Listen to the lungs last. Look at the patient first.

01 / Purpose

When to do a focused respiratory assessment.

A head-to-toe assessment covers every system briefly. A focused respiratory assessment goes deeper on one, and you do it whenever breathing is the problem or might become one: a patient admitted with a respiratory condition, new shortness of breath or cough, a falling oxygen saturation, a reassessment after a breathing treatment, or after any intervention meant to improve breathing.

02 / Ask

Ask: the subjective data.

If the patient can talk comfortably, start with a few targeted questions:

• History: Have you been diagnosed with a respiratory condition, such as asthma, COPD, pneumonia, or allergies?
• Breathing: Are you short of breath? At rest or with activity? Is it worse lying flat?
• Cough: Is it dry or productive? What color and amount is the sputum? Any blood?
• Pain: Does it hurt to breathe or cough? Where?
• Exposures and habits: Do you smoke or vape, now or in the past?
• Medications: Do you use inhalers, home oxygen, or other breathing treatments?

03 / Inspect

Inspect: rate, pattern, effort, and color.

Inspection is the most informative part of the exam. Look at:

Level of consciousness

New restlessness, confusion, or drowsiness can be an early sign of poor oxygenation.

Rate & pattern

Count for a full 30 to 60 seconds. Adults normally breathe 12–20 times a minute at rest. Under 12 is bradypnea; over 20 is tachypnea. Note rhythm and depth.

Effort

Accessory muscle use, retractions, nasal flaring, prolonged expiration, and whether the patient can speak in full sentences.

Color

Lips, nail beds, and skin for cyanosis (a bluish tinge) or pallor.

Chest shape

Symmetry, and the front-to-back vs. side-to-side diameter. It's normally about 1:2; a 1:1 ratio is a "barrel chest," often seen in chronic lung disease.

Fingers

Clubbing of the fingertips can be a sign of chronic low oxygen.

Oxygen & SpO₂

Device, flow rate, fit, and saturation compared with the prescribed target (often 94–98% for most adults).

04 / Palpate & percuss

Palpate and percuss.

Using light fingertip pressure on the front and back of the chest, check for tenderness, masses, crepitus (a popping or crackling feeling under the skin), and whether both sides expand equally when the patient breathes in. Unequal expansion suggests one side isn't filling well.

Not every program teaches percussion at the entry level, and many nurses don't routinely perform it. If yours does: normal lung tissue sounds clear and hollow (resonant), while dense areas, such as lung affected by pneumonia or collapsed lung (atelectasis), sound dull.

05 / Auscultate

Auscultate: technique, then sounds.

Sit the patient upright if possible (or turn side to side if they can't sit up). Use the diaphragm of the stethoscope directly on skin, not over clothing, and avoid bone. Listen to at least one full breath at each spot, and compare side to side rather than listening all the way down one side and then the other. For a tired patient, start at the bases, where problems often show up first, and work upward.

Normal breath sounds differ by location: bronchial sounds are loud and high-pitched over the trachea; bronchovesicular sounds are medium-pitched over the major bronchi; vesicular sounds are soft and rustling over most of the lung fields. Abnormal (adventitious) sounds include:

06 / Worked case

Mr. D.'s reassessment at 1100.

Mr. D. is the fictional 72-year-old with right lower lobe pneumonia from our clinical skills series. At 0800 he had respirations of 24, an SpO₂ of 90% on 2 L/min, and crackles at the right base, and the nurse called the provider. After positioning, coughing and deep-breathing coaching, fluids, and the treatment changes, the nurse does a focused reassessment:

Ask

"It's easier to cough stuff up now." Pleuritic pain 3/10 with coughing.

Inspect

Alert and oriented. Respirations 20, regular. No accessory muscle use. Speaks in full sentences. Lips pink. SpO₂ 93% on 2 L/min.

Palpate

Chest expansion slightly reduced on the right. No crepitus.

Auscultate

Crackles persist in the right lower lobe; diminished breath sounds at the right base. Left lung clear.

Interpret

Improving, not resolved: less work of breathing and better saturation, but the right base is still affected. Continue the plan and reassess per protocol.

That interpretation line is the point of the assessment. "Crackles RLL" on its own says nothing about direction. "Improving, not resolved" tells the next nurse exactly where Mr. D. stands. That's the evaluation step of his care plan.

07 / Life span

Older adults and children.

• Older adults: the chest wall becomes less flexible, so expansion decreases and breathing can be shallower. Patients tire more easily, so allow rest between parts of the exam. In patients with COPD, diminished breath sounds may be their baseline; compare with prior documentation.
• Infants: a normal respiratory rate is 30–60 breaths a minute in the first year. Count for a full minute while the infant is calm, not crying. Brief pauses in breathing of up to about 10 seconds can be normal. Young infants breathe mainly through the nose, so a blocked nose matters.

Keep going with Mr. D.

Document what you heard.