Respiratory Assessment: You Must Know PIPPA
It is also a valuable tool for identifying acute or chronic lung conditions.
A proper respiratory exam involves both skill and practice.
The following outlines the steps you should use in performing a respiratory assessment as well as how to identify potential problems.
What is a Respiratory Assessment?
A healthcare professional will perform a respiratory assessment as part of a complete physical exam or when a patient presents with the following:
- Shortness of breath or difficulty breathing, also known as dyspnea.
- Chest pain.
- Symptoms consistent with acute lung conditions, including pneumonia or bronchitis.
- A history of chronic lung conditions, including asthma or chronic obstructive pulmonary disease.
- Vital signs indicate a low oxygen saturation level, typically below 93 percent.
- Vital signs indicate an abnormal respiratory rate. For the average adult at rest, respirations should be approximately 12 to 25 per minute. Respiratory rates for infants and children are higher and vary depending on age.
Since some respiratory symptoms, such as chest pain, can mimic those associated with heart problems, the lung exam is often conducted along with a cardiac exam.
Steps for Performing a Respiratory Assessment:
The mnemonic “PIPPA” can help you remember the basic steps to any respiratory assessment.
PIPPA stands for the following:
1. Positioning the Patient and Adjusting the Environment:
To perform the exam, the patient should be sitting upright with their arms at their side.
The individual should be asked to expose their chest to make it easier to visualize their respiratory effort and listen to the anterior breath sounds.
Later in the exam, you will ask the patient to move their arms forward so that the scapulae will not interfere with you listening to the posterior breath sounds.
You should ensure that you perform the exam in a quiet, private area with plenty of lighting.
2. Inspection of the Patient:
You actually begin this step the minute you walk into the room with the patient.
As you watch the patient breathe, pay close attention to the following:
- Does the patient appear to be comfortable or in distress? Signs of respiratory distress include perfuse sweating, rapid or labored breathing, and use of accessory chest muscles when breathing.
- Does the patient’s coloring appear normal? A person in respiratory distress may show signs of cyanosis. This will cause the patient to have a blue tint around the lips and nail beds.
- Is the patient compensating due to breathing problems? A person with severe pulmonary dysfunction will often compensate by leaning forward and resting their hands on their knees. This is referred to as the “tripod” position and is often seen in patients with advanced emphysema or other forms of COPD. You may also notice that the patient breathes through pursed lips.
- Are they too short of breath to speak?
- Do you hear unusual breath sounds, such as gurgles or wheezes, with the naked ear?
- Does the patient have any visible deformities of the chest wall or spine? A concave or sunken chest wall can restrict normal inflation of the lungs and cause breathing difficulties. A barrel chest may indicate chronic overinflation of the lungs, which is often seen with emphysema. Spine deformities, such as kyphosis where the spine is bent forward and scoliosis were it is curved to one side, can also cause breathing difficulties.
3. Palpation of the Posterior Chest Wall:
Palpation is a relatively small part of the respiratory assessment since the lungs are protected by the rib cage and not directly palpable.
However, you can use palpation to accentuate chest movement.
For example, you can place both hands on either side of the spine in the middle of the patient’s back.
Both hands should lift symmetrically each time the patient takes a breath.
In cases of severe lung disease or fluid or air surrounding the lung, the hand on the affected side will rise to a lesser degree.
Move your hands along the length of the spine as the patient repeats the word “ninety-nine.”
The vibrations should feel the same.
Areas of increased or decreased vibrations may indicate fluid in or around the lungs.
4. Percussion of the Chest Wall:
This is a technique known as percussion and is used to identify potential areas of density in the lung fields.
To perform percussion, you should follow these steps:
- Stand to the back and slightly left of the patient.
- Direct the patient to cross their arms in front with their hands on the opposite shoulder.
- Identify the correct area for percussion, which is between the scapula and the spine.
- With the last two joints of the middle finger of your left hand resting on the patient’s back, strike the tip of your left finger with the tip of your right middle finger several times. You should allow your right wrist to swing freely to avoid pushing your finger into the target, which can alter the sound.
- Perform percussions along the entire right side of the thoracic spine, and repeat the process to the left side of the spine.
Normal percussion will sound slightly resonant.
Fluid or bacteria infiltration will sound dull.
A tympanic or drum-like sound indicates air is trapped in or around the lungs, which is a sign of emphysema or a pneumothorax.
5. Auscultation of Lung Sounds:
The following are examples of abnormal sounds that you might hear:
- Wheezes—Wheezing indicates a narrowing of the airway and is characterized by a musical sound when inhaling or exhaling.
- Crackles—These are brief, non-musical sounds heard during inspiration. Crackles may be soft and high-pitched or course and low-pitched. Congestive heart failure is a common cause of crackles.
- Stridor—This is a very high-pitched, musical sound. Stridor typically indicates obstructed airflow resulting from a foreign object, croup, or anaphylaxis.
- Rhonchi—This indicates fluid in the airway. The sound may be bubbly, musical, and low-pitched.
Don’t worry if you find some of the above steps awkward or difficult at first.
Like any skill, it takes time and practice to perfect the technique and develop an eye and ear for what is normal and abnormal.
Tags: Respiratory Assessment, Respiratory Exam
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