9.3 Brief Scan: Respiratory System

A brief scan (see Figure 9.6) involves inspection of the client’s breathing and includes elements of the primary survey (ABCCS). This assessment helps you quickly recognize cues of clinical deterioration, specifically signs of respiratory distress, and may influence your decision on whether immediate action is required. The steps of a brief scan are prioritized in order of importance. For example, you need to assess whether an airway is patent (i.e., not obstructed) before you assess presence of breathing and respiratory rate.

Guided by the primary survey (ABCCS), steps of the brief scan of the respiratory system include assessing respiratory effort and signs of respiratory distress:

Step 1. Assess airway patency

• Determine whether there is an open airway or the presence of obstructive airway symptoms (e.g., secretions [mucus, blood, vomit], snoring, stridor, difficulty breathing, coughing, drooling, wet-sounding voice, unable to speak). Partial or complete obstruction of airways is commonly associated with foreign objects, inflammation, and direct injury/trauma to the airway. An obstructed airway is a first-level priority of care because it affects oxygenation and can lead to clinical deterioration.

Step 2. Assess presence of breathing and respiration rate

• First, assess the presence of breathing and eupnea, which is normal automatic breathing with a regular rhythm. Apnea is the cessation of breathing and can be permanent or intermittent. It can result in severe hypoxia, and can be associated with respiratory depression from certain medications, and can also involve sleep apnea when breathing stops intermittently.
• If breathing is present, count the rate for 30 seconds if the rhythm is regular and one minute if it is irregular. Are there signs of bradypnea or tachypnea? See Table 9.2 for normal respiratory rates.

Step 3. Assess work of breathing and signs of respiratory distress.

• Is the breathing silent or noisy? Do you hear wheezing or stridor? Normal breathing is silent. Noisy breathing with wheezing or stridor is a sign of distress.
• Do you observe nasal flaring? (This is a common symptom of respiratory distress, particularly in infants and young children. However, keep in mind that newborns are nose breathers. Additionally, air does not enter the lungs until birth so the newborn may be congested and you may observe nasal flaring.)
• Do you observe use of the accessory muscles (i.e., sternomastoid and trapezius) and intercostal tugging/pulling/retractions? Unobstructed breathing with no respiratory distress should be quiet with no observable use of accessory muscles or intercostal tugging. Observable use of accessory muscles and intercostal tugging are signs of distress.
• Do you observe any abnormal patterns of breathing? One example of an abnormal pattern of breathing is agonal breathing; it involves an irregular rhythm with gasping and is a sign that a person is near death.

Step 4. Assess oxygen saturation.

• Is the oxygen saturation level below 95 to 97%? Although 97 to 100% is the normal range for oxygen saturation levels, older individuals may have a slightly lower saturation (also, see Knowledge Bites for information about when lower oxygen saturations are acceptable in certain populations). Keep in mind that a saturation below 97% in children should always be further investigated.
  • Nail polish should be removed before assessing oxygen saturation with a pulse oximeter on the finger.
  • The accuracy of pulse oximetry can be affected by low perfusion states (e.g., vasoconstriction or low cardiac output). If you suspect low perfusion or you are getting a weak signal on the finger, use a pulse oximeter that snaps on the ear or can be taped to the forehead. These approaches to measuring oxygen saturation are best when a client has artificial nails.

Step 5. Assess level of consciousness, facial expression, and body position for signs of respiratory distress.

• Does the client have an altered level of consciousness and confusion? Normally, clients should be alert and oriented.
• Does the client show signs of agitation such as wide eyes and grimacing? Normally, a client should have a relaxed facial expression.
• Is the client showing signs of distress including hunched over/tripod position or unable to sit up? A client should normally be in a relaxed posture, while those in respiratory distress often shift into a tripod position: leaning forward with hands and/or forearms resting on their legs or another surface such as a table.

Step 6. Assess color changes (and fingernails for clubbing and testing capillary refill)

• Are there signs of cyanosis or pallor in the lips, mucous membranes, fingernails, or conjunctiva? Cyanosis and pallor result from hypoxemia, and can have many causes.

• While assessing fingernails, also assess for presence of clubbing. Clubbing is related to conditions that lead to chronic hypoxia and cause the nail angle to flatten to 180 degrees or more, the nail bed to soften and become spongy, and the fingertips distal to the distal interphalangeal joint to become enlarged. Normally, the nail angle is about 160 degrees with firm nail beds, and no enlarged fingertips. It is often assessed on the index finger, but in cases of early clubbing it may not have advanced to that digit, so it is best to assess the thumb first. To assess for the presence of clubbing:
  • Ask the client to stick their thumb (or index finger) out so that it is parallel to the ground and view it at eye level (this is considered the profile sign).
  • Inspect the nail angle at the intersection of where the nail base meets the skin (the angle should be about 160 degrees).
  • Inspect for enlarged fingertips that look “bulb-like” (see Figure 9.7).
  • Palpate the nail bed (it should be firm to touch).

• Test capillary refill on two or three fingernails of each hand. Start by applying pressure with your own finger to the client’s nail; this causes the nail to blanch (become pale in color). Apply the pressure for about 5 seconds and then release and observe the return in color. It should return within 3 seconds or less; a more sluggish return (more than 3 seconds) suggests that there may be issues with oxygenated blood perfusion, which might be caused by respiratory, cardiac, and/or peripheral vascular system issues.

Step 7.  Note the findings.

• Normal findings might be documented as: “Patent airway, quiet breathing with no signs of respiratory distress. Alert. Oxygen saturations 98%. No color changes with translucent nails and pinkish undertone. No signs of clubbing. Capillary refill returns within 1–2 seconds.”
• Abnormal findings might be documented as: “Stridor present, nasal flaring and intercostal tugging, pallor noted around lips. Oxygen saturations 91%. Slow capillary refill at 4–5 seconds.”