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Learn about assessing breath sounds, heart sounds, apical pulse, CMS of extremities, and bowel sounds. Understand chest landmarks, respiratory assessment, abnormal sounds, and prioritization techniques. Perfect for nurses looking to enhance their skills.
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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
Respiratory Assessment • Physical Observation • Retractions • Respiratory Effort • Rate • Rhythm • Labored/non-labored Breath Sounds • Normal=broncho vesicular
Apical Pulse • Position • Identify PMI • Landmarks • Angle of Louis • 5th intercostal/mid clavicular • How long to count? • Normal • S1S2
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