Pediatric respiratory health history and physical assessment 43
Figure 2.1 (A–C) Anatomical landmarks.
(A) (B)
(A) Anatomical landmarks
(side view)
Anatomical landmarks (back view)
Anatomical landmarks (front view)
Nasal bridge
Temporal area
Kyphotic curve Axoila Flank area Lordotic curve Midaxilary line Submandibular area
Angle of jaw
Scapula
Submandibular area Supraclavicular space Sternal notch
Clavicle Upper arm Right costal margin
Right upper quadrant Left upper
quadrant Anticubital fossa Axila (armpit) Sternum
Left costal margin Nape of neck
Flank area Left posterior iliac crest
(C)
(A) Left scapular line
(B) Vertebral line
(C) Right scapular line (A) Midaxillary line
(A) Right midclavicular line
(B) Midsternal line
(C) Left midclavicular line
(A) (B) (C)
44
Pediatric respiratory health history and physical assessment 45
illustrated by an indentation of the sternum (Lippincott, 2007; Seidel et al., 2003).
It is helpful to record a respiratory rate during the inspection portion of the examination. For infants and toddlers, it is useful to measure the respi- ratory rate before beginning the hands-on portion of the examination because the child is more likely to be fussing or crying during that portion of the examination. For school-age and adolescent children, it is useful to measure the respiratory rate when they do not know you are counting because the child may have a self-conscious response to your measure- ment; this response may alter the results (Seidel et al., 2003). The respira- tory rate should be counted for a full minute. Normal respiratory rates based on age are as follows:
Age Rate (breaths/min)
Infants 30–40
Toddlers 24–26
Preschoolers 24
School-age children 20
Adolescents 20 (Custer & Rau, 2009)
Next, inspect respiratory effort, respiratory pattern, and chest expan- sion. Breathing should be relaxed and regular, and chest expansion should be symmetrical. The inspiratory-to-expiratory ratio (I : E ratio) should be 1:2. A list of respiratory patterns along with implications of the patterns are presented in Table 2.1 (Hilman, 1993; Lippincott, 2007; Seidel et al., 2003).
The chest should be inspected for the presence of retractions. The nurse should remember that newborns and infants have a chest wall that is more compliant than older children and adults. Therefore, some mild retractions may be present at baseline at this age. The location of retractions, if present, should be noted and documented. Retractions can be subcostal, substernal, intercostal, suprasternal, or supraclavicular; the higher up on the chest the retraction, the more severe the respiratory distress and the degree of airway obstruction.
Inspection of the respiratory system includes more than an evaluation of the chest. The child’s head should be assessed for signs of respiratory distress, such as head bobbing, nasal flaring, an anxious facial expression, or pursed lip breathing (O’Hanlon-Nichols, 1998). Grunting or mouth breathing should be noted. Additionally, skin, nail bed, and lip color should be assessed for cyanosis and pallor. Extremities should be assessed for digital clubbing. Clubbing is an abnormal enlargement and an increase in the angle of the finger (see Figure 2.2) and toe bases. To check for clubbing, ask the child to place both thumbs together (nail beds facing each other).
Normally, the nurse will see a diamond shape space between the fingers when the thumbs are in this position. Clubbing eliminates this space
46 Nursing Care in Pediatric Respiratory Disease
Table 2.1 Breathing patterns.
Pattern Description Potential implications
Tachypnea Abnormally high respiratory rate Respiratory disease with decreased compliance, fever, anxiety, metabolic acidosis Bradypnea Abnormally low respiratory rate Depression of central nervous
system, metabolic alkalosis Hyperpnea Unusually deep respirations Anxiety, exercise, fever, metabolic
acidosis
Hypopnea Shallow breathing Central nervous system depression,
metabolic alkalosis, pain Apnea Cessation of respirations for more
than 15 seconds or for less if accompanied by bradycardia or cyanosis
Periodic
breathing At least three respiratory pauses of 3- to 10-second duration with less than 20 seconds of respiration between pauses
Common in preterm infants and sometimes seen in normal full-term infants under 3 months of age
Paradoxical
breathing Seesaw breathing/
thoracoabdominal asynchrony Can be common in newborns (especially preterm infants) due to the compliant nature of their chest wall; it can also be due to respiratory distress
Kussmaul’s
breathing Deep, slow, regular respirations with
a prolonged expiratory phase Ketoacidosis Cheyne–Stokes
breathing Cycles of increasing and decreasing depths of tidal volumes separated by periods of apnea
Increased intracranial pressure, congestive heart failure Biot’s breathing Cycles of irregular respiration at
variable tidal volumes associated with periods of apnea of varying lengths
Severe brain damage
because the angle of the nail base is greater than 180° (Cox, 2001). Clubbing may be due to chronic hypoxia. However, it can be hereditary, so the nurse should always evaluate the parents’ fingers if he/she suspects clubbing.
Palpation
The chest should be palpated for pulsations, tenderness, depressions, and abnormal movements (Seidel et al., 2003). Palpation should be performed with the palm of your hand or the pads of your fingers.
Crepitus is a crinkly sensation that indicates air in the subcutaneous space. It can be present with a chest injury or pneumothorax. In newborns,
Pediatric respiratory health history and physical assessment 47
crepitus may be present with a clavicular fracture sustained after a difficult delivery (Seidel et al., 2003). In addition to visualizing chest expansion, it should also be palpated. To do so, posteriorly place thumbs along the spinal process at the level of the 10th rib with palms lightly in contact with the posteriolateral surfaces. During inspiration and exhalation, the thumbs should move symmetrically. This assessment should be repeated anteriorly by placing the thumbs along the costal margin and the xiphoid process.
Asymmetrical movement can be due to atelectasis, pneumonia, or pneu- mothorax (Lippincott, 2007; Seidel et al., 2003).
Tactile fremitus is the palpable vibration of the chest wall that results from verbalization. To check for tactile fremitus, lightly place open palms (fingers should not be touching the back) on the child’s back. Ask the child to repeat the word “99” several times. Vibrations produced should be equal on both sides. An increase in vibrations is related to consolidation, such as pneumonia. A decrease in vibrations is related to limited air movement such as pneumothorax (Lippincott, 2007). Tracheal position should be evaluated. To assess for tracheal deviation, place your index finger in the sternal notch and move it gently, side to side, along the upper edges of each clavicle and in the spaces above to the inner borders of the sterno- cleidomastoid muscles. The trachea should be midline directly above the suprasternal notch (Seidel et al., 2003).
Figure 2.2 Clubbing in a 20-year-old cystic fibrosis patient.
48 Nursing Care in Pediatric Respiratory Disease
Auscultation
Auscultation is used to assess normal lung sounds and to detect adventi- tious sounds. Auscultation should be performed using the diaphragm of the stethoscope. The stethoscope should be placed directly on the child’s skin. In addition, if old enough, the child should be instructed to breathe with his/her mouth open. It is essential to auscultate the full respiratory cycle (inhalation and exhalation) at each site, systematically moving side to side while comparing the sounds bilaterally.
Lung sounds are characterized by intensity, pitch, quality, and duration.
The normal lung sound is not musical and does not have distinct peaks (Pasterkamp, Kraman, & Wodicka, 1997). Normal lung sounds can be further differentiated into vesicular, bronchovesicular, and bronchial/
tracheal sounds. Vesicular sounds are low pitched and heard over healthy peripheral lung fields. Bronchovesicular sounds are moderately pitched and heard over the main bronchus. Bronchial/tracheal sounds are high pitched and heard over the trachea and larynx (O’Hanlon-Nichols, 1998).
Adventitious sounds are superimposed on normal lung sounds.
Wheezes are high-pitched, whistle-like, musical sounds that are continu- ous in nature (O’Hanlon-Nichols, 1998; Pasterkamp et al., 1997). Crackles (previously known as rales) are discontinuous sounds that can be classified as fine or coarse. Fine crackles are soft and high pitched. Coarse crackles are louder and lower in pitch (Lippincott, 2007). Crackles resemble the sound of rubbing hair between one’s fingers. Crackles are most often heard on inspiration and are not cleared by coughing (O’Hanlon-Nichols, 1998;
Pasterkamp et al., 1997). Rhonchi are snorelike, deep sounds usually heard on expiration (O’Hanlon-Nichols, 1998; Pasterkamp et al., 1997). Rhonchi usually clear with coughing. (O’Hanlon-Nichols, 1998).
Percussion
Percussion is a tapping technique used to produce sounds from underlying tissues and organs (O’Hanlon-Nichols, 1998). When percussing the poste- rior portion of the chest, ask the child to sit with head bent forward and arms folded in front if he is old enough. To percuss the lateral and anterior portions of the chest, ask the child to lift his arms over his head.
Percussion should be performed over the intercostal spaces. To percuss, place the distal joint of your middle finger (use your nondominant hand) firmly on the chest. With the index and the middle finger of your dominant hand, use a quick, sharp, relaxed wrist motion to hit the distal joint of the finger that is resting on the chest. This action will produce a sound. Each site should be percussed about three times. Like auscultation, percussion should be performed systematically and sounds should be compared bilaterally.
Sounds (resonance, hyperresonance, dull, flat, and tympanic) are again characterized by intensity, pitch, quality, and duration. Resonance is heard
Pediatric respiratory health history and physical assessment 49
when percussing over normal lung areas. If an area sounds hyperresonant, it may be due to asthma or a pneumothorax. If an area sounds dull or flat, it may be due to atelectasis or pneumonia. A full description of percussion sounds can be located in Table 2.2 (Cox, 2001; O’Hanlon-Nichols, 1998;
Seidel et al., 2003).
If percussion reveals an area of dullness, it should be followed by an assessment of vocal resonance or vocal fremitus. Vocal resonance is the transmission of the patient’s voice through lung fields. To assess for vocal resonance, ask the child to say “99” while you auscultate all lung fields with a stethoscope. The sound heard should be muffled. If 99 is heard clearly, it is known as bronchophony and is indicative of a consolidation such as pneumonia. If bronchophony is present, assess for egophony by asking the child to say “E” as you auscultate the abnormal area. If the E sounds like “A,” egophony is present and consolidation is likely (O’Hanlon- Nichols, 1998). Another test to determine if consolidation is present is called whispered pectoriloquy. To assess whispered pectoriloquy, ask the child to whisper “1, 2, 3.” Normally, it would be difficult to hear what the child is saying. However, if consolidation is present, the numbers will be heard clearly (Lippincott, 2007).
The diaphragm is the primary muscle of breathing. The diaphragm is usually higher on the right because of the liver. To measure diaphragmatic excursion in the older child, ask him/her to inhale deeply and to hold his/
her breath. Then, percuss along the scapular line until you reach the lower border (sound changes from resonant to dull when you reach the border of the diaphragm). Mark that point and allow the child to breathe. After a few breaths, ask the child to exhale as much as possible and to hold the exhalation. Percuss up from the marked area and make a mark when the sound changes from dull to resonance. Repeat on the opposite side. Then, measure the distance between the two marks on each side. Diaphragmatic excursion is usually 3–5 cm (Seidel et al., 2003). A decrease in excursion can be related to pain, a mass in the thoracic or abdominal cavity, or paralysis of one of the diaphragms.
Table 2.2 Percussion sounds.
Sound Intensity Pitch Quality Duration Example
Resonance +++ ** Hollow Long Normal, healthy lung
Hyperresonance ++++ */** Boomlike Long/longer Hyperinflated lung
Dull +/++ ***/*** Thudlike Moderate Heart or liver
Flat + **** Dull Short Bone or muscle
Tympanic +++ **** Drumlike Moderate Stomach
+, soft; ++, medium; +++, loud; ++++, very loud;
*, very low; **, low; ***, medium; ****, high.
50 Nursing Care in Pediatric Respiratory Disease
REFERENCES
Bhandari, A., & Panitch, H. B. (2006). Pulmonary outcomes in bronchopulmo- nary dysplasia. Seminars in Perinatology, 30, 219–226.
Cox, C. L. (2001). Respiratory assessment. In G. Esmond (Ed.), Respiratory nursing (pp. 21–37). London, UK: Harcourt.
Custer, J. W., & Rau, R. E. (2009). The harriet lane handbook: A manual for pediatric house officers (front cover). Philadelphia: Elsevier Mosby.
Driessnack, M. (2010). Overview of growth and development framework. In C. L. Edelman & C. L. Mandle (Eds.), Health promotion throughout the life span (pp. 361–377). St. Louis, MO: Mosby Elsevier.
Hilman, B. C. (1993). Clinical assessment of pulmonary disease in infants and children. In B. C. Hilman (Ed.), Pediatric respiratory disease and treatment (pp.
57–67). Philadelphia: W.B. Saunders.
Lippincott. (2007). Respiratory system. In A. L. Mosher & M. Foley (Ed.), Lippincott manual of nursing practice series: Assessment (1st ed., pp. 77–105).
Philadelphia: Lippincott Williams & Wilkins.
O’Hanlon-Nichols, T. (1998). Basic assessment series the adult pulmonary system. The American Journal of Nursing, 98(2), 39–45.
Pasterkamp, H., Kraman, S. S., & Wodicka, G. R. (1997). Respiratory sounds advances beyond the stethoscope. American Journal of Respiratory and Critical Care Medicine, 156, 974–987.
Seidel, H. M., Ball, J. W., & Dains, J. E. (2003). Mosby’s guide to physical examina- tion (5th ed.). St. Louis, MO: Mosby.
51