Assessing Lung Sounds(3) Normal Breath Sounds

Bronchial breath sounds: loud, harsh and high pitched. Heard over the trachea, bronchi—between clavicles and midsternum, and over main bronchus.Bronchovesicular breath sounds: blowing sounds, moderate intensity and pitch. Heard over large airways, either side of sternum, at the Angle of Louis, and between scapulae.Vesicular breath sounds: soft breezy quality, low pitched. Heard over the peripheral lung area, heard best at the base of the lungs.

ADVENTITIOUS LUNG SOUNDSSound Characteristics Lung Problem

CracklesPopping, crackling, bubbling, moist sounds

on inspirationPneumonia, pulmonary edema, pulmonary

fibrosis

Rhonchi Rumbling sound on expiration Pneumonia, emphysema, bronchitis, bronchiectasis

WheezesHigh-pitched musical sound during both

inspiration and expiration (louder)Emphysema, asthma, foreign bodies

Pleural Friction Rub Dry, grating sound on both inspiration and expiration

Pleurisy, pneumonia, pleural infarct

Assessing Heart SoundsThese tones are produced by the closing of valves and are best heard over 5 points:1.) Second intercostals space along the right sternal boarder. AORTIC AREA2.) Second intercostals space at the left sternal boarder. PULMONIC AREA3.) Third intercostals space at the left sternal boarder. ERB’S POINT4.) Fifth intercostals space along the left sternal boarder. TRICUSPID AREA5.) Fifth intercostals space, midclavicular line. MITRAL AREA—APEX This is where the Point of Maximal Impulse (PMI) is found—document location (note: with enlarged hearts mitral area may present at anterior axillary line) S1 (“lub”) the start of cardiac contraction called systole. Mitral and tricuspid valves are closing and vibration of the ventricle walls due to increased pressure.S2 (“dub”) end of ventricular systole and beginning of diastole. Aortic and pulmonic valves close. S3 (“Kentucky”) a ventricular gallop heard after S2. Normal in children and young adults, pregnancy, and highly trained athletes. In older adults it is heard in heart failure. Use bell of stethoscope and have pt in the left lateral position.S4 (“Tennessee”) atrial diastolic gallop. Resistance to ventricular filling and heard before S1. Heard in HTN and left ventricular hypertrophy. Listen at apex in left lateral position.

Grading MurmursGrade I Faint; heard with concentrationGrade II Faint murmur heard immediatelyGrade III Moderately loud, not associated with thrill

Grade IV Loud and may be associated with a thrillGrade V Very loud; associated with a thrillGrade VI Very loud; heard w/stethoscope off chest, associate w/a thrill

Normal B/P for all <120/<80; Prehypertension 120-139/80-89Guidelines and education site for adult B/P. http://www.nhlbi.nih.gov/hbp/index.htmlFor children & adolescents: http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Sawall RN, MS, MPH, CNSHealth Assessment 2005Note to students: the chart should be used as an organized reference guide and memory refresher and not substituted for assigned class work or a replacement for medical or nursing references. The chart should not be relied upon to provide any medical or nursing care.

EDEMA: Assess by placing thumb over dorsum of the foot or tibia for 5 seconds0 No edema1+ Barely discernible depression2+ A deeper depression (< 5 mm) w/

normal foot & leg contours3+ Deep depression (5-10 mm) w/ foot &

leg swelling4+ Deeper depression (> 1 cm) w/ severe

foot and leg swelling

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5 P’s of Circulatory Checks

Pain

Pallor

Paralysis

Paresthesia

Pulse

Formula to convert from Fahrenheit to Celsius: (5/9)*(deg F-32) to convert from Celsius to Fahrenheit: (1.8*deg C)+32

95º F = 35ºC 96ºF = 35.5ºC 98.6ºF = 37ºC110ºF = 37.7ºC 101ºF = 38.3ºC 102ºF = 38.8ºC103ºF = 39.4ºC 104ºF = 40ºC 105ºF = 40.5ºC

4 Primary Assessment Techniques: INSPECT, PALPATE, PERCUSS, AUSCULATEAssessment Area What To ObserveGeneral Survey General appearance and behavior, posture, gait, hygiene, speech, mental status, height, weight,

hearing and visual acuity, VS, nutritional statusHead and Neck Skull size, shape, symmetry, hair & scalp, auscultate for carotid bruits, clenched jaws, puff cheeks,

palpate TMJ, use cotton swab for facial sensations, test EOMs, cover/uncover test, corneal light reflex, Weber and Rinne test, use ophthalmoscope and otoscope, inspect and palpate teeth and gums, test rise of uvula, test gag reflex, test sense of smell and taste, inspect ROM neck, shrug shoulders, palpate all cervical lymph nodes, palpate trachea for symmetry, palpate thyroid gland

Upper Extremities Inspect skin, blanche fingernails, palpate peripheral pulses, rate muscle strength, assess ROM, test deep tendon reflexes (DTRs)

Posterior Thorax Inspect spine for alignment, assess anteroposterior to lateral diameter, assess thoracic expansion, palpate tactile fremitus, auscultate breath sounds

Anterior Thorax Observe respirations. pattern, palpate respirations, excursion, auscultate breath sounds, auscultate heart sounds, inspect jugular veins, perform breast exam

Abdomen Auscultate for bowel sounds, inspect, light and deep palpation, percuss for masses and tenderness, percuss the liver, palpate the kidneys, blunt percussion over CVA (posterior thorax) for tenderness

Lower Extremities Inspect skin, palpate peripheral pulses, assess for Homan’s sign, inspect and palpate joints for swelling, assess for pedal and ankle edema, assess ROM

General Neurologic Test stereognosis-object identification in hands, test graphesthesia-writing on body with closed pen, test two point discrimination, assess temp perception, inspect gait and balance, assess recent and remote memory, test cerebellar function by finger to nose test for upper extreme, and running each heel down opposite shin of lower extremity, test the Babinski reflex.

Sawall RN, MS, MPH, CNSHealth Assessment 2005Note to students: the chart should be used as an organized reference guide and memory refresher and not substituted for assigned class work or a replacement for medical or nursing references. The chart should not be relied upon to provide any medical or nursing care.

Averages for Age GroupingAGE WGT (kg) PULSE RESP B/P (syst.) Preemie 1-2 140 < 60 50-60 Term NB 3 125 < 60 706 Months 7 120 24-36 90 ± 301 yr 10 120 22-30 96 ± 30 3 yrs 15 110 20-26 100 ± 25 5 yrs 18 100 20-24 100 ± 206 yrs 20 100 20-24 100 ± 158 yrs 25 90 18-22 105 ± 1512 yrs 40 85-90 16-22 115 ± 2016 yrs > 50 75-80 14-20 120 ± 20Adult Female 50-75 60-100 12-20 90 + ageAdult Male 75-100 60-100 12-20 100 + agePULSES: Peripheral pulses

should be compared for rate, rhythm, and quality. 0 Absent+1 Weak and thready+2 Normal+3 Full

+4 Bounding

Symptom Analysis: This assists the client in describing the problem. P Provocate/Palliative: What caused it? What makes it better/worse? Q Quality/Quantity: How does it feel, sound, look, how much?R Region/Radiation: Where is it and does it spread?S Severity Scale: Rate on appropriate pain scale. Does it interfere with ADLs?T Timing: When did it start? Sudden/gradual? How often? How long does it last?

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