What subjective assessment data is relevant to the respiratory system?

Checklist 17: Chest / Respiratory Assessment

Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.

Safety considerations:

• Perform hand hygiene.
• Introduce yourself to patient.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain process to patient.
• Be organized and systematic in your assessment.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure patient’s privacy and dignity.
• Document according to agency guidelines.

Objective Data

The data that we can observe with our senses.

Steps

Additional Information

The patient may appear distressed and/or feel anxious. Likewise they may not appear distressed, depending on the severity and other comorbidities. Ability to speak may be affected.

Increased work of breathing may indicate respiratory compromise and impaired oxygenation caused by things like acute airway obstruction, pulmonary edema,  atelectasis, and others.

Unusual findings should be followed up with a focused respiratory assessment.

More resources:

• Khan Academy. (2012). Respiratory distress. Retrieved from https://www.youtube.com/watch?v=vO63j9m5grE.
• Some agencies use the following for objectively assessing respiratory distress and work of breathing (see page 22):
  • The Canadian triage & acuity scale. (2013). CTAS • ÉTG. Retrieved from http://ctas-phctas.ca/wp-content/uploads/2018/05/participant_
    manual_v2.5b_november_2013_0.pdf.

Chest expansion may be asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, pneumothorax, or hemothorax.

Likewise, placing your hand on the patient’s chest and counting the rise / fall cycles

• Newborn: 30–60
• Infant (6 months): 30–50 
• Toddler (2 years): 25–32
• Children (3–12 years): 20–30
• Adolescents (13–18 years): 12-20
• Adults: 12–20

If a patient’s respiratory status is stable, it may be appropriate to count respirations for 30 seconds and multiply by two to determine respiratory rate.

See Chapter 5.3 Pulse oximetry.

The presence of crackles or wheezing must be further assessed, documented, and reported. If such things are affecting the patient negatively, intervention is needed.

Crackles may indicated mucous related to asthma or chronic obstructive pulmonary disease (COPD), or fluid related to pulmonary edema.

Wheezing may indicate bronchoconstriction related to asthma, bronchitis, or emphysema.

Friction rub (creaking) may indicate inflammation related to pleurisy.

The nurse should always consider what interventions they can implement independently and what interventions have been ordered by the authorized prescriber to relieve impaired oxygenation.

More resources:

• Cable, C. (1997). The auscultation assistant. Retrieved from https://www.med.ucla.edu/wilkes/intro.html.

Reasons for coughing might include bacterial or viral infection, aspiration, or presence of sputum. Observe and ask if the cough is a concern for the patient.

If sputum is present, observe or inquire about amount, colour, and consistency. Ask if sputum is normal for the patient.

Subjective Data

• If you don’t already know, ask about respiratory diseases (COPD, asthma, cystic fibrosis). Presence of these may provide insight into explaining other respiratory assessment findings.
• Ask about use of respiratory medications. People with chronic respiratory disease often use one or more inhaled medications.
• Ask about breathing. Does the person experience trouble with breathing or shortness of breath?
• Do they have a cough?
• Is sputum present? If so what is the amount, colour, and consistency? Is this normal?
• Do they smoke? If so, what and how much?
• Ask about environmental exposures that may affect breathing. Some environmental allergies (airborne nut allergy, perfumes, cleaners) trigger respiratory difficulty.

Focused respiratory assessment may also include:

• Impaired oxygenation as evidenced by increased respiratory rate and use of accessory muscles to breathe.
• Risk of respiratory infection related to mucous production  associated with COPD.
• Readiness to stop smoking.