Introduction and Health History
Assessing a client with a respiratory disorder begins with a thorough health history. Nurses must explore current symptoms, past medical history, and environmental exposures. Pay close attention to the chief complaint, noting the exact onset, duration, and severity of breathing difficulties or cough.
- Dyspnea: Subjective feeling of shortness of breath, often graded by how it affects daily activities.
- Cough: Determine if it is dry and hacking or productive of sputum. Note the color, consistency, and amount of any phlegm.
- Chest Pain: Differentiate cardiac pain from pleuritic pain, which worsens with deep breathing and coughing.
- Smoking History: Calculate pack-years by multiplying the number of packs smoked per day by the number of years smoked.
- Occupational Exposures: Inquire about dust, fumes, or chemical inhalations common in local industries or farming.
Physical Examination Techniques
The physical examination follows a strict sequence: inspection, palpation, percussion, and auscultation.
- Inspection: Observe the client's breathing rate, depth, and rhythm. Look for use of accessory muscles in the neck and shoulders, nasal flaring, and skin color changes like cyanosis. Note the shape of the chest; an increased anteroposterior diameter suggests barrel chest seen in emphysema.
- Palpation: Feel for areas of tenderness, structural abnormalities, and tactile fremitus. Tactile fremitus involves placing hands on the chest wall while the client speaks to feel vibrations.
- Percussion: Tap the chest wall to produce sounds that indicate whether underlying tissue is air-filled, fluid-filled, or solid. Resonance is normal over lung tissue, whereas dullness indicates fluid or consolidation.
- Auscultation: Listen to breath sounds using a stethoscope. Normal sounds include vesicular, bronchovesicular, and bronchial sounds. Abnormal sounds, or adventitious sounds, include crackles, wheezes, rhonchi, and pleural friction rubs.
Auscultation and Breath Sounds
Listening to the lungs requires a quiet environment and a systematic approach, moving from the apices to the bases, comparing side to side.
| Sound Type | Description | Common Clinical Cause |
|---|
| Crackles | Short, popping, discontinuous sounds | Fluid in alveoli, pulmonary edema, pneumonia |
| Wheezes | High-pitched, continuous musical sounds | Narrowed airways, asthma, bronchitis |
| Rhonchi | Low-pitched, snoring, rattling sounds | Secretions in large airways, chronic bronchitis |
| Pleural Friction Rub | Grating, harsh, leather-like sound | Inflamed pleural surfaces rubbing together |
Misconception alert: Nurses sometimes mistake muscle tremors or room noise for abnormal lung sounds. Always place the stethoscope directly on the skin, never over clothing.
Diagnostic Tests and Procedures
Laboratory and diagnostic tests confirm clinical findings and guide medical management.
- Pulse Oximetry: Non-invasive measurement of arterial blood oxygen saturation using a sensor on the finger or earlobe.
- Sputum Culture: Identifies specific microorganisms causing an infection. A sterile container is required, and the sample must come from deep in the lungs, not just saliva.
- Chest X-ray: Visualizes lung structures, heart size, and fluid accumulation. Clients must remove metal objects and take a deep breath.
- Arterial Blood Gases (ABGs): Measures acid-base balance, oxygenation, and ventilation status through a direct arterial puncture, usually at the radial artery.
- Pulmonary Function Tests (PFTs): Measures lung volumes and capacities to diagnose restrictive or obstructive lung diseases.
Psychosocial Impact and Documentation
Respiratory distress provokes severe anxiety, fear, and panic because it directly threatens survival. Clients struggling to breathe often experience a sense of impending doom. Nurses must monitor psychological responses, ensure a calm environment, and stay with distressed clients.
Accurate documentation requires objective descriptions of respiratory rate, depth, effort, breath sounds, and oxygen saturation levels. Vague phrases like 'lungs clear' without noting the specific lobes auscultated, or 'breathing fine' instead of documenting exact rates and effort, compromise continuity of care. Always record the client's position during assessment, as a client requiring an upright posture to breathe indicates orthopnea.