Physical Assessment Breath Sounds Heart Sounds Apical Pulse

Physical Assessment: Breath Sounds Heart Sounds: Apical Pulse CMS of Extremities Bowel Sounds Keith Rischer, RN, MA, CEN, CCRN

Prioritization: Know Your A, B, C’s! ØA ØB ØC ØD

Chest Landmarks

What are you hearing?

Respiratory Assessment Ø Ø Ø Physical Observation Retractions Respiratory Effort Rate q Rhythm q Labored/non-labored Breath Sounds q Normal=broncho vesicular q

Auscultation: Posterior Chest

Auscultation: Anterior Chest

Abnormal Sounds

Apical Pulse Ø Ø Ø Position Identify PMI Landmarks Angle of Louis q 5 th intercostal/mid clavicular q Ø Ø How long to count? Normal q S 1 S 2

What am I hearing with an AP?

CMS of Extremities Ø Color q Ø Temperature q Ø Pink vs. pale Warm vs. cool Pulse q q Cap refill Strong vs. thready/absent ü Ø 1 -4+ Edema q Pitting vs. non-pitting

CMS: Extremity Assessment

Movement & Sensation Ø Movement (motion) q Upper extremity q Lower extremity Ø Sensation q Numbness q Tingling

Bowel Sounds

Assessment of Bowel Sounds Ø Ø Ø Palpate or auscultate first? Frequency of peristalsis Types Normal q Hyperactive q Hypoactive q Absent q Ø Auscultate all 4 quadrants

Putting it all together… A. H. a 78 yr. old male Ø Fractured right hip 5 days ago Ø Moderate swelling of RLE w/mild pain Ø q CMS Ø intact Last VS: q T-98. 8 Ø P-72 R-16 BP 128/80 sats 96 Current VS q T-99 P-90 R-24 BP 132/84 O 2 sats 91%

Later that shift… Appears anxious, labored resp Ø VS: Ø q T-99. 2 P-110 R-28 BP 148/88 O 2 sats 84%

Putting it all together… P. H. an 82 year old female Ø To transitional care for CVA Ø c/o anorexia, nausea with emesis x 1 in the last hour Ø VS: T-99. 4 P-88 R-20 BP-150/88 sats 95% Ø Abd distended, firm and tender in LLQ Ø q Bowel sounds absent in lower quads q Pain 5/10 in lower abd

Later that shift… N&V worsens, appears ill, color pale, pain in abd now 10/10 Ø T-102. 4 P-128 R-32 BP 90/40 sats 88% Ø Abd remains distended, firm with absent bowel sounds Ø