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! ABCDABCD

Chest Landmarks

What are you hearing?

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

Auscultation: Posterior Chest

Auscultation: Anterior Chest

Apical Pulse  Position  Identify PMI  Landmarks  Angle of Louis  5 th 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 P-128 R-32 BP 90/40 sats 88%  Abd remains distended, firm with absent bowel sounds