Guide — Respiratory

Respiratory Assessment for Nurses

A systematic respiratory assessment uses the four techniques of physical examination — inspection, palpation, percussion, and auscultation — to identify normal and abnormal findings and guide nursing priorities.

10 min read · Respiratory

Educational use only. Clinical assessment requires direct patient contact, institutional training, and clinical judgment. This guide supports learning and NCLEX preparation — it does not replace clinical education or provider evaluation. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.

Respiratory Assessment Sequence

A complete respiratory assessment follows the IPPA sequence: Inspection → Palpation → Percussion → Auscultation. For the respiratory system, this sequence is followed exactly — unlike abdominal assessment where auscultation precedes percussion and palpation.

Inspection: Observe rate, rhythm, depth, work of breathing, chest shape, skin color, and accessory muscle use

Palpation: Assess chest expansion symmetry, tactile fremitus, tracheal position, tenderness

Percussion: Identify resonance vs dullness vs hyperresonance over lung fields

Auscultation: Listen with stethoscope to all lung fields — anterior and posterior — comparing side to side

Inspection

Inspection provides immediate visual data about the patient's respiratory status. Begin before touching the patient.

What to Observe	Normal Finding	Abnormal / Concern
Respiratory rate	12–20 breaths/min (adult)	<12 = bradypnea (opioids, CNS depression); >20 = tachypnea (pain, infection, hypoxia)
Rhythm	Regular, even	Cheyne-Stokes, Biot, Kussmaul, or cluster breathing
Depth	Moderate, consistent tidal volume	Shallow (atelectasis, pain splinting) or deep/labored (metabolic acidosis)
Chest shape	AP:lateral ratio ~1:2	Barrel chest (AP ratio 1:1) — COPD; pectus excavatum; scoliosis
Accessory muscle use	None at rest	SCM, scalene, intercostal retractions — indicates increased work of breathing
Skin color	Pink, warm	Central cyanosis (hypoxia); pallor (anemia, shock); mottling (poor perfusion)
Nasal flaring	Absent	Present = respiratory distress (especially in children and neonates)
Lip pursing	Absent at rest	Present in COPD (prolongs exhalation to maintain airway pressure)

Palpation

Chest Expansion SymmetryPlace hands on the posterior chest with thumbs at the midspine and fingers spread laterally. Ask the patient to take a deep breath. Both thumbs should move apart equally. Unequal expansion suggests pneumothorax, effusion, or consolidation on the lagging side.

Tactile FremitusPlace the ulnar edge or palm on the chest wall. Ask the patient to say '99' or 'blue moon.' Vibrations felt are tactile fremitus. Increased fremitus: consolidation (pneumonia). Decreased fremitus: effusion, pneumothorax, emphysema (air or fluid between pleura and lung dampens transmission).

Tracheal PositionLightly place a fingertip in the suprasternal notch. The trachea should be midline. Tracheal deviation away from the affected side = tension pneumothorax (pushes mediastinum). Tracheal deviation toward the affected side = atelectasis (pulls mediastinum).

Tenderness and CrepitusPalpate the chest wall for tenderness (rib fracture, pleuritis) or subcutaneous emphysema — a crackling sensation under the skin indicating air has escaped into subcutaneous tissue (pneumothorax, tracheal injury).

Percussion

Percussion identifies air, fluid, or solid tissue under the chest wall. Strike the middle finger of the non-dominant hand placed flat on the chest with the middle finger of the dominant hand. Compare side to side.

Sound	Quality	Indicates
Resonance	Hollow, low-pitched, long	Normal aerated lung
Hyperresonance	Very hollow, booming	Pneumothorax, emphysema (excess air)
Dullness	Thudding, flat, short	Consolidation (pneumonia), pleural effusion, atelectasis, tumor
Tympany	Drum-like	Stomach; large pneumothorax
Flatness	Extreme dullness	Dense consolidation, large effusion, muscle or bone

Auscultation

Use the diaphragm of the stethoscope. Auscultate at least 4–6 points anteriorly and 6–8 posteriorly, moving side to side for comparison. Ask the patient to breathe deeply through the mouth.

Normal Breath SoundsVesicular (soft, low-pitched, longer inspiration) over most lung fields. Bronchovesicular (medium pitch, equal I:E) at the mainstem bronchi level. Bronchial (loud, high-pitched, longer expiration) over the trachea. These are normal positions — if bronchial sounds are heard peripherally, it suggests consolidation.

Crackles (Rales)Fine crackles: late-inspiratory, high-pitched, non-clearing with cough — pulmonary fibrosis, early pulmonary edema. Coarse crackles: early-inspiratory, low-pitched, may clear with cough — secretions, pneumonia, pulmonary edema.

WheezesHigh-pitched, musical, continuous sound — predominantly expiratory. Indicates airway narrowing (bronchospasm in asthma, COPD exacerbation, anaphylaxis). Inspiratory wheeze suggests upper airway obstruction.

RhonchiLow-pitched, snoring or gurgling quality — caused by secretions in large airways. May clear with coughing. Common in pneumonia, bronchitis, COPD with retained secretions.

StridorLoud, high-pitched inspiratory sound audible without a stethoscope — upper airway obstruction (croup, epiglottitis, foreign body, post-extubation edema). Requires immediate assessment and intervention.

Pleural Friction RubLeathery, grating sound — caused by inflamed pleural surfaces rubbing together (pleuritis). Heard during both inspiration and expiration. Does not change with coughing.

Absent or Diminished SoundsReduced or absent breath sounds suggest pneumothorax, large pleural effusion, severe atelectasis, or patient positioning issues (ETT in right mainstem bronchus).

Nursing Considerations

Document findings precisely — use standardized language: location (lobe, quadrant), quality (fine/coarse), timing (inspiratory/expiratory), and whether sounds clear with coughing.
Reassess after interventions — after suctioning, repositioning, bronchodilators, or diuretics, repeat auscultation to evaluate response.
SpO₂ correlation — always correlate breath sounds with pulse oximetry and, when available, ABG results.
Position matters — assess with the patient upright when possible. Dependent lung fields may have increased crackles from fluid accumulation.
Compare bilaterally — always compare right versus left at the same level before moving to the next location.
Acute change = escalate — new or worsening absent breath sounds, new stridor, or sudden respiratory rate changes require immediate provider notification.

NCLEX Pearls

›IPPA: Inspection, Palpation, Percussion, Auscultation — respiratory assessment follows this order (unlike abdomen, which uses IAPP).
›Tracheal deviation away from the affected side = tension pneumothorax (emergency). Toward the affected side = atelectasis.
›Tactile fremitus is increased in consolidation (pneumonia) and decreased in effusion, pneumothorax, and emphysema.
›Bronchial breath sounds heard peripherally (not over trachea) = consolidation — classic sign of pneumonia.
›Stridor = upper airway obstruction — assess, call provider immediately, prepare for airway management.
›Pleural friction rub is heard during both inspiration and expiration and does not change with coughing (differentiates from crackles).
›Normal adult respiratory rate is 12–20/min. Tachypnea (>20) is a sensitive early sign of deterioration.

Related Resources

Breath Sounds ReferenceVesicular, crackles, wheezes, rhonchi, stridor — descriptions and causes

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Breath Sounds Comparison ChartSide-by-side: sound, description, cause, and clinical significance

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Oxygen Delivery DevicesFlow rates, FiO₂ ranges, and nursing considerations

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Respiratory Failure ReferenceType I vs Type II — causes, ABG patterns, and nursing implications

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ABG Foundation GuideSystematic approach to arterial blood gas interpretation

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COPD vs Asthma GuideTwo obstructive diseases, different triggers and trajectories — compared

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Standards & sources

Fact-checked Jun 21, 2026

This page is written to align with American Association for Respiratory Care (AARC) · GOLD (COPD) / ATS / CHEST. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →