Med-Surg · chapter 11 · Gas Exchange, Airway Management, and Respiratory System Disorders
Upper and Lower Respiratory Assessment
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 3 practice questions with the reasoning.
Key points
Early systemic warning signs
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.
Breathing pattern and effort
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.
Position and respiratory status
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.
Activity and speaking cues
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.
Chest symmetry assessment
Evaluate the patient’s chest for symmetry and shape. The trachea should be midline; clavicles should be symmetrical.
Lower airway auscultation
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.
Bilateral lung sound comparison
Using the diaphragm of the stethoscope, systematically move the stethoscope side to side across all lung fields; this allows the nurse to compare lung sounds at the same level on both sides.
Causes of abnormal sounds
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.
Need for immediate intervention
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.
Consciousness changes
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.
Respiratory rate ranges
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 range
Oxygen saturation is also assessed; the normal range is 94 to 100 percent (SpO2).
Pulse oximetry limitations
Recent research shows, however, that pulse oximeter s 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.
Capnography monitoring
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.
Terms to know
- adventitious lung sounds
- Listen for any adventitious lung sounds, which are breath sounds other than a clear sound of air.
- fine crackles or rales
- Popping or crackling sounds heard on inspiration as collapsed airways reopen are called fine crackles or rales.
- wheezes
- Whistling-type noises produced during expiration (and sometimes inspiration) are called wheezes.
- rhonchi
- Coarse, loud sounds that occur due to constriction in the larger airways due to mucus or fluid are called rhonchi.
- stridor
- Heard only on inspiration, stridor is harsh, high-pitched, and is often loud enough to hear without a stethoscope.
- pulse oximetry
- Measuring oxygen saturation, or pulse oximetry, is commonly used as a part of a routine assessment.
- capnography
- End-tidal carbon dioxide (EtCO 2) monitoring, or capnography, is a noninvasive way to measure exhaled carbon dioxide and provide information about ventilation.
- clubbing
- Inspect the fingers for clubbing, a bulbous enlargement of the tips of the fingers due to chronic hypoxia.
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
At 1930, a patient is alert and oriented, with a respiratory rate of 30 and oxygen saturation of 90% on room air. At midnight, those measurements are unchanged, but breathing effort has increased and confusion has developed. Which entry best summarizes the respiratory trend?
- Respiratory status unchanged, with no change in respiratory rate or oxygen saturation.
- Respiratory trend cannot be determined until a decrease in oxygen saturation is recorded.
- Respiratory status unchanged; new confusion documented separately as a behavioral finding.
- Respiratory findings worsening, with increased breathing effort and new confusion despite unchanged oxygen saturation.
Answer: Respiratory findings worsening, with increased breathing effort and new confusion despite unchanged oxygen saturation.
Increased breathing effort can signal deterioration, and changes in consciousness can accompany respiratory compromise. The other entries either mistake unchanged measurements for stability, separate a relevant mental-status change from respiratory assessment, or incorrectly require oxygen saturation to fall before recognizing worsening.
At 1930 triage, a nurse drafts the entry "Cough present." Before completing the assessment, which details should the nurse assess and document to characterize the cough itself, rather than the broader respiratory history? Select all that apply.
- Whether the patient uses home respiratory equipment.
- How frequently the patient coughs.
- How severe the cough is and what it sounds like.
- Whether the cough produces sputum or blood.
- Which medications the patient takes for respiratory concerns.
Answer: How frequently the patient coughs., How severe the cough is and what it sounds like., Whether the cough produces sputum or blood.
Frequency, severity, sound, and production of sputum or blood characterize the cough and make the entry more informative. Home respiratory equipment and respiratory medications belong in the broader subjective assessment, but they do not describe the cough itself.
At 0800, the nurse is reassessing diminished breath sounds and increasing crackles. Which assessment-and-documentation plan best supports comparing findings between the right and left lung fields?
- Use the stethoscope diaphragm to move systematically side to side across all lung fields, documenting comparisons at matching levels.
- Auscultate the entire right side and then the entire left side, documenting one overall description for each side.
- Auscultate over the trachea, then document whether the sounds in each lung field match that reference sound.
- Auscultate both lung bases, then use those findings to document an overall description of sounds throughout the lungs.
Answer: Use the stethoscope diaphragm to move systematically side to side across all lung fields, documenting comparisons at matching levels.
Systematic side-to-side auscultation allows direct comparison of lung sounds at the same level on both sides. Tracheal sounds are not the expected reference for every lung field, and listening only at the bases leaves other fields unassessed. One overall description per side provides less detail for matching-level comparisons.
Where every quote comes from
Section 11.2 Upper and Lower Respiratory Assessment of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.
The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.