RN.com’s Assessment Series:
Focused Pulmonary
Assessment
Presented by:
12400 High Bluff Drive
San Diego, CA 92130
This course has been awarded one (1.0) contact hour.
This course expires on September 15, 2008.
Copyright © 2006 by RN.com.
All Rights Reserved. Reproduction and distribution
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express written authorization of RN.com.
First Published:
July 15, 2004
Acknowledgements ________________________________________________________2
Purpose & Objectives ______________________________________________________3
Introduction ______________________________________________________________4
Focused Pulmonary History _________________________________________________5
Adult Patient ____________________________________________________________5
Cough__________________________________________________________________5
Sputum Production ______________________________________________________6
Dyspnea ________________________________________________________________6
Wheezing _______________________________________________________________7
Chest Pain ______________________________________________________________7
Pediatric Patients ________________________________________________________9
Aging and Special Needs Patients _________________________________________10
Conclusion ______________________________________________________________14
References ______________________________________________________________15
Post Test Viewing Instructions______________________________________________16
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Acknowledgements
RN.com acknowledges the valuable contributions of…
… Lori Constantine MSN, RN, C-FNP, a nurse of nine years with a broad range of clinical
experience. She has worked as a staff nurse, charge nurse and nurse preceptor on many
different medical surgical units including vascular, neurology, neurosurgery, urology,
gynecology, ENT, general medicine, geriatrics, oncology and blood and marrow
transplantation. She received her Bachelors in Nursing in 1994 and a Masters in Nursing in
1998, both from West Virginia University. Additionally, in 1998, she was certified as a Family
Nurse Practitioner. She has worked in staff development as a Nurse Clinician and Education
Specialist since 1999 at West Virginia University Hospitals, Morgantown, WV.
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Purpose & Objectives
The purpose of Focused Pulmonary Assessment is to offer the healthcare provider an
overview of basic pulmonary assessment including normal and abnormal findings.
After successful completion of this course, the participant will be able to:
1. Discuss the components of a focused pulmonary assessment.
2. Discuss specific assessment findings that are determined by the history and
examination, including inspection, palpation, percussion, and auscultation.
3. Identify breath sounds that are often heard in specific pulmonary disorders.
Disclaimer
RN.com strives to keep its content fair and unbiased.
The author(s), planning committee, and reviewers have no conflicts of interest in
relation to this course. There is no commercial support being used for this course.
There is no "off label" usage of drugs or products discussed in this course.
You may find that both generic and trade names are used in courses produced by
RN.com. The use of trade names does not indicate any preference of one trade
named agent or company over another. Trade names are provided to enhance
recognition of agents described in the course.
Note: All dosages given are for adults unless otherwise stated. The information on
medications contained in this course is not meant to be prescriptive or allencompassing.
You are encouraged to consult with physicians and pharmacists about all
medication issues for your patients.
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Introduction
The process of respiration is what keeps each and every cell in our body alive. If there is
a disruption to this process, the whole body suffers. This course will discuss physical
exam techniques such as inspection, palpation, percussion, and auscultation. Throughout
the course, you will learn how alterations in pulmonary assessment findings could indicate
potential pulmonary problems.
The Process of Breathing
Expiration
Inspiration
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Focused Pulmonary History
Adult Patient
When conducting a focused pulmonary assessment on your patient, it is important to begin
with a thorough history of chest or pulmonary complaints. Elicit any information about any
experienced signs or symptoms of chest disease. Chest disease usually manifests as the
presence of any of the following:
•
•
•
•
•
Cough
Sputum
Dyspnea
Wheezing
Chest Pain
Cough
Ask if your patient has a cough. If the answer is “yes” investigate further
about the nature of the cough.
• How long have you had this cough?
An acute cough usually represents a viral infection or allergic response.
Chronic cough may be more ominous. Chronic coughs may manifest
from underlying disease processes such as gastroesophageal reflux
disease, asthma, chronic allergies, bronchitis, tuberculosis, or cancer.
Certain drugs may produce a side effect of a cough. Therefore, a
thorough medication history is also warranted.
• Is your cough productive or dry?
A productive cough usually indicates some infection or inflammatory process. A dry or nonproductive cough may indicate an “atypical” pneumonia (Fenstermacher & Hudson, 1997)
or a condition that is more ominous, such as pleural effusion, underlying cardiac condition,
or may be a side effect of radiation or chemotherapy.
• What is the severity of your cough?
Ask your patient to rank their cough on a scale of 1 - 10 to determine their perception of the
severity of their cough. Most patients can use a numerical rating scale to quantify their
symptom. When using a numerical scale, you should ask the patient to rate their cough on
a scale from 0 to 10. Zero means no cough. Ten means the worst cough they have ever
experienced.
• What make your cough better or worse?
Coughs that increase in severity and frequency at night may indicate an underlying cardiac
condition. Coughs that increase after meals may indicate gastroesophageal reflux disease.
A cough that is worse upon waking may indicate bronchitis and is sometimes termed a
“smokers cough.”
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Sputum Production
If your patient has a productive cough, investigate the characteristics of their sputum. The
patient’s healthcare provider may order a sputum specimen. Begin by asking your patient
about the following:
• How long have you been coughing up sputum?
This will help you quantify the severity of the symptoms.
• What color is your sputum?
Pink-tinged, frothy sputum may indicate pulmonary edema – a respiratory emergency.
Purulent, rust-colored sputum may indicate a typical “bacterial” pneumonia (Fenstermacher
& Hudson, 1997). Green sputum may indicate a viral process or pseudomonas. Yellow
sputum is usually indicative of a bacterial infection. Black sputum may be consistent with
occupational pneumoconiosis or “black lung.” Clear to mucoid sputum that occurs in the
mornings is consistent with emphysema (Fenstermacher & Hudson, 1997).
• Is there an odor to your sputum?
An odor to sputum usually indicates an infectious process.
• Is there blood in your sputum?
If your patient complains of blood in their sputum, the symptom must be assessed to
determine if the blood is pulmonary in origin or from the gastrointestinal tract. Often patient
will perceive that they have “coughed up blood” when indeed the blood has traveled up
through their esophagus to the carina where is causes the patient to cough – thus, the
patient thinks they “coughed up blood”. Blood tinged sputum may indicate tuberculosis.
Dyspnea
Diseases associated with dyspnea include: congestive heart
failure, chronic bronchitis, asthma, emphysema, airway
obstruction, tuberculosis, HIV-related pulmonary disorders,
pulmonary fibrosis, and infectious or inflammatory processes.
If your patient complains of shortness of breath, ask the
following question to hone your assessment.
• When do you become short of breath?
Paroxysmal nocturnal dyspnea (PND) wakes the patient up
at night. Is your patient orthopneic? If so, you may want to
ask them how many pillows they sleep on at night.
Orthopnea usually indicates an underlying cardiac condition.
Is your patient short of breath at rest or with exertion?
Lungs showing two types of pneumonia
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Wheezing
If your patient complains of wheezing, determine if the wheezing occurs during expiration or
inspiration. Expiratory wheezing is consistent with asthma and other conditions associated
with bronchospasm. If your patient has wheezes upon inspiration, rule out airway
obstruction.
Chest Pain
Often your patient with an underlying pulmonary condition will complain of chest pain. It is
important to rule out cardiac chest pain and chest pain from other origins before assuming
the chest pain is pulmonary in nature. Question your patient about the nature of their chest
pain.
• Describe your chest pain.
• Cardiac chest pain is usually squeezing or gripping in nature.
• Esophageal or gastric chest pain is usually increased or decreased depending on food
intake or antacid ingestion.
• Tracheal chest pain burns during inhalation.
• Chest wall or rib pain is easily localized and recurs with palpation.
• Pleural chest pain is usually described as “stabbing.”
• Pain associated with lung diseases such as tuberculosis and cancer may be described as
boring, dull, and aching.
In general, the pneumonic, PQRST, is very useful in assessing chest pain and other
pulmonary symptoms, such as difficulty breathing and cough. It provides a methodology in
which communication to other healthcare providers will be efficient and informative. Use
PQRST to assess all pain and after any interventions (Shaw, 1998):
Provoked or Palliative: What makes the pain or symptom(s) better or worse?
Quality: Describe the pain or symptom(s) (burning, dull, sharp)
Region or Radiation: Where in the body does the pain or symptom(s) occur? Is
there radiation or extension or the pain or symptom(s) to another area of the chest?
Severity: On a scale of 1-10, (10 being the worst) how bad is the pain or
symptom(s)?
Timing: Does it occur in association with something else? (i.e. eating, exertion,
movement)
After eliciting information about any experienced signs or symptoms of chest disease, ask
about family history, social history, occupational history, communicable disease risk, and
medications.
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Family History: Ask about hereditary disorders such as: cystic fibrosis, alpha 1 antitrypsin
deficiency, asthma, and allergies.
Social History: Ascertain the pack per year smoking history. This is done by multiplying the
number of years your patient has smoked with the number of packs per day they have
smoked. Smokers or past-smokers that have over a 30-year-pack history have the greatest
risk of developing lung cancer. If you smoked for 30 years, a pack a day, you would have a
30-pack-year history. You could also have a 30-pack-year history if you smoked 2 packs per
day for 15 years or 3 packs per day for only 10 years (Cancer Treatment Centers of America,
2004).
Social History: Ask your patient about environment or work-related risk factors for pulmonary
disease. Have they worked in a glass factory, coal mine or around asbestos? Also, ask
about the amount and duration of their exposure to fumes in the workplace.
Communicable Disease Risk: Communicable disease risk questions you will want to ask
your patient include their exposure to tuberculosis, living conditions, presence of birds in the
home, travel outside the United States, and their HIV status or risk.
Medication History: More than 100 medications are known to affect the lungs adversely.
Symptoms may manifest as a cough, asthma, interstitial pneumonitis, non-cardiac pulmonary
edema, and pleural effusions. Cardiovascular drugs that most commonly produce pulmonary
problems include amiodarone, angiotensin-converting enzyme (ACE) inhibitors, and betablockers. Other drugs that may produce pulmonary problems include aspirin, methotrexate,
and chemotherapeutic agents (Rosenow, 1994).
Smokers Pack Per Day History
2 packs per day x 10 years = 20 pack-year history
1 pack per day x 20 years = 20 pack-year history
3 packs per day x 7 years = 21 pack-year history
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Pediatric Patients
To obtain information about your pediatric patient you will most likely need to rely on your
observation skills and any information that the parents and/or caregiver can provide.
Additional questions to about your patient are listed below.
Additional History for Pediatric Patients
Rationale for Asking
Children are expected to have 4-6
respiratory infections per year in early
childhood.
Any frequent or severe colds?
Is there any history of allergies in the family? If
under two, ask about any new food introduced
into their diet and whether the child was breast
or bottle fed.
Investigate further any complaints of cough,
congestion, noisy breathing, or wheezing.
What has been done to childproof the home?
Are there smokers in the home?
Has the child and/or family members been
vaccinated against influenza in the past year?
What is the status of the child’s vaccinations?
New foods may be a possible allergen.
Formula may be a possible allergen.
Rule out or further screen for chronic
respiratory problems of childhood.
Young children are at high risk for
accidental aspiration and poisoning.
Second-hand smoke may increase the
frequency and severity of respiratory
infections in children.
Annual influenza vaccination is indicated
for children ages 6-23 months of age, as
well as household contacts and out-ofhome caregivers of children from newborn
to 2 years old. This includes grandparents
and siblings (Centers for Disease Control,
2004).
H. influenza and pneumonia vaccination
schedules should be assessed
(Jarvis, 1996)
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Aging and Special Needs Patients
Aging and special needs patients may not have the ability to effectively communicate
information about their health. It is not unusual to rely on the patient’s children or caregiver to
provide a health history for the patient. Observations about the patient‘s current status will
also assist in determining their history. Additional questions to consider are listed below.
Additional History for Aging
Patients
Rationale for Asking
Any shortness of breath or fatigue in
your daily activities?
As we age, our respiratory system becomes less
efficient in terms of a decreased vital capacity and
less surface area for gas exchange. Sedentary and
bed-ridden patients are at greatest risk for pulmonary
dysfunction.
For those with a chronic pulmonary
history, ask about how they are
getting along each day.
This assesses the potential for exacerbation of
symptoms and assesses their coping strategies.
Do you have chest pain with
breathing?
Have you had your pneumonia & flu
vaccine?
As we age, we experience pain less intensely and
pleuritic chest pain may go undetected unless
specifically asked about. Pain in the chest after a fall
may indicate a rib fracture or muscle injury.
The CDC recommends all persons over 65 and those
with chronic conditions or living in group settings be
vaccinated against influenza every year (Centers for
Disease Control, 2004).
Vaccine to prevent pneumonia is indicated in adults
age 65 and older as a one time dose. The vaccine
may be given more than once under specific
conditions.
(Jarvis, 1996)
The Physical Exam
When assessing the pulmonary system, examine the following as indicated by your patient’s
history, symptoms, or disease processes.
Inspect the thoracic cage
When you are using inspection as a physical exam tool, examine your
patient and observe with your eyes, ears or nose. Examples of
conditions you will want to inspect are skin color, location of lesions,
bruises or rash, symmetry, size of body parts, sounds, and odors. Note
any abnormal findings. As you inspect the thoracic cage, pay particular
attention to the symmetry of expansion during inspiration and expiration
and note the anterior-posterior (A/P) diameter of the chest. Unequal
symmetry of expansion during inspiration and expiration may indicate a
pneumothorax or flail chest. Additionally, you may visualize various
thoracic shapes. These include:
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•
•
•
•
Barrel chest – Diameter of the chest increases with age and disease processes.
Scoliosis and kyphosis – Abnormal lateral curvatures of the spine may affect expansion of
the thoracic cage.
Pectus carinatum – Anterior protrusion of the sternum
Pectus excavatum – Posterior depression of all or part of the sternum
Note the rate and depth of respirations.
respiratory rate and pattern.
Respiratory Alteration
Tachypnea and
Bradypnea
Cheyne-Stokes
Biot’s
Kussmaul’s
Apneustic or Apnea
Dyspnea
Prolonged expiration
The following table shows abnormalities in
Description
Tachypnea is a rate greater than 20 breaths per minute in the
healthy adult. Bradypnea is a rate less than 12 breaths per
minute in the healthy, resting adult. Rates vary according to
age and patient history. It is always important to know your
patient’s baseline respiratory rate.
Fast, irregular respirations with periods of apnea. Usually
indicative of heart failure, uremia, or central nervous system
disease.
Fast, regular, shallow respirations with periods of apnea.
Usually indicative of increased intracranial pressure or spinal
meningitis.
Fast, regular, and deep respirations without pause. Usually
indicative of an underlying metabolic acidosis, such as diabetic
ketoacidosis (DKA).
Absence of respirations.
Difficult or labored breathing. May show signs of accessory
muscle use during inspiration.
Occurs with asthma, COPD, emphysema, and other diseases
that make it difficult to expire air.
Palpate the thoracic cage
Palpation is another commonly used physical exam technique.
Palpation requires you to touch your patient with different parts of
your hand using different strengths and pressures. During light
palpation, you press the skin about ½ inches to ¾ inches with the
pads of your fingers. When using deep palpation, use your finger
pads and compress the skin about 1½ to 2 inches. Palpation allows
you to assess for texture, tenderness, temperature, moisture,
pulsations, masses, and internal organs (Shaw, 1998). When
palpating the thoracic cage, you will want to confirm symmetry of
chest expansion and note any unusual crepitations of the chest wall
that may occur with subcutaneous emphysema or crepitus.
Thoracic region of the body
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Fremitus is a palpable vibration, generated from the larynx and transmitted through the
patient’s bronchi and lung parenchyma to the chest wall. You may ask your patient to repeat
a phrase such as “ninety-nine” or “blue moon” as you palpate their chest wall. Increased
fremitus may be noted over areas of consolidation, such as lobar pneumonia where the
consolidation extend to the lung surface. Decreased fremitus occurs with any condition that
would decrease this sound transmission. Some of these conditions include obstructed
bronchus, pleural effusion, fibrosis, pneumothorax, and emphysema (Jarvis, 1996).
Crepitus, also known as subcutaneous emphysema, is palpable air trapped in tissues under
the skin covering the chest wall or neck. When palpated, it produces a “crispy” sensation as
gas moves under the skin. Crepitus may result after thoracic surgery or trauma to the chest.
Percuss the thoracic cage
Percussion requires skill and practice. Assessment Made Incredibly Easy (Shaw, 1998) best
describes the method of percussion.
“Press the distal part of the middle finger of your
non-dominant hand firmly on the body part. Keep
the rest of your hand off the body surface. Flex
the wrist, but not the foreman, of your dominant
hand. Using the middle finger of your dominant
hand, tap quickly and directly over the point where
your other middle finger contacts the patient’s skin,
keeping the fingers perpendicular. Listen to the
sounds produced.” (pp. 27).
Sounds produced by percussing the thoracic cage include:
•
•
•
•
Resonance is what normal, healthy lung tissue sounds like during percussion. It may vary
from patient to patient depending on their body mass and musculature (Jarvis, 1996).
Hyperresonance has a more hollow sound to it and is heard over areas of increased air
such as pneumothorax or emphysema (Jarvis, 1996).
Dullness is usually heard over solid organs or masses, such as the pericardium or over a
tumor (Jarvis, 1996).
Flatness is heard over dense tissues including muscle and bone (Shaw, 1998).
Auscultate the Lung Fields
When auscultating, ensure your room is quiet, auscultate over bare skin,
and listen to one sound at a time. Your bell or diaphragm should be
placed on your patient’s skin firmly enough to leave a slight ring on the
skin when removed. Be aware that your patient’s hair may also interfere
with true identification of certain sounds. The diaphragm is used to listen
to high pitched sounds and the bell is best used to identify low pitched
sounds (Shaw, 1998).
Auscultation pattern
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Auscultate the anterior and posterior chest. Have your patient breathe slightly deeper than
normal through their mouth, then, auscultate from C-7 to approximately T-8, in a left to right
comparative sequence. You should auscultate between every rib. Listen for vesicular,
bronchial, and bronchovesicular breath sounds. Identify any adventitious breath sounds,
their location, and timing in relation to the respiratory cycle (crackles or rales, and wheezes or
rhonchi). Auscultate voice sounds including bronchophony, egophony, and whispered
pectoriloquy. The following table summarizes the various sounds you may hear when
auscultating lung fields.
Sound
Vesicular
Bronchial
Bronchovesicular
Fine Crackles
Course Crackles
Wheezes
Stridor
Rhonchi
Bronchophony
Egophony
Whispered
Pectoriloquy
Pleural Friction Rub
Description
Normal breath sounds. Inspiration is longer, louder, and higher pitched
(Jarvis, 1996).
Heard normally over the trachea. Inspiration = Expiration
When heard over areas other than the trachea may indicate fibrosis,
atelectasis, or pneumonia (Jarvis, 1996).
Heard over upper ½ of sternum on anterior chest and between the scapulas
on the posterior chest (Jarvis, 1996).
Also known as rales. Noted as a “popping” sound. May also be referred to as
crepitation. If heard in
Early inspiratory crackles – related to bronchitis
Mid inspiratory crackles – atelectasis
Late inspiratory crackles – pneumonia, CHF, pulmonary fibrosis, tuberculosis
(Shaw, 1998).
Loud and low pitched. Usually present with increased fluid or mucous (Shaw,
1998).
High-pitched musical quality. Present in conditions that narrow the airways
such as obstruction, aspiration, pneumonia, and asthma (Shaw, 1998).
High-pitched, crowing sound heard with upper airway obstruction. Usually,
indicates an emergency situation (Shaw, 1998).
Present with large amounts of airway secretions. May also be referred to as
low-pitched wheezes (Shaw, 1998).
While your patient repeats “ninety-nine.” Normally, the words will be muffled
and unintelligible. Pathology that increases lung density will allow you to hear
the words clearly (Jarvis, 1996).
Ask your patient to make the “eee-eee-eee” sound. Normally, you can
recognize the “eee-eee-eee” sound. Pathology that increases lung density will
cause the “eee-eee-eee” sound to sound like “aaa-aaa-aaa” (Jarvis, 1996).
Ask your patient to whisper a phrase such as “one-two-three.” Normally, you
can recognize the words. Minimal pathology that increases lung density will
allow you to hear “one-two-three” clearly (Jarvis, 1996).
A low-pitched, grating, or rubbing sound caused by pleural inflammation
(Shaw, 1998)
It should be noted that the examination techniques presented in this course are intended for
use and interpretation for the adult patient. As a nurse caring for diverse population, you
must adapt your assessment based upon developmental, age-appropriate, and cultural
considerations of your patient population.
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Conclusion
Pulmonary assessment is a critical part of the total nursing assessment. This course
provides the information necessary to delve into pulmonary issues with your patients as you
complete a pulmonary assessment.
Check out this website
The following website allows you to actually
“hear” normal and abnormal breath sounds:
The Auscultation Assistant
www.med.ucla.edu/wilkes/intro.html
Please Read:
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References
Cancer Treatment Centers of America. (2004). Four lung cancer risk factors you should know.
Retrieved May 1, 2004, from http://www.cancercenter.com
Centers for Disease Control (2004). Prevention and control of influenza. Morbidity and mortality
weekly report, 53, 1-40. Retrieved May 1, 2004, from http://www.cdc.gov
Fenstermacher, K., & Hudson, B. (1997). Respiratory tract and related eye disorders. In
Practice guidelines for family nurse practitioners (pp. 77-97). Philadelphia: W.B. Saunders.
(Ed.),
Jarvis, C. (1996). Thorax and lungs. In (Ed.), Physical examination and health assessment (2nd ed.,
pp. 459-511). Philadelphia: W.B. Saunders.
Respiratory system. In M. Shaw (Ed.), (1998). Assessment made incredible easy (pp. 123-150).
Springhouse, PA: Springhouse.
Rosenow, E. (1994). Drug induced pulmonary disease. Disease a Month, 40(5), 253-310. Retrieved
May 1, 2004, from Pub Med Web Site: http://www.ncbi.nlm.nih.gov
Shaw, M. (Ed.). (1998). Assessment made incredibly easy (2nd ed.). Springhouse, PA: Springhouse.
© Copyright 2004, AMN Healthcare, Inc.
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Post Test Viewing Instructions
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then restore the window in order to review the course material if needed.
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