Physical Assessment:Breath Sounds

Heart Sounds: Apical PulseCMS of Extremities

Bowel Sounds

Keith Rischer, RN, MA, CEN, CCRN

Prioritization: Know Your A,B,C’s!

ABCD

Chest Landmarks

Chest Landmarks

What are you hearing?

Respiratory Assessment Physical Observation Retractions Respiratory Effort

Rate Rhythm Labored/non-laboredBreath Sounds Normal=broncho

vesicular

Auscultation: Posterior Chest

Auscultation: Anterior Chest

Apical Pulse Position Identify PMI Landmarks

Angle of Louis 5th intercostal/mid clavicular

How long to count? Normal

S1S2

What am I hearing with an AP?

CMS of Extremities Color

Pink vs. pale Temperature

Warm vs. cool Pulse

Cap refill Strong vs. thready/absent

1-4+ Edema

Pitting vs. non-pitting

Movement & Sensation Movement (motion)

Upper extremity Lower extremity

Sensation Numbness Tingling

Assessment of Bowel Sounds Palpate or auscultate

first? Frequency of peristalsis Types

Normal Hyperactive Hypoactive Absent

Auscultate all 4 quadrants

Putting it all together… A.H. a 78 yr. old male Fractured right hip 5 days ago Moderate swelling of RLE w/mild pain

CMS intact Last VS:

T-98.8 P-72 R-16 BP 128/80 sats 96 Current VS

T-99 P-90 R-24 BP 132/84 O2 sats 91%

Later that shift… Appears anxious, labored resp VS:

T-99.2 P-110 R-28 BP 148/88 O2 sats 84%

Putting it all together… P.H. an 82 year old female To transitional care for CVA c/o anorexia, nausea with emesis x1 in the

last hour VS: T-99.4 P-88 R-20 BP-150/88 sats 95% Abd distended, firm and tender in LLQ

Bowel sounds absent in lower quads Pain 5/10 in lower abd

Later that shift… N&V worsens, appears ill, color pale, pain

in abd now 10/10 T-102.4 P-128 R-32 BP 90/40 sats 88% Abd remains distended, firm with absent

bowel sounds