Respiratory assessment: a step-by-step guide for nursing students

Respiratory assessment is one of the most critical physical examination skills in nursing. The respiratory system can deteriorate rapidly — a patient who is breathing comfortably at the start of your shift can be in acute distress within an hour. A systematic, consistent assessment approach allows you to detect deterioration early, interpret findings accurately, and communicate clearly with the rest of the care team.

Nurses perform respiratory assessments on admission, at the start of every shift, after any respiratory intervention, whenever a patient reports new or worsening shortness of breath, and as part of every head-to-toe assessment. This guide covers the complete process — preparation through clinical interpretation — along with the normal and abnormal findings you need to know for clinical practice and NCLEX.

Quick-reference: what a complete respiratory assessment must include

• Respiratory rate, depth, and rhythm (counted for a full 60 seconds)
• Oxygen saturation (SpO2) via pulse oximetry
• Inspection: work of breathing, accessory muscle use, chest symmetry, skin color, jugular venous distension
• Palpation: chest expansion, tactile fremitus, tracheal position, tenderness
• Percussion: resonance across lung fields
• Auscultation: all lung fields, anterior and posterior, comparing side to side

The four assessment techniques: overview

Step-by-step respiratory assessment

Step 1: Prepare the patient and environment

Before touching the patient, gather your equipment and create conditions for an accurate assessment.

Equipment needed:

• Stethoscope (diaphragm and bell)
• Pulse oximeter
• Watch with a second hand (or phone timer) for respiratory rate
• Penlight (for inspecting oropharynx if upper airway concern)

Preparation steps:

1. Perform hand hygiene and don appropriate PPE per precaution status.
2. Introduce yourself and explain the procedure. Obtain verbal consent.
3. Position the patient sitting upright at 90 degrees (high Fowler’s) if tolerated — this position maximizes diaphragmatic excursion and makes posterior auscultation accessible. If the patient cannot sit, use semi-Fowler’s and note the position in documentation.
4. Expose the chest fully. Gown and draping should allow clear access to the anterior and posterior chest. Never auscultate through clothing.
5. Ensure the room is quiet enough for auscultation. Ask visitors to step out briefly if necessary.
6. Warm the stethoscope diaphragm in your hands before placing it on the patient.

Step 2: Inspection

Inspection is conducted throughout the entire assessment — you begin gathering visual data from the moment you enter the room. Inspect systematically from general to specific.

Respiratory rate and rhythm

Count respiratory rate for a full 60 seconds with your hand resting lightly on the patient’s chest or abdomen — patients alter their breathing pattern if they know they are being watched, so count discreetly while appearing to take a pulse. Normal adult respiratory rate is 12–20 breaths per minute at rest (Jarvis, Physical Examination and Health Assessment, 2020).

• Tachypnea (>20/min): seen in fever, pain, anxiety, hypoxia, respiratory distress, sepsis
• Bradypnea (<12/min): seen in opioid overdose, head injury, profound metabolic alkalosis
• Apnea: cessation of breathing — immediate intervention required

Note rhythm: normal breathing (eupnea) is regular and effortless. Document irregular patterns by name if recognizable (Cheyne-Stokes, Kussmaul, Biot’s).

SpO2 (oxygen saturation)

Apply the pulse oximeter before auscultation. Normal SpO2 in healthy adults is 95–100%. Values below 90% indicate significant hypoxemia requiring prompt assessment and intervention. Review pulse oximetry and capnography for full interpretation guidance, including the limitations of oximetry in patients with carbon monoxide poisoning, anemia, or peripheral vasoconstriction.

Depth and effort of breathing

Assess the tidal volume of each breath visually. Shallow breaths (hypopnea) reduce alveolar ventilation even when the respiratory rate is normal. Note:

• Nasal flaring: widening of the nares on inspiration — an early sign of increased respiratory effort
• Pursed-lip breathing: a compensatory mechanism commonly used by patients with COPD to maintain airway patency during expiration
• Prolonged expiration: ratio of inspiration to expiration is normally 1:2; a ratio of 1:3 or longer suggests obstructive disease

Accessory muscle use

At rest, quiet breathing uses only the diaphragm. Accessory muscle recruitment — visible contraction of the sternocleidomastoid, scalenes, or intercostals — indicates the patient is working harder than normal to move air. Severe distress may also produce subclavicular and suprasternal retractions.

Chest symmetry and shape

Observe the chest from the front and sides. The normal anteroposterior (AP) to transverse diameter ratio is approximately 1:2. An AP:transverse ratio approaching 1:1 (barrel chest) suggests chronic air trapping, as seen in advanced emphysema or COPD.

Observe for:

• Asymmetric chest expansion: one side expands less than the other — suggests pneumothorax, pleural effusion, or unilateral atelectasis on the diminished side
• Pectus excavatum (funnel chest): sternal depression; may restrict lung expansion
• Pectus carinatum (pigeon chest): forward sternal protrusion
• Scoliosis or kyphosis: can restrict thoracic expansion and reduce total lung capacity
• Paradoxical breathing: chest wall moves inward on inspiration (instead of outward) — seen in flail chest; requires urgent escalation

Skin color and peripheral signs

• Central cyanosis (blue discoloration of lips, oral mucosa, tongue): indicates significant arterial oxygen desaturation — a late and serious sign
• Peripheral cyanosis (fingertips, nail beds): may reflect poor perfusion rather than hypoxemia; less specific
• Pallor: anemia reducing oxygen-carrying capacity even when SpO2 is normal
• Clubbing: rounding and widening of the nail beds with loss of the normal angle; associated with chronic hypoxia, cystic fibrosis, lung cancer, and bronchiectasis
• Jugular venous distension (JVD): visible distension of the external jugular vein with the patient at 45 degrees suggests elevated central venous pressure — seen in right-sided heart failure, cardiac tamponade, and tension pneumothorax
• Peripheral edema: bilateral dependent edema in conjunction with respiratory symptoms suggests right-sided heart failure or cor pulmonale

Step 3: Palpation

Palpation uses tactile information to confirm visual findings and identify structural abnormalities. Use a firm but gentle touch throughout.

Chest expansion (excursion)

Assess both anterior and posterior chest expansion.

Posterior: Place your hands flat on the patient’s posterior lower chest with thumbs meeting at the spine and fingers spread laterally. Ask the patient to take a deep breath. Your thumbs should separate symmetrically by at least 3–5 cm with each full breath. Asymmetric movement indicates reduced expansion on the lagging side.

Anterior: Place thumbs on either side of the lower sternum with fingers spread laterally. Repeat the observation.

Tactile fremitus

Fremitus is the vibration felt on the chest wall when the patient speaks. Place the ulnar surface of your hand on the posterior chest and ask the patient to say “ninety-nine” or “one-two-three” repeatedly as you systematically move your hand across both lung fields, comparing side to side.

Tracheal position

Place one finger in the suprasternal notch and gently palpate the trachea. It should be midline. Tracheal deviation is a significant finding:

• Deviation toward the affected side: atelectasis (lung volume loss pulls trachea toward it), fibrosis
• Deviation away from the affected side: tension pneumothorax, large pleural effusion (mediastinum pushed away) — tension pneumothorax with tracheal deviation is a medical emergency requiring immediate intervention

Tenderness and crepitus

Systematically palpate the chest wall for tenderness. Localized tenderness is common after rib fracture, pleuritis, or chest wall injury. Subcutaneous emphysema — a crackling, crunching sensation under the fingers resembling bubble wrap — indicates air has tracked into soft tissues, often after pneumothorax, tracheal injury, or barotrauma during mechanical ventilation.

Step 4: Percussion

Percussion involves tapping the chest wall with the tip of the middle finger on one hand striking the middle phalanx of the middle finger of the other hand (which rests flat on the chest). The resulting sound reflects the density of underlying tissue.

Percuss in a systematic zigzag pattern across the posterior chest, comparing each level side to side before moving down. Repeat across the anterior and lateral fields.

Expected normal findings on percussion: resonance throughout all lung fields except over the heart (dull) and the liver inferiorly on the right (dull). The level at which resonance transitions to dullness on the right side helps approximate the diaphragmatic position.

Step 5: Auscultation

Auscultation is the most information-rich component of the respiratory assessment. Use the diaphragm of the stethoscope (which transmits high-frequency sounds best) for most breath sounds. The bell is used for low-frequency sounds and is rarely needed in routine respiratory assessment.

Technique

Ask the patient to breathe slowly and deeply through an open mouth. Place the diaphragm firmly against skin — never over clothing, hair, or drainage tubes. Listen for a complete breath cycle (inspiration and expiration) at each location before moving.

Auscultate in a systematic pattern comparing side to side at each level. The standard approach is a posterior zigzag pattern descending from the apices (above the scapulae) to the bases at approximately the 10th thoracic vertebra, then anterior and lateral fields. This side-to-side comparison is essential — isolated unilateral abnormalities are often missed if you auscultate one side completely before moving to the other.

Normal breath sounds by location

Bronchial sounds heard over the peripheral lung fields are abnormal — they indicate consolidation is conducting the centrally generated sounds to the periphery.

Adventitious (abnormal) breath sounds

For a comprehensive breakdown of adventitious lung sounds including audio descriptions, wave patterns, and full differential diagnoses, see the adventitious lung sounds guide.

Voice sounds (confirmatory, when abnormality found)

When percussion or auscultation suggests consolidation, voice transmission tests can confirm:

• Bronchophony: Ask the patient to say “ninety-nine.” Normally muffled over peripheral lung; if heard clearly and loudly, consolidation is present.
• Egophony: Ask the patient to say “eee.” If it sounds like “ayyy” through the stethoscope, the underlying tissue is consolidated (E-to-A change).
• Whispered pectoriloquy: Ask the patient to whisper “one-two-three.” Normally inaudible peripherally; clear transmission indicates consolidation.

Normal findings summary

Abnormal findings and clinical interpretation

When assessment yields abnormal findings, interpret them as a cluster rather than in isolation — a single sign rarely confirms a diagnosis, but a pattern of findings pointing in the same direction provides strong clinical evidence.

Reduced or absent breath sounds on one side

• Pneumothorax: hyperresonant percussion, absent breath sounds, possible tracheal deviation away from affected side, decreased fremitus. See pneumothorax nursing for management priorities.
• Pleural effusion: dull percussion, absent or greatly reduced breath sounds at the base, decreased fremitus, possible tracheal deviation away from large effusion. E-to-A change may be heard just above the effusion line.
• Atelectasis: dull to flat percussion, reduced breath sounds, increased fremitus over consolidated area, possible tracheal deviation toward the affected side.

Bilateral crackles, worse at bases Suggests fluid accumulation in the alveoli or small airways. With dyspnea, elevated JVD, peripheral edema, and a history of heart failure, this pattern is consistent with acute pulmonary edema. With fever, productive cough, and consolidation on percussion, pneumonia is likely. The clinical history, vital signs, and chest imaging together confirm the diagnosis. Initiate oxygen therapy as indicated and escalate for provider assessment.

Diffuse expiratory wheezing Bronchoconstriction causing airflow limitation on expiration. In a patient with a known asthma or COPD history, this is an acute exacerbation until proven otherwise. Bronchodilator therapy and close monitoring are indicated. A silent chest in a severe asthma attack — no wheeze despite obvious distress — is an ominous sign indicating near-complete airflow obstruction.

Stridor Upper airway obstruction: immediate priority. Causes include anaphylaxis, foreign body aspiration, epiglottitis, post-extubation subglottic edema, and angioedema. Call for help, position the patient upright, prepare for airway management, and administer epinephrine if anaphylaxis is suspected.

Unilateral consolidation findings (dullness, bronchial breath sounds, increased fremitus) Combined with fever, productive cough, and elevated WBC, this pattern is consistent with lobar or segmental pneumonia. Refer to the pneumonia nursing guide for the full care framework including antibiotic stewardship and oxygenation management.

Abnormal respiratory patterns

• Kussmaul breathing: deep, rapid, regular — metabolic acidosis (DKA, renal failure). Correlate with ABG interpretation for pH and HCO3 values.
• Cheyne-Stokes: cyclical crescendo-decrescendo pattern with periods of apnea — severe heart failure, stroke, or end-of-life.
• Biot’s breathing: irregular rate and depth with sudden apneic pauses — severe neurological injury, meningitis, opioid toxicity.

NCLEX tips for respiratory assessment

1. Count respiratory rate for a full 60 seconds — 15-second counts multiplied by 4 introduce significant error. The NCLEX and clinical practice both require a full-minute count.

2. Tachypnea is often the earliest sign of respiratory decompensation — before SpO2 drops, the body compensates by increasing rate. Unexplained tachypnea (RR >20) always requires investigation.

3. SpO2 has limits — pulse oximetry measures oxygen saturation of hemoglobin but cannot detect carbon monoxide poisoning (carboxyhemoglobin reads as normal oxyhemoglobin) or anemia. Always pair SpO2 with clinical assessment.

4. A silent chest in asthma is worse than a wheezing chest — wheezing requires airflow. No wheeze with visible severe distress means near-complete obstruction. This is a life-threatening emergency.

5. Tracheal deviation direction is key on NCLEX — tension pneumothorax pushes the trachea away from the affected side. Atelectasis and fibrosis pull toward the affected side. Know which direction for each condition.

6. Adventitious sounds that clear with coughing are rhonchi — rhonchi are secretion-based. Fine crackles do not clear with coughing because they are caused by alveolar opening, not secretions.

7. Stridor is always inspiratory — stridor originates at the level of the upper airway. Wheezes are typically expiratory (lower airway). Stridor = upper airway obstruction until proven otherwise.

8. The diaphragm of the stethoscope is used for breath sounds — the bell is used for low-frequency cardiac sounds. Know this for NCLEX questions on auscultation technique.

9. Increased fremitus over a lung field indicates consolidation — sound conducts more readily through dense tissue. Decreased fremitus indicates air or fluid between lung and chest wall.

10. Barrel chest indicates chronic air trapping — not a normal finding. It is associated with COPD and emphysema where hyperinflation has permanently increased the AP diameter.

11. High Fowler’s position (90 degrees) maximizes respiratory function — gravity lowers the diaphragm and increases tidal volume. Always position dyspneic patients upright unless contraindicated.

12. Pursed-lip breathing is therapeutic in COPD — it maintains positive pressure in the airways during expiration, preventing early airway collapse. Teach this technique actively.

13. Clubbing indicates chronic hypoxia — it does not develop from an acute episode. NCLEX often uses clubbing as a clue to chronic underlying respiratory disease (COPD, cystic fibrosis, lung cancer).

14. Egophony (E-to-A change) confirms consolidation — when the patient says “eee” and you hear “ayyy” through the stethoscope over a lung field, consolidation is present. This is high-yield NCLEX content.

15. Pleural friction rub does not change with coughing — this differentiates it from rhonchi, which do. The rub is caused by inflamed pleural surfaces and is unchanged by airway clearance maneuvers.

16. A patient with COPD may have a baseline SpO2 of 88–92% — this is their acceptable range. Targeting 98–100% with supplemental oxygen risks suppressing hypoxic drive. Know the target SpO2 for COPD (88–92%) vs. standard patients (94–100%).

17. Cheyne-Stokes breathing at end of life is expected — recognize this pattern as a normal physiological change in dying patients. It does not require intervention and should be explained to families.

18. ABG interpretation follows respiratory assessment — after identifying an abnormal breathing pattern or SpO2, the next diagnostic step is often an arterial blood gas. Review ABG interpretation alongside respiratory assessment skills.

NCLEX practice scenarios

Scenario 1

A nurse is assessing a 68-year-old male with a history of COPD who is admitted for an acute exacerbation. On assessment, the nurse notes an RR of 26/min, pursed-lip breathing, SpO2 of 87% on room air, bilateral expiratory wheezes, and a barrel-shaped chest. Which action should the nurse take first?

A. Administer oxygen at 2 L/min via nasal cannula
B. Place the patient in high Fowler’s position
C. Prepare for endotracheal intubation
D. Obtain a sputum specimen for culture

Answer: B — High Fowler’s position

Rationale: Positioning is the first, fastest, zero-risk intervention. High Fowler’s maximizes diaphragmatic excursion and reduces the work of breathing immediately. Oxygen may then be initiated at low flow (2 L/min targeting SpO2 88–92% in COPD). Intubation is not indicated at this stage, and sputum collection is not a priority action when the patient is in respiratory distress.

Scenario 2

A nurse auscultates the lungs of a post-operative patient who had an abdominal surgery 18 hours ago. Fine crackles are heard at both lung bases. The patient is afebrile, SpO2 is 95% on room air, and RR is 18/min. What is the most appropriate nursing intervention?

A. Notify the provider immediately for a possible pneumonia
B. Administer a bronchodilator per PRN order
C. Encourage deep breathing exercises and incentive spirometry
D. Place the patient in Trendelenburg position to mobilize secretions

Answer: C — Deep breathing and incentive spirometry

Rationale: Basilar crackles in the early post-operative period indicate atelectasis — alveolar collapse from shallow breathing and immobility after surgery. This is expected and manageable with deep breathing exercises and incentive spirometry, which reopen collapsed alveoli. There is no fever or other evidence of pneumonia. Bronchodilators are for bronchospasm. Trendelenburg is contraindicated post-abdominal surgery and is not indicated here.

Scenario 3

While performing a respiratory assessment, a nurse observes tracheal deviation to the right, absent breath sounds on the left, and hyperresonance to percussion on the left. The patient is diaphoretic, hypotensive (BP 84/52), and in acute distress. What does the nurse suspect and what is the priority action?

A. Left pleural effusion — prepare for thoracentesis
B. Left tension pneumothorax — call for emergent needle decompression
C. Left-sided pneumonia — obtain blood cultures and start antibiotics
D. Pulmonary embolism — administer anticoagulation

Answer: B — Left tension pneumothorax

Rationale: Tracheal deviation away from the affected side (to the right, away from the left) combined with absent breath sounds, hyperresonance, hypotension, and distress is the classic presentation of tension pneumothorax — air accumulating in the pleural space under pressure, compressing the mediastinum. This is an immediately life-threatening emergency. Needle decompression (2nd intercostal space, midclavicular line on the affected side) is required before imaging. Pleural effusion causes dullness to percussion, not hyperresonance.

Scenario 4

A nurse caring for a patient with heart failure performs an evening assessment and finds new bilateral crackles at the lung bases, JVD at 45 degrees, and 2+ pitting edema bilaterally. SpO2 has dropped from 97% to 91% since morning. What is the nurse’s priority assessment finding?

A. The bilateral pitting edema
B. The JVD
C. The drop in SpO2 to 91%
D. The bilateral crackles

Answer: C — Drop in SpO2 to 91%

Rationale: SpO2 of 91% represents a significant decline from baseline and indicates deteriorating oxygenation. This is the priority finding because it directly reflects the patient’s ability to maintain adequate oxygen delivery to tissues. All other findings (edema, JVD, crackles) corroborate pulmonary congestion consistent with decompensated heart failure, but the SpO2 change is the most acutely actionable finding requiring immediate provider notification and oxygen supplementation per oxygen therapy protocol.

Scenario 5

A nurse hears a grating, leathery sound during both inspiration and expiration in a patient with pleuritic chest pain. The sound does not change when the patient coughs. What adventitious sound is the nurse hearing?

A. Coarse crackles
B. Pleural friction rub
C. Rhonchi
D. Stridor

Answer: B — Pleural friction rub

Rationale: A pleural friction rub is a grating or creaking sound produced by inflamed pleural surfaces moving against each other. It is present during both inspiration and expiration and does not change with coughing — this distinguishes it from rhonchi, which do clear with coughing. It is associated with pleuritis, pulmonary embolism, and pneumonia involving the pleural surface.

Scenario 6

A patient is brought to the emergency department with sudden onset of severe dyspnea and a harsh, high-pitched inspiratory sound audible without a stethoscope after eating at a restaurant. What is the nurse’s immediate priority?

A. Auscultate the lung fields and apply oxygen by nasal cannula
B. Assess for foreign body airway obstruction and prepare for emergency airway intervention
C. Obtain a chest X-ray and call pulmonology
D. Administer a nebulized bronchodilator

Answer: B — Assess for foreign body airway obstruction and prepare for emergency airway intervention

Rationale: The harsh inspiratory sound (stridor) following eating in a restaurant strongly suggests foreign body aspiration causing upper airway obstruction. Stridor is an upper airway emergency. The Heimlich maneuver (abdominal thrusts) should be attempted in a conscious patient, and airway management resources including laryngoscopy equipment should be prepared immediately. Administering oxygen via nasal cannula will not relieve mechanical obstruction. Bronchodilators are for lower airway bronchospasm and will not address an obstruction.

Scenario 7

During a shift assessment, a nurse asks a patient to say “ninety-nine” and notices the voice sounds clearly and loudly through the stethoscope over the right lower lobe. Percussion over the same area is dull. The patient has a productive cough and temperature of 38.9°C (102°F). What do these findings indicate?

A. Right-sided pleural effusion
B. Right lower lobe pneumothorax
C. Right lower lobe consolidation consistent with pneumonia
D. Normal findings for an adult patient

Answer: C — Right lower lobe consolidation consistent with pneumonia

Rationale: Bronchophony (clear, loud voice transmission through the stethoscope) indicates the underlying lung tissue is consolidated — dense tissue conducts sound more readily than air-filled lung. Combined with dullness to percussion, fever, and productive cough, this is classic right lower lobe pneumonia. Pleural effusion also causes dullness, but typically produces decreased (not increased) fremitus and absent (not louder) voice sounds. See the pneumonia nursing guide for full assessment and management.

References

• Walker HK, Hall WD, Hurst JW (eds). Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Butterworths; 1990. Chapter 22: Chest Examination. Available from: https://www.ncbi.nlm.nih.gov/books/NBK368/
• Sinnatamby CS (ed). Respiratory Assessment. In: Nursing Skills — Open Resources for Nursing (Open RN). NCBI Bookshelf. NBK593192. Available from: https://www.ncbi.nlm.nih.gov/books/NBK593192/
• Jarvis C. Physical Examination and Health Assessment. 8th ed. Elsevier; 2020. Chapter 19: Thorax and Lungs.
• Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. Elsevier; 2021.
• Bickley LS. Bates’ Guide to Physical Examination and History Taking. 13th ed. Wolters Kluwer; 2021. Chapter 8: The Thorax and Lungs.
• National Council of State Boards of Nursing (NCSBN). 2023 NCLEX-RN Test Plan. Chicago: NCSBN; 2023.