Heart Sounds Apical Pulse CMS of Extremities Bowel Sounds Keith Rischer RN MA CEN CCRN Prioritization Know Your ABCs A B C D Chest Landmarks Chest Landmarks What are you hearing ID: 627859
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Slide1
Physical Assessment:
Breath Sounds
Heart Sounds: Apical Pulse
CMS of Extremities
Bowel Sounds
Keith Rischer, RN, MA, CEN, CCRNSlide2
Prioritization: Know Your A,B,C’s!
A
B
C
DSlide3
Chest LandmarksSlide4
Chest LandmarksSlide5
What are you hearing?Slide6
Respiratory Assessment
Physical Observation
Retractions
Respiratory
Effort
Rate
Rhythm
Labored/non-labored
Breath Sounds
Normal=
broncho
vesicularSlide7
Auscultation: Posterior ChestSlide8
Auscultation: Anterior ChestSlide9
Abnormal SoundsSlide10
Apical Pulse
Position
Identify PMI
Landmarks
Angle of Louis
5
th
intercostal/mid clavicular
How long to count?
Normal
S1S2Slide11
What am I hearing with an AP?Slide12
CMS of Extremities
Color
Pink vs. pale
Temperature
Warm vs. cool
Pulse
Cap refill
Strong vs. thready/absent
1-4+
Edema
Pitting vs. non-pittingSlide13
CMS: Extremity AssessmentSlide14
Movement & Sensation
Movement (motion)
Upper extremity
Lower extremity
Sensation
Numbness
Tingling Slide15
Bowel SoundsSlide16
Assessment of Bowel Sounds
Palpate or auscultate first?
Frequency of peristalsis
Types
Normal
Hyperactive
Hypoactive
Absent
Auscultate all 4 quadrantsSlide17
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%Slide18
Later that shift…
Appears anxious, labored resp
VS:
T-99.2 P-110 R-28 BP 148/88 O2 sats 84%Slide19Slide20
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 abdSlide21
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