Respiratory assessment for registered nurses using a systematic approach: the RIPPAS framework

02 February 2025
Volume 30 · Issue 2

Abstract

Systematic assessment of the respiratory system is an important skill for both the identification of pertinent patient symptoms and for the evaluation of care provided. Although this assessment has historically been performed by advanced clinical practitioners in the community setting, since 2019, the Nursing and Midwifery Council made it a required skill for its new registrants and all nursing students in the UK. Students and existing registered nurses are expected to upskill and embed these advanced physical assessment techniques within their daily clinical practice. This article provides a theoretical overview of the systematic respiratory assessment process using the RIPPAS mnemonic, enabling practitioners to develop the required knowledge and skills. Through ongoing learning, clinical practice, regular consolidation and clinical supervision, RIPPAS can then be embedded into clinical practice for all registered nurses.

In the community setting, registered nurses are involved in the assessment and care of patients with both acute and chronic respiratory and cardiac diseases including asthma, chronic obstructive pulmonary disease and heart failure. Respiratory assessment involves the evaluation of a patient's function of breathing.

This can be undertaken to identify pathophysiological signs of respiratory disease, identify symptoms of abnormal function and to measure the severity of these symptoms. Respiratory assessment can also be used to evaluate the effectiveness of treatment or to monitor the progression of a disease process, making it an important clinical skill for registered nurses working in the community setting, which has been linked to positive patient outcomes (Duff et al, 2007; Squires, 2021).

Assessment of the respiratory system requires a systematic and comprehensive approach (Innes et al, 2018). In the community setting, these skills are commonly used by medical practitioners, allied health professionals and advanced clinical practitioners (Raleigh and Allan, 2017). Since the publication of the new Nursing and Midwifery Council (NMC) curriculum in 2019, which mandated that pre-registration nursing students should receive education and training in respiratory assessment, there is an increasing number of newly registered nurses on preceptorship programmes with competency in these skills (NMC, 2023).

There is evidence that clinical skill learning requires multiple and varied sources of education (eg demonstration of skills, observation of practice etc). This article provides registered nurses the knowledge to develop clinical skills under supervision from an expert in the clinical setting (Raleigh and Allan, 2017).

Adequate foundation knowledge of relevant anatomy, physiology and pathophysiology is essential to enable learners to understand the findings of the assessment process. While this is outside the scope of this article, the following citation will be useful to ensure the required level of foundation knowledge (Wheeldon, 2023). Using a structured framework for assessment can be beneficial for learning clinical skills such as respiratory assessment. One such framework is the RIPPAS mnemonic, which stands for:

  • Respiratory rate—counting
  • Inspection—looking
  • Palpation—feeling
  • Percussion—tapping
  • Auscultation—listening
  • Saturations—oxygen (Royal College of Surgeons, 2023).
  • This article provides an overview of the respiratory history taking and physical assessment process and consider how these clinical assessment findings can be synthesised to identify and understand different pathophysiological processes.

    Emergency assessment of life‑threatening symptoms

    Registered nurses must be able to identify life-threatening symptoms that need immediate treatment (Smith and Bowden, 2017). The Resuscitation Council UK (2021) advocate the Airway, Breathing, Circulation, Disability and Exposure (ABCDE) approach, ensuring timely recognition of life-threatening conditions. A comprehensive assessment of the respiratory system can only begin after healthcare practitioners are confident that emergency escalation and treatment is not required.

    Respiratory history taking

    Communication with patients is key in developing the nurse-patient therapeutic relationship and is important in understanding the patient's needs and concerns. Effective history taking is key to the majority of diagnoses, which mean that pertinent information should be ascertained and synthesised alongside physical assessment (Davis and Murray, 2021). The history taking process should be structured in the following way:

  • Presenting problem and history of presenting problem
  • Past medical history including previous surgical interventions
  • Drug history, including over-the-counter, herbal and homeopathic treatments
  • Consider alcohol consumption, recreational drug history, use of nicotine and tobacco products and/or vaping
  • Explore family history to identify diseases with hereditary links
  • Consider travel history to assess risk of tropical disease and venous thromboembolism
  • Take a social history including living and working circumstances (Innes et al, 2018).
  • While it is beyond the scope of this article to cover respiratory history taking in depth, it is important to fully explore important signs and symptoms relevant to the respiratory system. These might include:

  • Fatigue
  • Breathlessness
  • Trauma/injury
  • Chest pain
  • Cough
  • Sputum production
  • Audible wheezing
  • Unexpected weight loss (Cockerill, 2024).
  • Respiratory rate

    Measurement of the respiratory rate and pattern is key to both the identification of patient deterioration and the evaluation of the impact of treatments. Ventilation is driven primarily by the arterial partial pressure of carbon dioxide and then the arterial partial pressure of oxygen. The compensatory mechanism in the presence of hypoxaemia and hypercapnia involves increasing respiratory rate and tidal volumes (Brinkman et al, 2023). Respiratory rate remains an important vital sign as its association with cardiac arrest and admission to a critical care unit has been repeatedly reported in the literature (Garrido et al, 2018). Despite this, the accuracy of manual respiratory rate measurement and documentation remains poor in some settings (Palmer et al, 2023). Although the range of normal respiratory rates varies significantly, it is recognised that a respiratory rate greater than 20 breaths per minute can represent a potentially unwell patient and a rate greater than 24 breaths per minute can represent potential critical illness (Chourpiliadis and Bhardwaj, 2022).

    Inspection

    Inspection is the first stage of the systematic assessment of the respiratory system. This process starts with a general inspection of the patients’ extremities and culminates in a focused inspection of the thorax. A nurse's visual observational skills during bedside inspection are invaluable for detecting both life-threatening and subtle respiratory variations or complications, informing further evaluation and intervention for optimal patient care. Table 1 presents the key signs which may be examined during inspection.


    Sign Relevant examination finding
    Upper limbs Peripheral cyanosis Blue tinge to the nail bed; indicates hypoxia
    Finger clubbing Indicative of chronic disease process but can indicate neoplasm in otherwise healthy people
    Head Scleral jaundice Yellowing of the white section of the eye; early sign of jaundice and raised bilirubin
    Conjunctival pallor Conjunctiva of eye appears white or pale; indicates potential anaemia
    Central cyanosis Blue tinge to lips, tongue or oral mucosa; indicates hypoxia
    Oral mucosa and dental hygiene Mucus membranes including the tongue are pink and moist; teeth and gums look healthy
    Neck Neck veins Raised neck veins––consider increased jugular venous pressure which can indicate raised heart failure or vena cava obstruction; flat neck veins can indicate hypovolaemia
    Lymphadenopathy Raised, tender or non-tender lymph nodes in the face and neck
    Trunk Thoracic shape/deformity Inspect thoracic shape/deformity; eg barrel chest––widened chest transverse diameter because of diseases causing sustained high airway pressures
    Spinal deformity Consider spinal shape and deformity; kyphosis––upper spinal curvature causing humped upper back; scoliosis––lower spinal curvature causing lower back deformity
    Chest movement/symmetry Bilateral chest movements; unilateral chest movements; paradoxical chest movement
    Respiratory effort Breathing pattern; rate, rhythm and depth
    Lower limbs Neurovascular status Check that the patient has distal perfusion and sensation; check that calves are soft and not tender to touch
    General inspection Skin lesions Rashes/lesions; scars; bruising and haematomas; dilated blood vessels; jaundice
    Position Sitting upright; semi recumbent/recumbent; tripod positioning

    Palpation

    Palpation complements inspection and provides additional information about the respiratory system by assessing expansion (movement) and feeling for chest wall abnormalities. Palpation of the chest wall involves the practitioner placing their hands on the anterior, transverse and posterior aspects of the thorax, always comparing one side to the other. Through this process of touching and feeling the chest wall, the practitioner can identify general information about the patients’ central temperature and perfusion. They can also identify specific information about the function of the respiratory system including chest movement, deformity and tenderness, and tactile vocal fremitus. Table 2 describes the key signs that can be elicited through effective palpation.


    How is this sign elicited?? What are the significant abnormal findings?
    Tracheal position Using the palmar aspect of the thumb and index finger, feel for the position of the trachea below the level of the cricothyroid membrane (at the suprasternal notch) A deviated trachea can indicate significant pathology; for example, deviation toward the affected side may be seen in atelectasis, whereas deviation away from the affected side can occur in tension pneumothorax or large pleural effusions
    Chest wall expansion Place both hands on the lower anterior and posterior chest with thumbs meeting at the midline. Ask the patient to take a deep breath and the clinician observes the movement of the hands Asymmetrical movement can indicate conditions such as lobar pneumonia, pleural effusion, pneumothorax or phrenic nerve paralysis
    Chest wall deformity and tenderness Press gently over all aspects of the chest wall, assess for deformity and/or any tenderness Palpable deformity or tenderness on palpation should be explored within the context of the patient's history as it could indicate rib fractures, costochondritis or pleurisy
    Subcutaneous emphysema Palpation over subcutaneous emphysema produces a crackling or popping sensation under the skin This finding suggests air leakage into the subcutaneous tissues, typically from trauma or surgical complications
    Tactile vocal fremitus Place the palmar aspect of both hands on the chest wall while the patient is talking. Compare the symmetry of vibrations from both sides of the chest Increased vibrations may indicate lung consolidation, as seen in pneumonia. Decreased fremitus suggests pleural effusion or pneumothorax, where air or fluid disrupts the transmission of vibrations

    Percussion

    Percussion is a technique that produces sounds when the examiner taps on the patient's chest wall. The method requires the examiner to rest a finger of the non-dominant hand (normally the middle finger) on the patient's chest at different levels and tap using the opposing finger of the dominant hand. Use a ‘stepladder approach’ to percuss down the anterior and posterior aspects of the thorax, comparing each side sequentially (Morgan, 2022). When percussing on the posterior aspect, ask the patient to fold their arms in front of them to move the scapulae laterally (Innes et al, 2018).

    The different sounds produced by percussion indicate the density of the underlying tissues below the chest wall. Percussion over healthy lung tissue produces a resonant note—a hollow, ringing sound. This should be heard over all sites except the lower left sternal edge, where the examiner will hear cardiac dullness (Innes et al, 2018). A dull percussion note elsewhere suggests the presence of fluid, consolidation or an area of lung collapse, whereas a hyper-resonant note may be present in emphysema or a pneumothorax (Ball et al, 2019). Try practising this technique on friends and family, or alternatively on various surfaces around the house. Listen for changes in the percussion note while percussing different surfaces or body regions.

    Auscultation

    The final step in a respiratory examination is auscultation. This involves listening to the sounds generated by breathing, assessing their quality and checking for any adventitious (added) sounds using a stethoscope.

    Procedure for auscultation

  • Decontaminate the stethoscope before and after use, in line with the local infection control policy
  • The patient's chest and back are exposed to effectively auscultate. Make sure that the stethoscope and the environment is comfortably warm
  • Wear the stethoscope with the ear pieces pointing forwards and perform the auscultation of lung sound using the diaphragm. Use the bell of the stethoscope at the apex of the lungs since it is smaller
  • Ask the patient to breathe slowly and deeply with their mouth open to ensure that they maintain a comfortable pace to avoid hyperventilation
  • Place the diaphragm of the stethoscope on the chest wall applying light pressure. Using the same stepladder approach as for percussion, systematically move from apices to bases while comparing the left and right sides at each intercostal space
  • Do this anteriorly and posteriorly, asking the patient to fold their arms in front of them when auscultating posteriorly (Innes et al, 2018; Ball et al, 2019; Proctor and Rickards, 2020).
  • Audible breath sounds are generated because of air flow through the bronchi. These sounds are termed vesicular, bronchovesicular, tracheal or bronchial, depending on their pitch, intensity and the duration of inspiratory and expiratory phases (Ball et al, 2019). Normal breath sounds are presented in Table 3. Pathology within the lungs (eg pleural effusion, consolidation and pneumothorax) may lead to sounds being heard in abnormal locations or possibly not being heard at all. Alternatively, pathology may cause adventitious sounds, sounds superimposed on normal breath sounds (Bickley et al, 2024), such as crackles or wheezes. Adventitious sounds are summarised in Figure 1.


    Location normally heard Pitch Intensity Duration
    Bronchial Over the manubrium High Loud Expiratory>inspiratory
    Tracheal Over the trachea High Very loud Expiratory=inspiratory
    Bronchovesicular 1st and 2nd intercostal spaces Intermediate Intermediate Expiratory=inspiratory
    Vesicular Over most of both lungs Low Soft Expiratory<inspiratory
    Adapted from Bickley et al, 2024
    Figure 1. Adventitious lung sounds.

    To conclude the auscultation process, assess vocal resonance. Listen to the patients' chest in the auscultation regions while asking them to repeatedly say a number or phrase (eg 99) when auscultating. In healthy lungs, this sound becomes muffled as the practitioner moves further from the larynx. In consolidated or fibrotic lungs, this sound will be transmitted clearly throughout the chest (Innes et al, 2018).

    Oxygen saturations

    Oxygen saturation monitoring is an important non-invasive technique commonly used in respiratory assessment. An oxygen saturation probe contains a light-emitting diode and a photodetector which measures the amount of light penetrating the vascular bed, commonly of a fingertip or ear lobe (Hafen and Sharma, 2022). This provides a measurement of how much haemoglobin is actively bound to oxygen compared to the amount of unbound haemoglobin. Commonly, oxygen saturation measurements >94% are considered normal in otherwise healthy patients, although it is recognised that normal limits for patients with chronic obstructive pulmonary disease are between 88% and 92% (British National Formulary, 2024). Abnormally reduced oxygen saturations indicate underlying hypoxia and should alert nurses to the need for escalation and medical review.

    Oxygen saturations and respiration rate measurement should always be undertaken as part of complete vital sign measurement. The collective scoring of all vital signs will enable the calculation of the National Early Warning Score 2, which facilitates nurses to follow an evidence informed escalation process when assessing a deteriorating patient in the community setting (Tavaré et al, 2022).

    Assessment findings in respiratory pathophysiology

    It is crucial for registered nurses conducting respiratory assessments to understand and recognise the abnormal findings associated with both common and less common pathophysiological processes. Table 4 presents the assessment findings associated with some common diseases which could be identified by registered nurses working in the community setting. The assessment findings should be documented in a logically structured way in the patient medical notes using the RIPPAS mnemonic, alongside further investigations (eg vital signs and/or peak expiratory flow measurement) and a clear documentation of actions. These actions may include treatments provided (through prescription, patient group direction or administered as prescribed by a clinician) and/or non-pharmaceutical interventions (change in positioning). Where abnormality is detected, it is important that practitioners are confident to escalate appropriately to the clinician in charge of the patient's care in the community or to the emergency service.


    Inspection Palpation Percussion Auscultation
    Asthma Shape: no change; respiratory rate: increased Bilaterally reduced chest wall movements Normal or hyperresonance bilaterally Breath sounds: vesicular with prolonged expiration; added sounds: wheeze/rhonchi
    Chronic obstructive pulmonary disease Shape: barrel chest; respiratory rate: increased Bilaterally reduced chest wall movements Normal or hyperresonance bilaterally Breath sounds: vesicular with prolonged expiration; added sounds: wheeze/rhonchi
    Pneumonia Shape: no change; respiratory rate: increased Normal or reduced expansion of the effected side Dull over the affected side (left vs right) Breath sounds: bronchial; added sounds: course crackles
    Pneumothorax Shape: no change; respiratory rate: increased Reduced expansion of the effected side Hyperresonance on the affected side Breath sounds: diminished or absent on the affected side; added sounds: none
    Haemothorax Shape: no change; respiratory rate: increased Reduced expansion of the effected side Dull over the affected side (left vs right) Breath sounds: diminished or absent on the affected side; added sounds: none
    Pleural effusion Shape: no change; respiratory rate: increased Normal or unilateral reduced chest wall movement Dull over the affected lung regions Breath sounds: reduced over affected area o lung; added sounds: potential pleuritic rub
    Pulmonary oedema Shape: no change; respiratory rate: increased Normal or bilateral reduced chest wall movement Normal resonance Breath sounds: vesicular; added sounds: fine crackles

    For further instructional information on any advanced assessment techniques, Bates' Guide to Physical Examination and History Taking is a recommended as a comprehensive guide (Bickley et al, 2024). When developing new clinical skills, it is important to have sufficient clinical supervision. In relation to advanced respiratory assessment, general practitioners, allied health professions (eg respiratory physiotherapists) and advanced clinical practitioners are ideally suited to provide the level of supervision required to develop expertise in these skills.

    Conclusions

    Systematic respiratory assessment is an important skill for registered nurses in all clinical settings and using the RIPPAS mnemonic is an effective structural method. Effective implementation of these clinical skills is equally valuable in the assessment of pathology and evaluation of administered treatments. This article offers the theoretical knowledge required to develop and embed these skills in clinical role. Beyond this article, registered nurses who are developing these skills may need practical education, consolidation and supervision to achieve competence.

    KEY POINTS

  • All registered nurses are required to be skilled in respiratory assessment including auscultation.
  • By following the RIPPAS mnemonic, registered nurses can develop the skills needed to complete a systematic respiratory assessment.
  • The RIPPAS mnemonic stands for: respiratory rate, inspection, palpation, percussion, auscultation and (oxygen) saturations.
  • Following this approach will enable registered nurses to identify general and specific signs of pathophysiological process and respiratory diseases.
  • Registered nurses working in the community may have to supplement this theoretical content with regular practice, consolidation and clinical supervision to achieve and maintain clinical competency.
  • CPD reflective questions

  • Consider what specific learning needs you might have in relation to developing the clinical skills needed to undertake a systematic respiratory assessment.
  • What are the main benefits of having additional clinical skills to supplement your current respiratory assessments in the community setting and how might these skills change your nursing role?
  • When observing a patient with a respiratory complaint as part of your clinical assessment, what are the important features and signs that you might be looking for?
  • Which common respiratory diseases do your patients have and what are the main signs and symptoms that you commonly find in these patients during your assessments?
  • Briefly reflect on how this article will impact on and influence your clinical practice as a community nurse.