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Physical Assessment: Breath Sounds Heart Sounds: Apical Pulse CMS of Extremities Bowel Sounds Keith Rischer, RN, MA, CEN, CCRN.

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Presentation on theme: "Physical Assessment: Breath Sounds Heart Sounds: Apical Pulse CMS of Extremities Bowel Sounds Keith Rischer, RN, MA, CEN, CCRN."— Presentation transcript:

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ABCD

3 Chest Landmarks

4

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  5 th 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

20 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

21 Later that shift…  N&V worsens, appears ill, color pale, pain in abd now 10/10  T P-128 R-32 BP 90/40 sats 88%  Abd remains distended, firm with absent bowel sounds


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