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: 774697
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Slide1
Physical Assessment:
Breath Sounds
Heart Sounds: Apical Pulse
CMS of Extremities
Bowel Sounds
Keith Rischer, RN, MA, CEN, CCRN
Slide2Prioritization: Know Your A,B,C’s!
A
B
C
D
Slide3Chest Landmarks
Slide4Chest Landmarks
Slide5What are you hearing?
Slide6Respiratory Assessment
Physical ObservationRetractionsRespiratory EffortRateRhythmLabored/non-laboredBreath SoundsNormal=broncho vesicular
Slide7Auscultation: Posterior Chest
Slide8Auscultation: Anterior Chest
Slide9Abnormal Sounds
Slide10Apical Pulse
PositionIdentify PMILandmarksAngle of Louis5th intercostal/mid clavicularHow long to count?NormalS1S2
Slide11What am I hearing with an AP?
Slide12CMS of Extremities
ColorPink vs. paleTemperature Warm vs. coolPulseCap refillStrong vs. thready/absent1-4+EdemaPitting vs. non-pitting
Slide13CMS: Extremity Assessment
Slide14Movement & Sensation
Movement (motion)
Upper extremity
Lower extremity
Sensation
Numbness
Tingling
Slide15Bowel Sounds
Slide16Assessment of Bowel Sounds
Palpate or auscultate first?Frequency of peristalsisTypesNormalHyperactiveHypoactiveAbsentAuscultate all 4 quadrants
Slide17Putting 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%
Slide18Later that shift…
Appears anxious, labored resp
VS:
T-99.2 P-110 R-28 BP 148/88 O2 sats 84%
Slide19Slide20Putting 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
Slide21Later 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
Slide22