Now we will cover the components of
a pediatric respiratory assessment.
There are a couple steps to the
respiratory clinical exam.
This includes history taking, inspection,
palpation, percussion, and auscultation.
We'll touch on all of these.
First, the history.
When you take a history from a patient,
you need to really listen carefully.
Ask clarifying questions.
And this information is going to usually
come from the parents and caregivers.
Sometimes, depending on the patient's
age, you can also interview the child,
and you want to do a thorough chart review.
You will get a lot of your clinical
answers by looking through the chart.
Next, you ask about the
history of present illness.
This is, why is the patient there?
You're going to ask about the origin;
when did their concerns start?
How long has this been going on?
And what's the progression of their concern?
Is there anything that makes
their symptoms worse,
and is there anything that
makes their symptoms better?
And what have they tried
to remedy this condition?
Next, you'll ask about their past
medical and surgical history.
And this is sort of the,
what happened before?
You may or may not
know this pediatric patient
and this will, sort of, set the scene.
Do they have any sort
of respiratory history,
and this includes patients with asthma,
have they ever had pneumonia?
Do they have any allergic
disorders like eczema, urticaria,
which are hives or hay fever, because
we know that allergic conditions
are also associated with certain
Has the patient ever been put in the
hospital, and have they ever had surgery?
Are there any previous radiology
studies such as a chest X-ray
that can be helpful in comparing
with today's studies?
What is your patient's immunization status?
Are they up to date on vaccines?
A lot of conditions that cause respiratory
problems are vaccine preventable.
Next, you want to delve into
the family and social history.
This includes secondhand smoke exposure,
and is there any family history
of asthma or similar conditions
because these are familial?
Next, we'll move on to
the inspection category.
This involves a primary observation of
your patient's respiratory movements.
You're going to assess
for the respiratory rate.
Now, for infants, you're going
to count for 1 full minute
because the respiratory rhythm
or tempo can vary significantly.
In older children and adults, you can
do 30 seconds and multiply it by 2.
You'll assess the respiratory rhythm.
Is this regular, is it irregular, or periodic?
You're going to look at
the depth of respirations.
Is your patient breathing deeply,
or do they have shallow breathing?
What is the quality?
Are they working to breathe
or are they calm?
If it's unlabored, that's normal.
They're breathing well.
If it's labored, that means they
have increased respiratory effort.
Next, you want to assess the breath
sounds without any listening device,
and this is where you're just
sitting next to your patient
and listening for sounds
coming when they breathe.
The normal pediatric respiratory
rates are going to vary greatly
based on the age of the patient,
and this is really important for the
nurse and the clinician to know.
So, here we see, starting with premature
babies, all the way down to >12 year olds,
there's extreme variation on the normal
respiratory rate and breaths/minute.
On the right hand column, the heart
rate's going to vary as well.
The nurse really needs to know the
ballpark of these norms to know
if your patient is in, sort of, a red
flag zone; too fast or too slow.
So you're going to want to pay
attention to these numbers.
The next step is palpation,
and this is where the clinician's
going to assess the temperature
and integrity of the skin.
They're going to palpate for cervical
and axillary lymph adenopathy.
And this means palpate the lymph
nodes in the neck and in the armpit.
These are the chains that filter
the chest wall and the lungs
and these can enlarge
with certain conditions.
You're going to palpate for bulges,
abnormal movements, and tenderness.
Next, you're going to check for symmetric
respiratory excursion or chest expansion.
And this is where the provider puts
their hands along the patient's spine,
and you have the patient
take a big, deep breath.
When they're maximally inhaled, their
hands will spread apart evenly.
When the patient breathes out, the hand
should come back together symmetrically.
If they don't come back symmetrically,
the patient may have a respiratory
condition like a collapsed lung,
which is a pneumothorax, or a
consolidation or pneumonia.
Next, the clinician will do tactile fremitus.
This is where the clinician will
assess the density of the structures
below the skin by feeling for
vibrations as the patient says, "99."
An increase in tactile fremitus
indicates denser or inflamed tissue,
and that can be caused by certain
diseases such as pneumonia.
A decrease suggests air or
fluid in the pleural space,
which can be caused by
onditions like asthma.
Next, you're going to percuss your patient.
This can help you determine
if an air-filled or tissue-filled
cavity is below the skin.
Air filled structures produce a
resonant sound, like a drum,
and fluid or tissue-filled
cavities generate a dull sound.
This can be used to detect
conditions like pneumonia
or other infiltrations in your patient.
So, this technique is more
of an art than a science.
This takes a lot of practice.
Allow your hand to swing
freely at the wrist,
hammering your finger onto the target
at the bottom of your down stroke.
Your wrist has to stay relaxed
because a stiff wrist is going to force
you to push your finger into the target,
and that's not going to
get you the correct sound.
This technique takes a while to
discern the different sounds.
Now when you percuss over the
patient's chest and back,
if you percuss over a bone,
you're going to get a flat sound.
When you reach the lungs,
you're going to get a more tympanic
or resonant sound, like a drum.
And when you're over the
patient's visceral organs,
you're also going to get a flat sound.
Remember, this technique
is all in the wrists.