Respiratory Assessment by Brienne Leary.
Healthcare workers in all healthcare settings should always adhere to the latest World Health
Organization guidelines on hand hygiene and barrier precautions before and after contact
with a patient, bodily fluids, or patient surroundings. For more information, please
watch our video entitled Hand Hygiene. Introduction.
Hi, my name is Brienne Leary, and I’m a nurse in the pediatric medical surgical ICU here
at Boston Children’s Hospital. I’m here today to talk about performing a comprehensive nursing
assessment of the respiratory system and how to perform safe and effective monitoring of
your patient’s respiratory system. While it is essential for the critical care
nurse to continually assess and monitor the patient as a whole, the respiratory system
is often involved in a pediatric patient in the ICU. As a result, it is critical to obtain
a baseline and accurate assessment of the respiratory system before continuing any further.
The nursing assessment and monitoring is composed of two parts, the physical exam and the non-invasive
monitoring that we’ll use. As the bedside critical care nurse, it’s important that you
are very competent in these skills and assessment parameters. You’ll need to be identifying
patient changes at a minute-to-minute basis and able to notify the appropriate care provider.
First, let’s talk about how to perform a comprehensive respiratory exam. This exam is going to be
made up of three key parts, the look, listen, and feel model. Before we start, let’s talk
about a few basic terms that you’ll need to be familiar with.
The first is that of tachypnea, otherwise known as a fast breathing rate. Bradypnea
is the term we use to describe a low breathing rate. Apnea describes the patient is not breathing
at all or has a respiratory rate of zero. Dyspnea, or respiratory distress, speaks to
the patient’s difficulty in their ability to breathe.
As you’ll notice, the patient in front of me here is intubated or has an endotracheal
tube in their mouth to assist their breathing. Some of your patients in the ICU will have
a breathing tube and others will not. The basic principles of our respiratory exam are
going to be the same for both intubated patients and extubated patients. Any differences that
are important will be highlighted throughout this video.
Physical Exam. As we said, the physical exam has three parts.
You want to look, listen, and feel your patient. The first step is to just take a look. You
can always gain a great amount of information simply by looking at the general appearance
of your patient. First, you want to ask yourself, how does
this patient’s breathing look? Do they look calm and comfortable? Are they in a position
where they’re trying to put themselves in order to breathe more easily? In an extubated
patient that’s ill, they’ll often try to find a position of comfort, one in which they’re
able to breathe the easiest. For a baby with croup, that may be in their mother’s arms
where they’re calm and comfortable. It is always best to leave an extubated patient
in the most comfortable position for them, especially while you’re performing your exam.
You may see a patient tripoding, or actually on their hands and knees, bent over, hunching,
or you may notice that they’re drooling a lot.
Next you want to look at their face. Do they look afraid? Are they having a hard time breathing?
Do they look drowsy, lethargic? Are they not responding to you at all? Are they anxious,
irritable, restless? All of these things can indicate that they are not effectively breathing.
Next, you want to look at their overall skin color. Do they look pale? Are they mottled?
Do you even notice some cyanosis or a bluish tint to their color? You may notice these
things around their lips, which is known as circumoral cyanosis. You also may see that
their hands or their feet appear a little bit blue. These things could indicate they’re
not getting enough oxygen. Next, you, want to take a look at the child’s
trachea, which is located midline in their neck. You always want to assess and make sure
that that trachea remains in the middle of the neck position. If the trachea has moved
to either side, that could indicate that the patient is experiencing a pneumothorax.
The next thing you want to assess for is the respiratory rate. This can be done simply
by watching your patient breathe. What you want to do is count for a minimum of 30 seconds
to see how many breaths the patient takes. It is very important to count for this long,
because infants and children often have some variation in their respiratory pattern. And
if you don’t count long enough, you may end up with an inaccurate respiratory rate.
The normal rates for patients should be as follows. In newborns you can expect the baby
to breathe between 30 and 60 breaths a minute. For young children it should be about 20 to
40 breaths per minute. In an older child, anything from 15 to 25 breaths per minute
is acceptable. In the adult patient, 12 to 20 breaths should be expected.
The next thing you want to assess is whether or not that breathing pattern is regular or
irregular. Do you see the patient breathe at a nice steady rate, even if it is fast,
or are they taking very quick breaths and then having pauses in their breathing? These
are important to note. In many normal pediatric patients there is
some variation in their respiratory pattern. However, if the patient is taking very quick
breaths, and then all of a sudden stops or slows way down, and the breathing rate picks
back up again, this can be a very ominous sign of impending respiratory failure. In
addition, in a baby or a small child who is breathing too slow, that can also indicate
that a child is experiencing respiratory distress and soon to be failure.
The next thing we want to look for is if the child is experiencing any drainage from their
nose, from their mouth, from their endotracheal tube. All of these things should be assessed
for color, consistency, and their amount. It could be a small, moderate, copius. They
could be thick, thin, white, clear. The color will often indicate the type of drainage that
the patient is having. Clear drainage will often indicate normal secretions. Yellow or
green secretions often indicate that the child has some sort of a bacterial infection.
Next we want to look for any signs that it’s hard for your patient to breathe. We call
these signs and symptoms of respiratory distress. You will often see that a child is using extra
muscles, or ways to get a good solid breath in. The first and most common thing that we
see in children is something called nasal flaring. This is when you will see the child’s
nostrils actually flare out and in as they try and take their breaths.
Head bobbing is something that we often see in babies. You will actually see their head
bob back and forth as they try and take their breaths. This indicates extra effort in their
breathing pattern. Retractions are the next thing you want to
be aware of. You can see retractions in many different places. But a retraction is defined
as the skin pulling in from the outer walls in toward the ribs. The location of the retractions
is very important. You want to assess the child from their neck down to their thorax.
You can have retractions in the upper part, the middle part or the lower part of the chest.
You will always need to classify your retractions in terms of their location and their severity.
Next you want to look at how the patient’s chest rises and falls as they breathe. You
should see that the patient is having equal expansion on both sides of their chest as
they take a breath. One side you may notice is rising more than the other. This would
indicate a problem and needs further investigation. In infants, it’s normal to see their abdomen
move and expand as they take a breath. However, if you see a sick baby breathing heavily with
their abdomen pulling forward and higher, and their chest dipping below, this can be
known as diaphragmatic breathing and is also a concern. It is also a concern if you note
this in an older child. Next, we want to look at the timing that it
takes a patient to take a breath in and a breath out. We talk about this is the I to
E ratio, or the inspiratory to expiratory ratio. It should take about two times as long
for a patient to exhale their breath as it did to take it in. If it’s taking longer for
the patient to breathe in, this could indicate an obstruction in their upper airway. If it
is taking longer to breathe out, this could mean there’s an obstruction in their lower
airways, and it is making it harder for them to force the air out of their lungs. In a
healthy patient there should be no extra effort at all or any change in that I to E ratio,
and any increased effort should be considered abnormal.
Next, we want to move on to the listening component of your exam. This is step two.
As we said before, you want to optimize your patient’s position. In a baby you don’t want
them crying. It will be difficult to hear their lung sounds. So if the child is comfortable
in their parents’ arms, make every effort to leave them there and keep them calm and
comfortable so that you can get an effective exam. For the exam, you’ll obviously need
a stethoscope. In addition, if at all possible, and the patient is not intubated, it will
be best to be able to listen to their chest on both the front as well as the back.
The first thing we’re going to do is listen without a stethoscope. There are a few things
you’ll be able to listen to. First is stridor. That’s known as a high pitched noise that
is heard as the patient takes their breath in.
[STRIDOR NOISES] If you hear stridor, it often indicates that
the patient has an obstruction somewhere in their upper airway. This could be a foreign
body, or it could be swelling on their internal airway. Then you want to listen for any upper
airway congestion. [NASAL CONGESTION NOISES]
Do you hear noises around their nose? Their throat? Are they coughing a lot? All of these
things could indicate that they have stuffiness or secretions collecting in their upper airway.
Next, does the child have a cough? The description of the cough is also important. Is it effective?
Are they actually coughing up sputum? [PRODUCTIVE COUGH NOISES]
Or is it dry and hacking? [DRY AND HACKING COUGH NOISES]
Does the patient tell you that something makes the cough worse, maybe when they lay down
or sit up? Is it barking and hoarse sounding? [COUGH WITH CROUP NOISES]
If the cough is producing sputum, it may be important to collect that for specimen. All
of these characteristics can help the provider to diagnose the patient.
Now it’s time to listen with our stethoscope. The lung has a number of areas that you want
to focus on. But the most important thing to remember is that you always want to compare
the right side to the left side, and make sure you listen to both the upper portions
and the lower portions of the lungs. We talk about doing this in what we describe as a
z pattern. I’ll demonstrate this now. We’ll start on
the right upper part. Make sure you listen to both the in and out. Next you want to move
over to the left upper. In similar fashion, you continue to move down the patient’s chest,
left to right, right to left. Always moving down, before you change sides.
Again, it’s important to compare the depth and the quality on each side of the patient.
As you listen, you want to listen for other noises as well, not just the aeration. Do
the lungs sound clear? Is the air moving in and out with a nice clear sound?
[CLEAR BREATH NOISES] Or do you see here extra audible sounds?
[COURSE BREATH NOISES] This could indicate things like secretions.
If you don’t hear any aeration, this is incredibly concerning. This is why it’s important to
note, do you hear no aeration on either side? Or is it only on the left? Only on the right?
Sometimes you’ll hear air on the right and the left in the upper, but maybe not in the
lower portions. All of this information, again, will help you to determine and troubleshoot
your patient. Another sound that you should be very familiar
with is the wheeze. A wheeze is a high pitched noise that can be heard on both inspiratory
and expiratory breaths. [WHEEZE NOISES]
If the wheeze is heard on the inspiratory portion of the breath, it often indicates
an obstruction in the upper portions of the airways. However, if you hear the expiratory
wheeze on the lower portions, it can indicate that there is a lower airway obstruction.
This is commonly heard in as asthmatics or bronchiolitics. It is a very important note
to say, that if you’ve heard wheeze on your initial respiratory exam, and that wheeze
disappears, be sure that the patient has not lost their ability to aerate at all. Sometimes
we’re reassured by the absence of the wheeze, but in fact, that may indicate that those
airways have closed so much there is now no air movement at all through them.
Coarse breath sounds are the noises you’ll hear when the patient has secretions or fluid
buildup in the lungs. [COARSE BREATH NOISES]
This generally indicates that the patient needs to cough, or if they have an endotracheal
tube, you may need to suction them. Crackles or rales, are often heard in the lower portions
of the lungs. [CRACKLE NOISES]
This typically indicates that there is extra fluid or friction taking place in the lower
portions of the lungs, and is usually associated with pneumonia or pleural effusion. These
sounds can all be heard on both inspiration and expiration, though may be more audible
in the expiratory phase. The next thing we want to do is feel the patient.
When the patient talks, you can feel something like tactile fremitus. If you place your hands
on the patient’s lungs and they speak, you should actually hear the vibration. These
should be equal on both sides. Crepitus is something very specific and will happen if
air develops under the subcutaneous tissue in the child’s chest wall. You can palpate
around and will often feel tiny air bubbles along their chest.
[CREPITUS NOISES] This is also incredibly concerning, as it
can mean there is an air leak somewhere under the patient’s skin.
Considerations for the Intubated Patient. Additional assessments that you want to make
for the intubated patient. The most important thing is to determine that
the endotracheal tube is still in good position. You can easily do this by, first, visually
assessing the patient’s mouth, and where the endotracheal tube enters. It should be well-secured
with tape in place and stuck to the child’s face. Or there may be another sort of device.
As long as it’s used as a securement device, as long as it’s intact, you’re good to go.
The next thing you want to do is note the exit point and measurement of the endotracheal
tube on the child. This should be documented well and visibly in the child’s chart. You
want to continually reassess this, a minimum of every four hours.
In addition, if you have any concern that the tube has become dislodged or dispositioned,
you want to, again, take a listen with your stethoscope and compare the noise you hear
from the right side to the left side to ensure that the endotracheal tube is still in good
position. Point of Clarification.
If you have any concern that the endotracheal tube has been dislodged and the patient is
no longer intubated, you should call an emergency response to the patient’s bedside for help
immediately. The next thing you want to watch is, again,
their comfort and their breathing. Intubated patients often experience some sort of agitation
related to the breathing tube and may require some sort of sedation to keep them comfortable.
This also becomes important, because some of the pressures we deliver through the ventilator
are uncomfortable and the patient may actually fight that positive pressure that the ventilator
is delivering to them. You want to watch to make sure that it appears the patient is breathing
in synchrony with the ventilator. And if not, discuss with your provider how you can intervene.
The other thing that you may hear in an intubated patient is something known as an air leak.
In this patient, we have a cuffed endotracheal tube in which we can inflate the cuff to close
the leak around the tube to the trachea. If, however, either this cuff is deflated,
the tube is too small for the patient, or the tube does not have a cuff, you may actually
experience a leak. This will be an audible noise that will be heard coming, sort of,
from the patient’s upper airway. For us here, we use a minimal leak. However,
every institution’s a little bit different. You will just need to be aware of whether
or not that leak is present or not. So, the similarities in the extubated and
intubated patient are always going to be the same. You have equal chest rise, watch your
inspiratory and expiratory ratio, listen to your lung sounds, and watch for their breathing
rate. Tachypnea, bradypnea, each of those will always be the same.
Finally, we want to talk about an emergency checklist that should be available to you
in all intubated patients, as well as any ICU patient requiring respiratory support.
You always want to have available, immediately, a working oxygen source. For everyone this
may be different, but here, some sort of emergency airway bag should be available, such as an
anesthesia bag or a self-inflating Ambu bag. This should be connected to a working supply
of oxygen, ideally, a wall supply that is unlimited.
In addition, you want to make sure that you have a mask that is appropriately sized for
the patient. This will be in case of emergencies. It is important and critical to note that
this should be available, even for the intubated patient, in case of tube dislodgment or emergency
extubation. You also want to make sure you have suction
source and equipment available. This would include a Yankauer or a large bore suction
catheter that you would be able to use for nasal and oral secretions, as well as an appropriately
sized, soft suction catheter for the endotracheal tube.
Reassessment and Monitoring. Remember, once you have gained a comprehensive
respiratory exam on your patient, it is critical to continually reassess your patient. Pediatric
respiratorially ill children can change at a moment’s notice. For that reason, you must
be continually reassessing their breathing rate, effort, distress, and utilize this information
to move forward with your care. On that note, it’s now time to change over
and talk about how you can safely and effectively monitor your patient’s respiratory status
while in the ICU. Every monitor is going to vary a little bit. However, in principle,
they’re all pretty much the same. Typically, you’ll have between three and five
leads to work with. You’ll want to look at your patient and be careful with your lead
placement. The lead placement is critical to getting an accurate reading for your patient
onto the monitor. First, you’ll have the right upper, or the
white lead. We’ll place that anywhere in the right upper chest or the right upper extremity.
Next, you’ll have the left chest or left upper extremity. That is often black. Finally, you’ll
have the left lower extremity, or left abdomen. This typically gets placed on the child’s
lower left abdomen. You’ll have to note that each cable comes
back appropriately to match the cable here. That means that the white will need to match
the white, the black will need to match the black, and the red or green will need to match
the entry on the cable here. All monitors, as we’ve said, may be set up
a little bit differently. However, they can typically all be used to measure a few things–
the respiratory rate and the oxygen saturation. The oxygen saturation is measured using an
oximeter. This will often come in the form of a probe. This can be a self-adhesive probe
such as this, where it will attach to a cable, or it may be a manual clip.
This sat probe can be placed in a number of different places on the patient– any of their
fingers, their toes, in small babies on their hands or their feet. And if you are having
a difficulty with perfusion, you can also use the patient’s ear or their earlobe as
placement for the probe. So here we can see what a continuous monitor
might look like. As we said, each mother will have a little variation, but the numbers and
the information that they give you will all be similar. The first thing that the monitor
can be useful for is to monitor the patient’s breathing rate or respiratory rate. In this
monitor, this will come up as a single number. This number is registering the amount of breaths
the patient is taking per minute. The nice part about the monitor being used
continuously is that you’ll be able to trend the patient’s respiratory pattern over time.
This might help you to identify if the patient is becoming more tachypneic, or perhaps they’re
improving and their respiratory rate is coming down from a number that’s too high into a
more normal range. In some monitors, you may actually see a wave on the monitor, which
will indicate the depth and pattern of the breathing.
The next number that we’ll see is the end tidal CO2, or the expired amount of carbon
dioxide from a patient. Typically, and most usually, this number is gained in an intubated
patient using an adaptor at the end of the endotracheal tube, which then connects to
the monitor. Here you’ll see this identified as a waveform and the number at the present
moment. This normal value should be between 35 and 45. There are ways to monitor this
in extubated patients, but that will depend on whether or not you have that technology
available to you. This number is useful in determining both
the placement of the endotracheal tube– in other words, if the endotracheal tube is no
longer in the patient’s lungs, you will lose that value completely. It is also useful in
helping to assess the ventilation of the patient and then the effectiveness of their breathing.
Finally, this monitor also shows us the oxygen saturation, often labeled as the SpO2 on the
monitor. This number will give you the percentage of hemoglobin that is saturated with oxygen
in your child. A normal value is between 95% and 100%. This was monitored using that self-adhesive
sticker with the red infrared light on the patient.
This will also give you a second number, a pulse or a heart rate. This is because the
number is being measured using the pulsatile flow of blood through the patient’s extremity
where you’re measuring from. So again, this number should be continuously monitored in
all patients in the ICU, particularly those who are intubated or in respiratory distress.
You’ll want to be able to identify and be notified by your monitor immediately if your
child is experiencing a change in their oxygen saturation.
This is a great time to take a pause about the safety and efficacy of monitors. It is
absolutely critical that if you’re going to rely on a continuous monitor that you use
acceptable and safe alarm limits. The most important thing you must do is ensure that
your alarm limits are on, and also that they are set appropriately for your patient. This
means that you must use vital signs which are assessed and determined based on your
patient’s age, size, weight, and their condition. In other words, your patient may not have
a normal respiratory rate, and therefore, it would be inappropriate to set the alarm
limits based on a normal rate for that patient that size. However, as your patient changes,
you may need to keep in mind that you will need to change your alarm limits as well.
One other useful tip we can give you is troubleshooting your monitor. Keep in mind that this is technology
and not a human being, and that the first thing that you should do if your alarm were
to go off for your patient, is to actually assess your patient. For example, the respiratory
rate may alarm that the patient has stopped breathing, that they’ve gone apneic. However,
when you go in to assess the patient upon that alarm, you find that perhaps they’ve
pulled off a lead. So we just would like to reiterate that if the alarm goes off, that
you will want to take a look and actually assess the patient in person.
Some of the things that can cause your alarm to go off unnecessarily might be patient movement,
which can cause artifact. It may be the dislodgement of a lead. Also of note, placing a wet cloth
over the patient’s body will affect the ability of the electrodes to work effectively. Hopefully
this can help you work through any problems that you may have.
So, in summary, the respiratory assessment and monitoring of your patient in the ICU
will be critical. We want you to use the look, listen, and feel model to complete your comprehensive
respiratory exam so that you look at your patient for any signs of distress or difficulty
breathing, listen for any abnormal lung sounds, and to feel for any crepitus or secretions.
Once you’ve gained your comprehensive nursing respiratory assessment, you can use your continuous
monitoring to evaluate your patient’s continually changing condition. This will help to keep
your patient as safe as possible while in the ICU, as well as to help you move them
forward in their healing. Thank you for taking the time to listen to
our respiratory nursing assessment and continuous monitoring lecture.
Please help us improve the content by providing us with some feedback.