15.3 Focused Assessment for Respiratory Disorders
When a client has a respiratory alteration, signs may show in the respiratory system, as well as in other body systems. Nurses complete a focused assessment to determine the effects of the respiratory illness on the child. Review Table 15.3 for an overview of general manifestations of respiratory alterations across body systems.
For an in-depth discussion of assessment and diagnostic tests of the respiratory system, please visit the “General Respiratory Assessment and Interventions” section of the “Respiratory Alterations” chapter of Open RN Health Alterations.[1]
Table 15.3. Manifestations of Respiratory Alterations by Body System[2],[3],[4],[5],[6]
| Body System | Clinical Manifestations |
|---|---|
| Respiratory | Dyspnea, tachypnea, bradypnea, apnea, decreased pulse oximetry reading, use of accessory muscles, nasal flaring on inspiration, adventitious or decreased lung sounds, coughing, sputum production, retractions (sternal or intercostal), expiratory grunting
Gastrointestinal: Decreased oral intake (due to difficulty breathing or inflammation of the pharynx or associated structures) Genitourinary: Decreased urine output and decrease in wet diapers (due to dehydration) HEENT: Sunken fontanels (in dehydrated infants), sore and/or red throat and tonsils, nasal discharge, nasal congestion |
| Cardiovascular | Tachycardia (in response to hypoxia, fever, or dehydration) |
| Neurological | Altered mental status, confusion, disorientation, dizziness, syncope (fainting), or headaches (due to hypoxia) |
| Musculoskeletal | Decreased activity tolerance, fatigue, and weakness (related to hypoxia). Decreased muscle mass or poor growth in children with chronic illness |
| Integumentary | Cyanosis, clubbing of the nailbeds due to chronic hypoxia, dry mucous membranes, and poor skin turgor if dehydration is present |
Life Span Considerations
When performing an assessment on a pediatric client, there are some key differences the nurse must be aware of in regard to the respiratory system[7],[8],[9]:
- Although some disorders can manifest with apnea as a clinical manifestation, periods of apnea (up to 20 seconds) are common in newborns.
- Due to their irregular breathing rhythms, respirations should be counted for a full minute for infants. The respiratory rate should also be taken when the infant is calm instead of crying.
- Infants have faster respiratory rates due to increased metabolic needs. For example, the normal respiratory rate for a newborn is 30-60 breaths per minute. The rate can vary based on whether the infant is asleep or awake.
- Infants are obligatory nose breathers, meaning they have a physiological instinct to breathe through their nose rather than their mouth. If their nose or nasal passage becomes occluded, they can develop respiratory distress.
- Based on the age of the client, subjective respiratory assessment data may need to be collected from the client’s caregiver.
- Some respiratory disorders may cause the pediatric client to experience pain, which they may be unable to describe on a scale of 0 to 10. Review pediatric pain scales in the “Applying the Nursing Process to Caring for an Ill or Hospitalized Pediatric Client” section of the “Planning Care for the Ill or Hospitalized Child” chapter.
- Ernstmeyer, K., & Christman, E. (Eds.). (2024). Health alterations. Access for free at https://wtcs.pressbooks.pub/healthalts/ ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2024). Health alterations. Access for free at https://wtcs.pressbooks.pub/healthalts/ ↵
- Teall, A. M., Pittman, O. A., & Pandian, V. (2020). Evidence-based assessment of the lungs and respiratory system. In Gawlik, K. S., Melnyk, B. M., & Teall, A. M. (Eds.). Evidence-based physical examination: Best practices for health & well-being assessment. Springer Publishing Company. https://doi.org/10.1891/9780826164544.0007 ↵
- Reyes, F., Le, J., & Modi, P. (2024). Lung exam: Treatment & management: Point of care. StatPearls. [Internet] https://www.statpearls.com/point-of-care/24499 ↵
- Dezube, R. (2022). Medical history and physical examination for lung disorders. Merck Manual Consumer Version. https://www.merckmanuals.com/home/lung-and-airway-disorders/diagnosis-of-lung-disorders/medical-history-and-physical-examination-for-lung-disorders ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2023). Nursing Skills 2e. Access for free at https://wtcs.pressbooks.pub/nursingskills/ ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2023). Nursing Skills 2e. Access for free at https://wtcs.pressbooks.pub/nursingskills/ ↵
- Connelly, S., Meissbach, S., Schmidt, M., & Ascano, F. (2022). Respiratory system in pediatrics. Stanford Medicine Children's Health. https://www.stanfordchildrens.org/content-public/pdf/respiratory-system-in-pediatrics.pdf ↵
- Teall, A. M., Pittman, O. A., & Pandian, V. (2020). Evidence-based assessment of the lungs and respiratory system. In Gawlik, K. S., Melnyk, B. M., & Teall, A. M. (Eds.). Evidence-based physical examination: Best practices for health & well-being assessment. Springer Publishing Company. https://doi.org/10.1891/9780826164544.0007 ↵