Medical-Surgical Nursing · Gas Exchange, Airway Management, and Respiratory System Disorders
Upper and Lower Respiratory Assessment
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In 30 seconds
A respiratory assessment is a systematic way of collecting information about how well a person breathes and why they might be having trouble. It blends a focused health history with a physical examination that follows the classic sequence: Inspection Looking at breathing pattern, effort, chest shape, and color Full entry →, palpation, Percussion Tapping the chest wall and judging the note Full entry →, Auscultation Listening with a stethoscope. The airway is divided into the upper respiratory tract (nose, mouth, pharynx, larynx) and the lower respiratory tract (trachea, bronchi, and lungs). Both need attention: upper-airway problems (obstruction, Stridor Loud, high-pitched inspiratory sound from upper airway narrowing Full entry →, secretions) and lower-airway problems (consolidation, bronchospasm, effusion) produce different findings and different priorities.
Assessment is not a one-time event. A baseline exam gives you a picture of "this person at rest," and repeat assessments — after activity, after treatment, or when the person reports a change — show the trend. Trends, not single snapshots, are what signal improvement or deterioration. The findings are recorded in the person's health record using standard terminology so any team member can compare exams.
Why this matters
The physical assessment is the first — and often only — tool available at the bedside, and it drives everything downstream: which diagnostic tests are ordered, which position helps the person breathe, whether oxygen or airway clearance is needed, and how urgently the provider is called. Respiratory deterioration can be rapid, so recognizing subtle changes — a slight increase in rate, a new sound, a change in effort — matters. The exam also has limits: some conditions are barely visible or audible, and findings must be interpreted alongside vital signs, SpO₂ Pulse oximetry estimate of oxygen saturation Full entry →, imaging, and lab work. And because breath sounds are described with very specific vocabulary, using the words correctly keeps the whole team on the same page.
The college version
Core Concepts
Health history: the questions that frame the exam
Start with the chief concern: shortness of breath (at rest? with activity? at night?), cough (dry or productive? how long? what makes it worse?), sputum (amount, color, consistency, odor), chest pain, wheezing, and any recent illness. Ask about smoking or vaping, including secondhand and environmental exposure; occupation and home exposures (dust, fumes, mold); allergies; and past respiratory illness such as asthma, COPD, pneumonia, or tuberculosis. Note medications (prescribed and over-the-counter), home oxygen use, and how the person's breathing affects daily life. In some settings, nurses may use validated questionnaires for cough or dyspnea — use of specific tools follows facility policy.
Inspection: look before you listen
Observe the person's overall appearance and effort: rate, rhythm, and depth of breathing; use of accessory muscles (neck, shoulders, intercostals); retractions; nasal flaring; and the position the person chooses — people who cannot lie flat often prefer upright, a clue in itself. Note the chest shape: a barrel-shaped chest suggests chronic hyperinflation; other deformities (pectus excavatum or carinatum) change how the lungs sit beneath the chest wall. Look at the skin and mucous membranes for pallor or cyanosis, and at the fingers for Clubbing Enlargement of fingertips with loss of the nail angle Full entry → — a sign of chronic oxygen problems. Inspect the upper airway with a light: nasal passages, mouth, and throat for redness, swelling, discharge, or obstruction. Document the breathing pattern — for example, abnormally deep rapid breathing (Kussmaul), periodic patterns such as Cheyne-Stokes, or irregular patterns — and interpret what a pattern means only within the whole clinical picture. Inspection happens before auscultation because listening changes once the person coughs or moves.
Palpation and percussion: feel and thump
Palpation checks the chest wall for tenderness, masses, and symmetric expansion (place hands on the lower chest and watch them move symmetrically with inspiration). Tactile fremitus Vibration felt on the chest while the person speaks Full entry → — the vibration felt when a person speaks — is assessed by placing the palms on symmetric chest areas while the person repeats a resonant phrase: vibrations increase over consolidated lung (fluid and solid tissue conduct sound well) and decrease over pleural effusion, pneumothorax, or hyperinflation. Percussion involves tapping the chest wall and judging the note: resonance over normal air-filled lung; hyperresonance (too hollow) over hyperinflated areas or a pneumothorax; dullness over consolidation, effusion, or masses. Percussion is more reliable in experienced hands and may be used selectively in nursing practice per facility policy.
Auscultation: the language of breath sounds
Use the diaphragm of the stethoscope, ask the person to breathe through an open mouth a bit more deeply than usual, and compare side to side at each level, covering all lobes anteriorly, posteriorly, and laterally. Normal sounds are named by where you hear them: tracheal (harsh, over the trachea), bronchial (loud, high-pitched, over the manubrium; expiration longer than inspiration), bronchovesicular (medium, near the main bronchi and between the scapulae), and vesicular (soft, low-pitched, over the peripheral lung; inspiration longer than expiration). Adventitious (added) sounds include Crackles Popping sounds from fluid or collapsed small airways opening Full entry → (fine or coarse popping — think fluid or collapsed airways popping open), Wheezes Musical sounds from narrowed airways Full entry → (musical, usually expiratory — narrowed airways), rhonchi (low-pitched, coarse, often clears with coughing — large-airway secretions), stridor (loud, high-pitched, inspiratory — upper airway obstruction; an emergency sign), and pleural friction rub (a grating, leathery sound with breathing — inflamed pleura). Adventitious sounds should be described by location, timing, and response to coughing, not just named.
Putting the pieces together — and knowing the limits
A complete picture combines history, inspection, palpation, percussion, auscultation, vital signs, SpO₂, and often ABG values. Findings change with age (older adults may have weaker breath sounds and less elastic lungs), body habitus, and cooperation. An abnormal finding is a clue, not a diagnosis: crackles could mean pneumonia, heart failure, or fibrosis — the context decides. Scope of practice varies by state, country, and facility: some advanced assessments, formal percussion mastery, or test interpretation may belong to advanced practice clinicians, and the nurse performs those steps allowed by policy and education. Document precisely, using standard terms, so the next examiner can compare.
Common Confusions
| Do not confuse | With | Difference |
|---|---|---|
| Crackles | Rhonchi | Crackles are fine or coarse popping (small airways/fluid) that usually do not clear with cough; rhonchi are low-pitched, coarse, large-airway sounds that often DO clear with coughing |
| Wheezes | Stridor | Wheezes are musical, mostly expiratory, from narrowed lower airways; stridor is loud, inspiratory, from upper airway obstruction — an emergency |
| "Loud breath sounds = good" | Reality | Air movement must be judged by quality, location, and symmetry; bronchial sounds heard in the periphery signal consolidation |
| SpO₂ reading | Adequate ventilation | Normal SpO₂ can coexist with rising CO₂ (hypoventilation) — oximetry cannot detect CO₂ retention |
| One abnormal sound | A diagnosis | The same sound (for example, crackles) occurs in pneumonia, heart failure, and fibrosis; context, history, and tests decide |
| Upper airway | Lower airway | Upper = nose, mouth, pharynx, larynx (stridor, obstruction); lower = trachea, bronchi, lungs (crackles, wheezes, consolidation) |
Eli explains
The same idea, in plain words
Explain it like I’m 10
Checking the lungs is like being a detective with a checklist: you look at how the person is breathing (inspection), gently feel and tap the chest (palpation and percussion), and listen through a stethoscope (auscultation). Normal lungs sound like a soft breeze; sick lungs add new sounds — pops like tiny bubbles (crackles), whistles (wheezes), or a loud crowing on the way in (stridor). Each sound is a clue pointing to a different part of the mystery.
Worked example
A nurse is assigned a person who reports "a cough that won't quit" and shortness of breath with light activity. The history reveals a productive cough with thick sputum and a long smoking history. Inspection shows slightly faster breathing, use of shoulder muscles with inspiration, and the person choosing to sit upright leaning forward. Palpation and percussion are limited by the person's position; the nurse notes symmetric expansion and a dull note over the right lower chest. Auscultation reveals fine crackles at the right base that do not clear with cough, with clear vesicular sounds elsewhere. The nurse documents the findings with standard terms, records SpO₂ and vital signs, and reports the pattern — right-lower-lobe crackles, dullness, increased effort — to the provider, who decides the next diagnostic steps. Nothing is diagnosed at the bedside; the assessment narrows the possibilities and guides what happens next.
Key takeaways
- Assessment sequence: history → inspection → palpation → percussion → auscultation.
- Always compare side to side at the same levels and document with standard terminology.
- Vesicular sounds over the periphery; bronchial sounds over the manubrium — hearing bronchial sounds in the periphery is abnormal (consolidation).
- Crackles = popping sounds (fluid or collapsed airways); wheezes = narrowed airways; rhonchi = large-airway secretions that often clear with cough; stridor = upper airway emergency.
- Use accessory muscles, retractions, and the upright position the person chooses as effort clues — not just the sounds.
- Clubbing and barrel chest are chronic findings; cyanosis is late and unreliable.
- SpO₂ and vital signs are partners to the exam, not substitutes for it.
- Perform the steps your scope and facility policy allow, and flag findings that need the provider's attention.
Check yourself
6 review questions from the chapter. Try each one, then open the answer.
What is the correct order of the four physical exam techniques for the chest?
Show answer
Inspection, palpation, percussion, auscultation — look, feel, thump, listen.
Where would you expect to hear vesicular breath sounds, and what do they sound like?
Show answer
Over the peripheral lung fields — soft, low-pitched, with inspiration longer than expiration.
What does dullness on percussion suggest?
Show answer
Dullness suggests something denser than air in that region: consolidation (pneumonia), pleural fluid, or a mass — to be sorted out with the rest of the picture and tests.
Which adventitious sound is an emergency, and why?
Show answer
Stridor — a loud, high-pitched inspiratory sound from upper airway narrowing. The airway can close completely, so it requires immediate attention and provider notification.
Why is "the person chose to sit upright" a useful finding?
Show answer
Because people who cannot breathe well lying down naturally seek upright positions; it is a visible clue to orthopnea or increased work of breathing that the person may not put into words.
Why can't a normal SpO₂ prove the lungs are working well?
Show answer
Because SpO₂ measures hemoglobin saturation, not ventilation: a person can hypoventilate and retain CO₂ while still showing a normal saturation, especially if receiving supplemental oxygen.
Study tools & related lessonsKey vocabulary · Related
Key vocabulary
- Inspection
- Looking at breathing pattern, effort, chest shape, and color
- Tactile fremitus
- Vibration felt on the chest while the person speaks
- Percussion
- Tapping the chest wall and judging the note
- Auscultation
- Listening with a stethoscope
- Crackles
- Popping sounds from fluid or collapsed small airways opening
- Wheezes
- Musical sounds from narrowed airways
- Stridor
- Loud, high-pitched inspiratory sound from upper airway narrowing
- Clubbing
- Enlargement of fingertips with loss of the nail angle
- SpO₂
- Pulse oximetry estimate of oxygen saturation
Sources & references
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