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Physical Assessment:

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:

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  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. Abnormal Sounds

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

  11. What am I hearing with an AP?

  12. 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

  13. CMS: Extremity Assessment

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

  15. Bowel Sounds

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

  17. 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%

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

  19. 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

  20. 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

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