1 / 17

Physical Assessment:

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. Chest Landmarks. Chest Landmarks. What are you hearing?. Respiratory Assessment. Physical Observation

efuru
Download Presentation

Physical Assessment:

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. Prioritization: Know Your A,B,C’s! • A • B • C • D

  3. Chest Landmarks

  4. Chest Landmarks

  5. What are you hearing?

  6. Respiratory Assessment • Physical Observation • Retractions • Respiratory Effort • Rate • Rhythm • Labored/non-labored Breath Sounds • Normal=broncho vesicular

  7. Auscultation: Posterior Chest

  8. Auscultation: Anterior Chest

  9. Position Identify PMI Landmarks Angle of Louis 5th intercostal/mid clavicular How long to count? Normal S1S2 Apical Pulse

  10. What am I hearing with an AP?

  11. 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

  12. Movement & Sensation • Movement (motion) • Upper extremity • Lower extremity • Sensation • Numbness • Tingling

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

  14. 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%

  15. Later that shift… • Appears anxious, labored resp • VS: • T-99.2 P-110 R-28 BP 148/88 O2 sats 84%

  16. 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

  17. 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

More Related