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