Physical Assessment:
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Transcript of Physical Assessment:
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
Abnormal Sounds
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
CMS: Extremity Assessment
Movement & Sensation Movement (motion)
Upper extremity Lower extremity
Sensation Numbness Tingling
Bowel Sounds
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