache/sinus pressure
Assess for self-treatment actions
Suspect: allergies or a common cold
Encourage to increase fluids
Encourage to seek medical attention if symptoms persist
Assess for length of time cough has been occurring
Assess for characteristics of sputum/phlegm production
Assess for actions to self-treat the cough and effectiveness of actions
Suspect: smoking history; chest cold/bronchitis; other lung infection
Encourage to increase fluids
Encourage to seek medical attention if cough persists
Shortness of breath
Assess for precipitating factors: activity, at rest, eating, while asleep
Assess for length of time shortness of breath has been occurring
Assess for actions taken to reduce episodes of shortness of breath
Assess for associated symptoms such as nasal stuffiness or cough
Assess if currently smoking cigarettes, exposed to cigarette smoking or other environmental irritants
Suspect: chronic lung disease/infection; pneumonia; chronic heart condition
Encourage to seek medical attention for ongoing shortness of breath
How long has this been going on?
Are you having any chest pain?
Describe the color:
Streaks of blood
What other health problems do you have?
What medications are you taking? (assess for anticoagulants, aspirin)
Suspect: infectious process (such as tuberculosis) or cancer pathology
Encourage to seek medical attention for the bloody sputum
See Chapter 13 for additional information about respiratory system disorders.
1. While conducting a wellness call the participant begins to cough.
a. What characteristics of the cough should you document?
b. What should you ask the participant about the cough?
2. Several times during a conversation the client stops talking and blows the nose.
a. What questions should you ask about the nasal drainage?
3. During the course of a conversation about another health problem, the client asks “what does it mean when there’s blood in my spit?”
a. What questions would be a priority for you to ask?
b. What should you encourage the patient to do?
4. While completing demographic information during the first call, the client needs to walk to another part of the room to locate the insurance card. You notice that, while he goes to the other part of the room, the client begins to pant/breathe faster and is unable to verbally complete a sentence while walking.
a. What should you focus on during the next few questions?
b. What health problems should you suspect this client might be experiencing?