We all know the key to a thorough patient assessment is to approach it systematically so that we don’t become distracted (by that bleeding scalp wound) or skip steps that may yield valuable information (like listening to breath sounds). There’s a reason we are all taught “head-to-toe” surveys: so that we work our way through essential assessment points, avoiding a haphazard exam where key signs are missed.
Assessing the respiratory system is no different. It must be approached systematically, in much the same way as a general assessment. And it begins with the patient’s general appearance.
During a respiratory assessment, some of the most critical information can be gleaned in the first few seconds. As you approach the patient, begin your assessment! When it comes to air exchange and oxygenation, deficits are usually obvious. Here are a few key points:
- Patient’s mental status – Is the patient alert or altered?
- Skin – Is the patient dry or diaphoretic?
- Breathing – Are there spontaneous respirations, and, if so, are they adequate?
- Work of breathing – Is the patient moving air efficiently or using accessory muscles?
- Chest expansion – Is it equal or diminished on one side?
- Signs of obvious injury, such as penetrating injury or contusions
- Presence of artificial airway/adjuncts, such as a tracheotomy or oxygen
What you see in those first few seconds can provide useful information for your overall respiratory assessment and can yield valuable clues to your patient’s medical history.
Once you’ve assessed your patient’s general appearance, it’s time for the physical assessment. Palpating the chest can provide vital information concerning several serious conditions:
- Temperature – Is the skin warm and dry or cool and clammy?
- Crackling – A crackling or popping beneath the skin can indicate subcutaneous emphysema and air leakage.
- Tracheal alignment – Is it midline or deviated?
- Excursion – Does the chest rise equally and symmetrically?
- Percussion – This is a useful tool, but it requires practice to perfect; normal lung fields produce resonance.
Be sure to include a detailed physical assessment as part of gauging respiratory sufficiency. Only by placing your hands on the patient can you obtain this valuable information.
The final critical component of a respiratory assessment is one that should NEVER be skipped: listening to lung sounds. Be thorough. Don’t just check both sides of the chest in a single location. Auscultate anteriorly, posteriorly, and along the midaxillary lines of each side, to ensure all lobes are functioning. If abnormal sounds are heard, be sure to note where they are located. Abnormal sounds include:
- Crackles – indicating air passing over fluid in the smaller airways
- Rhonchi – indicating air encountering secretions in the larger airways
- Wheezing – indicating air moving through narrowed airways
- Inspiratory – occurs in upper-airway obstruction
- Expiratory – occurs in asthma
Should you encounter abnormalities in your respiratory assessment, be sure to have the necessary equipment on hand to provide treatment. This includes a well-supplied airway bag, cardiac monitor, and, of course, your portable suction unit.
It is your responsibility to perform an accurate and thorough assessment of each patient. And no system is more important than the respiratory in gauging the overall stability of the patient’s condition. So, don’t skimp and don’t skip steps. Each stage of your assessment might yield lifesaving information.
2011, Pollak, A., Ed.
Critical Care Transport, American College of Emergency Physicians, Jones and Bartlett.