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436 PHYSICAL EXAMINATION
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HEALTH EDUCATION
UNIT 2
Maintaining respiratory health
The following considerations should be noted during assessment of the consumer’s
respiratory health history and will depend on their context.
> Avoid smoking; encourage those living with you to stop.
> Do not smoke or allow others to smoke around infants and children.
> If you live with a smoker, ask that smoking be conned to one well-ventilated room or,
preferably, undertaken outside.
> If dust and mould are allergy triggers or aggravating factors for other respiratory
ailments, clean the house frequently, avoid wall-to-wall carpeting, use easily washed
curtains, and avoid having a cluttered room.
> Change lters on heaters, air conditioners, exhaust systems and range hoods as the
manufacturer species.
used heavily.
> Have home inspected for radon and take remedial steps as needed.
> Check carbon monoxide and smoke detectors monthly.
> If oxygen is used in the home, use and store away from heat; avoid contact with open
ames and cigarettes.
PLANNING FOR PHYSICAL EXAMINATION
The planning phase refers to evaluating subjective data to narrow the focus on
physical examination, determining what objective data needs to be gathered, as well
as considering the environment and equipment that will be required.
At this time, you will identify which of the four diagnostic techniques you will
need to implement the physical examination, and how you will sequence these. For
the physical examination of the respiratory system comprising thorax and lungs,
you will include inspection, palpation, percussion and auscultation.
Objective data is:
> collected during the physical examination of the consumer
> usually collected after subjective data
> information that is measured or observed by the clinician as opposed to being
reported by the consumer
> vital to the overall health assessment, to enable you to make clinical decisions
that are representative of the whole consumer picture.
Evaluating subjective data to focus physical assessment
Before commencing the physical examination of the consumer’s thorax and lungs,
consider what information the health history has provided. Critical consideration,
linked to knowledge of anatomy and physiology, should focus the physical
assessment so your examination will be more effective and efcient.
Environment
Assessing the respiratory system requires a physical environment in the healthcare
setting that has:
> a at table/surface for the consumer to lie on
> adequate lighting
> adequate privacy for the consumer.
Equipment
Assemble items before placing the consumer on the examination table; materials
should be arranged in order of use and within easy reach.
RESPIRATORY 437
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> Stethoscope
> Tape measure
> Washable marker
> Watch with second hand
> Examination table
> Pen light
> Personal protective equipment (PPE).
HEALTH EDUCATION
Inuenza vaccine
The following persons are STRONGLY recommended to receive inuenza vaccine every year:
> Children aged <5 years
> Adults aged 65 years and over
> Aboriginal and Torres Strait Islander people
> Individuals >55 years of Māori or Pasika ethnicity
> People aged 6 months and over with medical conditions associated with an increased
risk of inuenza disease and complications
> Pregnant women
> Healthcare workers, carers, household contacts of people in high-risk groups
> Teachers and support staff in schools, early childhood education
> Residents, staff, volunteers and visitors to aged care, longer-term residential care facilities
> Commercial poultry and pork industry workers
> Essential services providers
> People who are travelling during the inuenza season
> Homeless people.
For further information regarding changes, dosage, administration, contraindications and
adverse events, please review the government guidelines.
Sources: Australian Technical Advisory Group on Immunisation (ATAGI) (2018); Ministry of
Health/Manatù Hauora (2022d) version 17a released 2022
CHAPTER 13
HEALTH EDUCATION
COVID-19 vaccine
On 22 February 2021, the rst doses of COVID-19 vaccine were administered in Australia and
Aotearoa New Zealand. Vaccination for COVID-19 is recommended for all persons 5 years
of age and over. In Australia and Aotearoa New Zealand, two doses of vaccine are currently
recommended for people aged over 5 years. Up to ve doses of vaccine are currently
recommended for special populations. Special populations include those who are severely
immunocompromised, pregnant, breastfeeding or planning pregnancy, residents of aged or
disability care facilities, and Aboriginal and Torres Strait Islander people aged over 50 years.
There are currently no recommendations for vaccination for neonates and children aged
less than 5 years of age.
COVID-19 vaccination is strongly recommended for the following at risk groups:
> All adults aged ≥65 years
> Aboriginal and Torres Strait Islander people
> People of Māori and Pasika ethnicity
> Pregnant and breastfeeding women
> People with cardiac disease, obesity, chronic respiratory and liver disease
> Other groups such as residents and staff of long-term and aged-care facilities,
homeless people, essential service providers, carers and household contacts of those
in high-risk groups.
Australian Technical Advisory Group on Immunisation (ATAGI) (2022, May). Australian Technical Advisory Group on
Immunisation (ATAGI) recommended COVOD-19 vaccines and doses. https://www.health.gov.au/; Ministry of Health/
Manatù Hauora (2022d, 6 May). Immunisation Handbook. http://www.health. govt.nz/
438 PHYSICAL EXAMINATION
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HEALTH EDUCATION
UNIT 2
Pandemics
A pandemic is an epidemic where an infectious disease spreads worldwide, affecting a
substantial number of people.
The most recent and signicant pandemic outbreak, declared on 11 March 2020, was
Severe Acute Respiratory Syndrome (SARS), an acute respiratory disease caused by
a coronavirus (CoV). In 2022, the World Health Organization reported over 515 million
cumulative cases of SARS CoV-2 causing COVID-19 worldwide. Strict national systems of
surveillance are in place to monitor, manage and control communicable respiratory and like
diseases. National guidelines direct individuals to safe preventative practices.
For further information go to:
> Australian Government Department of Health (2023). Coronavirus (COVID-19) pandemic.
https://www.health.gov.au/health-alerts/covid-19
> Ministry of Health/Manatù Hauora (2022a). COVID-19 (novel coronavirus). https://www.
health.govt.nz/covid-19-novel-coronavirus
IMPLEMENTATION: CONDUCTING THE
PHYSICAL EXAMINATION
Physical examination of the respiratory system is undertaken in the one sequence
of assessments. Implementation of the physical examination requires you to
consider your scope of practice. In this section, depending on your context, you
may be performing a foundation assessment or the addition of advanced assessment
techniques if you are practising in a specialised area.
EXAMINATION IN BRIEF: RESPIRATORY (THORAX AND LUNG)
Examination of the thorax and lungs
Inspection
> Shape of thorax
> Symmetry of chest wall
> Presence of supercial veins
> Costal angle
> Angle of the ribs
> Intercostal spaces (ICS)
> Muscles of respiration
Examination of respirations
Inspection
> Rate
> Pattern
> Depth
> Symmetry
> Audibility
> Consumer position
> Mode of breathing
> Sputum
Palpation
> General palpation
> Pulsations
> Masses
> Thoracic tenderness
> Locating the site of a fractured rib
> Crepitus
Thoracic expansion
> Tactile fremitus
> Tracheal position
Percussion
> General percussion
> Diaphragmatic excursion
Auscultation
> General auscultation
> Breath sounds
> Voice sounds
Assessing consumers with respiratory
supportive equipment
Oxygen
Pulse oximeter
Incentive spirometer
Endotracheal tube
Peak ow meter
Tracheostomy tube
Mechanical ventilation
Advanced Assessment
RESPIRATORY 439
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General approach to respiratory assessment
Prior to assessment:
1. Undertake a risk assessment to determine if standard or transmission-based
precautions are required.
2. Greet the consumer and explain the assessment techniques that you will
be undertaking.
3. Ensure that the examination room is at a warm, comfortable temperature to
ensure the consumer is relaxed and comfortable.
4. Use a quiet room that will be free from interruptions.
5. Ensure that the light in the room provides sufcient brightness to
adequately observe the consumer.
6. Instruct the consumer to remove all their clothes from the waist up and to
don an examination gown.
7. Place the individual in an upright sitting position on the examination table.
8. Expose the entire area being assessed. Provide a drape that women can use
to cover their breasts (if desired) when the posterior thorax is assessed.
9. When palpating, percussing or auscultating the anterior thorax of female or
obese consumers, ask them to displace the breast tissue. Assessing directly
over breast tissue is not an accurate indicator of underlying structures.
10. Visualise the underlying respiratory structures during the assessment process
to accurately describe the location of any pathology.
11. Always compare the right and the left sides of the anterior thorax and the
posterior thorax to each other, as well as the right lateral thorax to the left
lateral thorax.
12. Use a systematic approach every time the assessment is performed. Proceed
from the lung apices to the bases, right to left to lateral.
CHAPTER 13
Examination of the respiratory system
Inspection
Shape of thorax
E
1. Stand in front of the consumer and observe.
2. Estimate visually the transverse diameter of the thorax.
3. Move to one side of the consumer.
4. Estimate visually the width of the anteroposterior (AP) diameter of the thorax.
5. Compare the estimates of these two visualisations.
In the normal adult, the ratio of the AP diameter to the transverse diameter is
N
approximately 1:2 to 5:7. In other words, the normal adult is wider from side to
side than from front to back. The normal thorax is slightly elliptical in shape.
A barrel chest is normal in infants and sometimes in the older adult. (See
Chapter 20 for a discussion of the paediatric consumer.)
normal and abnormal cross sections of the thorax.
With a barrel chest, the ratio of the AP diameter to the transverse diameter is
A
approximately 1:1. The consumer’s chest is circular or barrel-shaped in
appearance (Figure 13.7B).
The consumer with COPD has a barrel chest due to air being trapped in the
P
alveoli and subsequent lung hyperination. Lung volume thus increases and the
diaphragm attens over time. The ribs are forced upwards and outwards.
Collectively these changes result in the barrel chest appearance.
Pectus carinatum, or pigeon chest, is a marked protrusion of the sternum.
A
This increases the AP diameter of the thorax (Figure 13.7C).
Pectus carinatum can result from a congenital anomaly. A consumer with severe
P
pectus carinatum will exhibit respiratory difculty.
Figure 13.7 illustrates the
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
440 PHYSICAL EXAMINATION
D. Pectus excavatum
C. Pectus carinatum
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UNIT 2
x
1:2 ratio
A. Normal adult
Protrusion
FIGURE 13.7 Chest congurations
x
2x
B. Barrel chest
Depression
x
1:1 ratio
FIGURE 13.8 Pectus excavatum
Rickets can result from a vitamin D deciency. In this condition, the bones
P
become demineralised and weak. The loss of bone strength allows the intercostal
muscles to pull the ribs and sternum forwards, resulting in pectus carinatum.
Pectus excavatum, or funnel chest (Figures 13.7D and 13.8), is a depression in the
A
body of the sternum. This indentation can compress the heart and cause
myocardial disturbances. The AP diameter of the chest decreases.
Pectus excavatum results from a congenital anomaly. Respiratory insufciency
P
can ensue from the compression of the lungs in marked pectus excavatum.
Kyphosis, or humpback, is an excessive posterior convexity of the thoracic
A
vertebrae (Figure 13.9A). Gibbus kyphosis is an extreme deformity of the spine.
Most kyphosis cases are idiopathic. Respiratory compromise is manifested only
P
in severe cases.
Scoliosis is a lateral curvature of the thorax or lumbar vertebrae (Figure 13.9B).
A
See Chapter 16 for further discussion.
Most cases of scoliosis are idiopathic, although scoliosis can also result from
P
neuromuscular diseases, connective tissue diseases and osteoporosis. Marked
scoliosis can interfere with normal respiratory function. The total lung capacity
and vital capacity decline in proportion to the severity of the scoliosis.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
RESPIRATORY 441
B. ScoliosisA. Kyphosis
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FIGURE 13.9 Abnormalities of the spine
CHAPTER 13
Symmetry of chest wall
E
1. Stand in front of the consumer.
2. Inspect the right and the left anterior thoraxes.
3. Note the shoulder height. Observe any differences between the two sides of
the chest wall, such as the presence of masses.
4. Move behind the consumer.
5. Inspect the right and the left posterior thoraxes, comparing right and
left sides.
6. Note the position of the scapula.
The shoulders should be at the same height. Likewise, the scapula should be the
N
same height bilaterally. There should be no masses.
Having one shoulder or scapula higher than the other is abnormal.
A
The presence of scoliosis can lead to a shoulder or a scapula that is higher than
P
its corresponding part. Marked scoliosis impairs lung function.
The presence of a visible mass is abnormal.
A
A visible chest mass is always abnormal. Likely aetiologies are mediastinal
P
tumours or cysts. If large enough, they can compress lung tissue and impair
normal lung function.
Presence of supercial veins
E
1. Stand in front of the consumer.
2. Inspect the anterior thorax for the presence of dilated supercial veins.
In the normal adult, dilated supercial veins are not seen.
N
The presence of dilated supercial veins on the anterior chest wall is an
A
abnormal nding.
Dilated veins on the anterior thorax may be indicative of superior vena cava
P
obstruction. Due to the obstruction, the supercial veins and collateral vessels
become engorged with blood and dilate. Venous return to the heart is diminished,
compromising oxygenation. A consumer may present with dyspnoea.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
442 PHYSICAL EXAMINATION
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UNIT 2
CLINICAL REASONING
Practice tip: Assessing nail bed clubbing and capillary rell
The presence of nail bed clubbing provides information on a consumer’s long-term oxygen
status (hypoxia), and capillary rell indicates peripheral circulation. Note these ndings
when assessing respiratory function.
You undertake a respiratory physical examination of Sharon, a 59-year-old woman, and
identify she has the presence of clubbing and a barrel-shaped chest. She reports increasing
fatigue, dyspnoea post exertion and coughs ‘a lot’. These signs and symptoms are
consistent with her recent diagnosis of COPD. For more information about the assessment
techniques, normal ndings and abnormal ndings associated with clubbing and capillary
rell, refer to Chapter 8.
Costal angle
E
1. Stand in front of the consumer.
2. In a consumer whose thoracic skeleton is easily viewed, visually locate the
costal margins (medial borders created by the articulation of the false ribs).
3. Estimate the angle formed by the costal margins during exhalation and at
rest. This is the
4. In a heavy or obese consumer, place your ngertips on the lower anterior
borders of the thoracic skeleton.
5. Gently move your ngertips medially to the xiphoid process.
6. As your hands approach the midline, feel the ribs as they meet at the apex of
the costal margins. Visualise the line that is created by your ngers as they
move up the oating ribs towards the sternum. This is the costal angle
(see
Figure 13.10A). Approximate this angle.
The costal angle is less than 90° during exhalation and at rest. The costal angle
N
widens slightly during inhalation due to the expansion of the thorax.
A costal angle greater than 90° is abnormal.
A
Processes in which hyperination of the lungs (emphysema) or dilation of the
P
bronchi (bronchiectasis) occurs result in a costal margin angle greater than 90°.
The diaphragm attens out and the ribs are forced upwards and outwards,
leading to the change in the costal margin angle.
costal angle.
Angle of the ribs
E
1. Stand in front of the consumer.
2. In a consumer whose thoracic skeleton is easily viewed, visually locate the
midsternal area.
3. Estimate the angle at which the ribs articulate with the sternum.
4. If you are unable to visually locate the angle of the ribs, such as in an obese
consumer, place your ngertips on the midsternal area.
5. Move your ngertips along a rib laterally to the anterior axillary
line. Visualise the line that is created by your hand as it traces the rib.
Approximate this angle. See Figure 13.10B.
The ribs articulate at a 45° angle with the sternum.
N
An angle greater than 45° is considered abnormal. Consumers with particular
A
respiratory pathology may have ribs that are nearly horizontal and perpendicular
to the sternum.
Conditions characterised by an increased AP diameter, such as emphysema,
P
bronchiectasis and cystic brosis, result in an angle greater than 45° because the
lungs are forced out due to hyperination or dilation of the bronchi.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
RESPIRATORY 443
Normal adult
Barrel chest
B. Angle of ribs
A. Costal angle
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> 908
< 908
CHAPTER 13
458 angle
FIGURE 13.10 Rib cage angles
> 458 angle
Intercostal spaces (ICS)
E
1. Stand in front of the consumer.
2. Inspect the ICS throughout the respiratory cycle.
3. Note any bulging of the ICS and any retractions.
There should be an absence of retractions and of bulging of the ICS.
N
The presence of retractions is abnormal. Retractions occur during inspiration.
A
Conditions that obstruct the free inow of air may lead to retractions. These
P
include emphysema, asthma, tracheal or laryngeal obstruction, and the presence
of a foreign body or tumour that compresses the respiratory tract.
URGENT FINDING
Tension pneumothorax
A tension pneumothorax occurs when air accumulates progressively in the pleural space
and exerts positive pressure on mediastinal and intrathoracic structures. The person most
often presents with difculty breathing, hypoxia, tachycardia, chest pain and unexplained
hypotension. A tension pneumothorax is a medical emergency and requires immediate
intervention to decompress the lung.
The presence of bulging of the ICS is abnormal. Bulging of the ICS tends to occur
A
during expiration.
P
Abnormal bulging of the ICS occurs when there is an obstruction to the free
exhalation of air, such as in emphysema, asthma, an enlarged heart, aortic
aneurysm, massive pleural effusion, tension pneumothorax and tumours.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
444 PHYSICAL EXAMINATION
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UNIT 2
Muscles of respiration
E
1. Stand in front of the consumer.
2. Observe the consumer’s breathing for a few respiratory cycles, paying close
attention to the anterior thorax and the neck.
3. Note all the muscles that are being used by the consumer.
URGENT FINDING
Respiratory rate emergencies
Extreme tachypnoea (greater than 30 breaths per minute in an adult), bradypnoea and
apnoea are emergency conditions. These require immediate intervention and escalation.
No accessory muscles are used in normal breathing.
N
The use of the accessory muscles is a pathological nding.
A
P
Any condition that creates a state of hypoxaemia or hypermetabolism may lead
to the use of accessory muscles. Accessory muscles are attempting to create an
extra respiratory effort to inhale needed oxygen. Consumers experiencing
hypermetabolic states (such as exercise, fever or infection) or hypoxic events
(such as COPD, pneumonia, pneumothorax, pulmonary oedema or pulmonary
embolus) usually present with accessory muscle use.
Examination of respirations
The inspection of the respiration process includes seven components: rate, pattern,
depth, symmetry, audibility, consumer position and mode.
Inspection
E
1. Stand in front of the consumer or to the right side.
2. Observe the consumer’s breathing without stating what you are doing,
because the consumer may change the respiratory rate (increase or decrease
it) if aware that you are watching the chest rising and falling. This assessment
can be conducted simultaneously with the pulse rate assessment.
3. Count the number of respiratory cycles that the consumer has for one full
minute. A respiratory cycle consists of one inhaled and one exhaled breath.
In the resting adult, the normal respiratory rate is 12 to 20 breaths per minute.
N
This type of breathing is termed eupnoea, or normal breathing (Figure 13.11A).
A respiratory rate greater than 20 breaths per minute is termed
A
tachypnoea
Tachypnoea is frequently present in hypermetabolic and hypoxaemic states. By
P
(Figure 13.11B).
increasing the respiratory rate, the body is trying to supply additional oxygen to
meet the body’s demands. Tachypnoea occurs in many disease states, such as
pneumonia, bronchitis, asthma and pneumothorax.
Tachypnoea is often a sign of stress. In stressful situations, the body releases
P
catecholamines that elevate the respiratory rate to supply sufcient oxygen.
A respiratory rate lower than 12 breaths per minute is termed
A
bradypnoea (
Injury to the brain may cause bradypnoea because of excessive intracranial
P
Figure 13.11C).
pressure applied to the respiratory centre in the medulla oblongata.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
RESPIRATORY 445
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REFLECTION IN PRACTICE
Respiratory distress
You are away with a couple of friends camping and enjoying sitting around the campre.
Just as you are about to toast some marshmallows in the coals of the campre, one of your
friends sitting next to you grabs your hand and says, ‘I can’t breathe.’
> What questions would you ask the person?
> What assessments would you undertake?
> How would you proceed?
In drug overdoses (barbiturates, alcohol and opiates), bradypnoea is a sign of the
P
drug’s depressant effect on the respiratory centre.
Bradypnoea occurs in sleep because of the lowered metabolic state of the body.
P
The respiratory rate also slows in non-REM sleep due to changes in the response
of the respiratory centre to chemical signals.
Apnoea is the lack of spontaneous respirations for 10 or more seconds (
A
Traumatic brain injury may lead to apnoea because of herniation of the brain stem.
P
Sleep apnoea can be central or obstructive in nature. In central sleep apnoea, the
P
respiratory drive is altered, leading to periods of respiratory cessation. In
obstructive sleep apnoea, enlarged upper airway anatomy leads to a physical
blockage in the oropharynx.
Figure 13.11D).
CHAPTER 13
Pattern
E
1. Stand in front of the consumer.
2. While counting the respiratory rate, note the rhythm or pattern of the
breathing for regularity or irregularity (
Normal respirations are regular and even in rhythm.
N
Cheyne-Stokes respirations occur in crescendo and decrescendo patterns
A
interspersed between periods of apnoea that can last 15–30 seconds (
This can be a normal nding in older adults and in young children. CheyneStokes respiration is an example of a regularly irregular respiratory pattern; that
is, the respirations predictably or regularly become irregular.
Central cerebral or high brain stem lesions that occur in brain injury produce
P
Cheyne-Stokes respirations.
Cheyne-Stokes respirations can also appear in sleep due to alterations in the
P
respiratory centre’s ability to accurately perceive chemical and mechanical stimuli.
Biot’s respirations, or ataxic respirations, are examples of an irregularly
A
irregular respiratory pattern (
Figure 13.11F). In an irregularly irregular rhythm,
there is no identiable pattern to the respiratory cycle. There is an absence of a
crescendo and decrescendo pattern. Deep and shallow breaths occur at random
intervals interspersed with short and long pauses. Periods of apnoea can be long
and frequent.
Biot’s breathing indicates damage to the medulla.
P
Apneustic respirations are characterised by a prolonged gasping during
A
inspiration followed by a very short, inefcient expiration. These pauses can last
30–60 seconds (Figure 13.11G).
Injury to the upper portion of the pons can lead to apneustic breathing.
P
Agonal respirations are irregularly irregular respirations (Figure 13.11H). These
A
are of varying depths and patterns.
Impending death, where there is little or no oxygen supplying the brain, or
P
compression of the respiratory centre, may lead to agonal breaths.
Figure 13.11).
Figure 13.11E).
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
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