Health Assessment 125 Respiratory assessment Cardiovascular assessment Peripheral vascular assessment Abdominal assessment Neurological assessment Jerry Thompson RN, MSN

So….. How’s it going?

At the completion of this class the student will be able to: Describe the basic skill in performing a Respiratory assessment Cardiovascular assessment Abdominal assessment Neurological assessment Peripheral-vascular assessment Explain what the findings may indicate

Thorax and Lungs Examination Inspection Palpation Auscultation •Diagnostic equipment such as x-ray films, magnetic resonance imaging (MRI), and computed tomography (CT) scans creates little need for the use of percussion as an assessment measure. •Before assessing the thorax and lungs, be familiar with the landmarks of the chest. These landmarks help you to identify findings and to use assessment skills correctly. The patient’s nipples, angle of Louis, suprasternal notch, costal angle, clavicles, and vertebrae are key landmarks that provide a series of imaginary lines for sign identification. Keep a mental image of the location of the lobes of the lung and the position of each rib. [Image is Figure 30-31 (on text p. 523), Anatomical chest wall landmarks. A, Posterior chest landmarks. B, Lateral chest landmarks. C, Anterior chest landmarks.] Chest / Lungs (5)   Inspect for breathing pattern Palpate for respiratory excursion Palpate the chest for tactile fremitus Auscultate breath sounds bilaterally / anterior and or and posterior and trachea

Respiratory Assessment Have patient sit up if possible Observe breathing patterns = respiratory rate, the rhythm (whether it is labored or unlabored), and depth (shallow or deep). Palpate for Fremitus = feeling for vibrations while patient says “99” Palpate for excursion = hands on both sides, lower back, have patient breath, see if both sides expand equally http://www.youtube.com/watch?v=yQTLWvQItjQ&feature=related Auscultate his breath sounds with the diaphragm of stethoscope between the spine and the scapula and between the 10th and 11th vertebrae http://www.youtube.com/watch?v=W-YrpzSgmmc&feature=r

Thorax and Lungs (cont’d) Posterior thorax Inspect for deformities, position of the spine, slope of the ribs, retraction of the intercostal spaces during inspiration, bulging of the intercostal spaces, and rate and rhythm of breathing. •Reduced mental alertness, nasal flaring, somnolence, and cyanosis are examples of assessed signs that indicate oxygenation problems. •Inspect the posterior thorax by observing the shape and symmetry of the chest from the patient’s back and front. •Standing at a midline position behind the patient, look for deformities, position of the spine, slope of the ribs, retraction of the intercostal spaces during inspiration, and bulging of the intercostal spaces during expiration. •Assess the rate and rhythm of breathing (see Chapter 29). •Palpation of the posterior thorax provides further information about a patient’s health status. [Images are Figure 30-33 (on text p. 524), A, Hand position for palpation of posterior thorax excursion. B, As patient inhales, movement of chest excursion separates thumbs.]

Thorax and Lungs (cont’d) Tactile fremitus Created by vocal cords Transmitted through lungs to chest wall Palpation http://www.youtube.com/watch?v=yQTLWvQItjQ&feature=related •Sound created by the vocal cords is transmitted through the lung to the chest wall and can be palpated externally. The vibrations are called vocal or tactile fremitus. The accumulation of mucus, the collapse of lung tissue, or the presence of one or more lung lesions blocks the vibrations from reaching the chest wall. •To palpate for tactile fremitus, place the palmar surfaces of the fingers or the ulnar part of the hand over symmetrical intercostal spaces, beginning at the lung apex and using a firm, light touch. Ask the patient to say, “ninety-nine,” or “one-one-one.” Palpate both sides simultaneously and symmetrically (from top to bottom) for comparison, or use one hand, quickly alternating between the two sides. •Auscultation assesses the movement of air through the tracheobronchial tree and detects mucus or obstructed airways. Recognizing the sounds created by normal airflow allows you to detect sounds caused by airway obstruction. [Image is Figure 30-34 (on text p. 525), A to C, A systematic pattern (posterior-lateral-anterior) is followed when the thorax is palpated and auscultated.]

Thorax and Lungs Auscultation Normal breath sounds upper lobes = moderate pitched “blowing” = bronchovesicular Normal breath sounds in lower lobes = low-pitched “gentle sighing” = vesicular sounds. http://www.youtube.com/watch?v=nhUT5BfAFic Crackles / rales = wet cracking sound (similar to rolling a lock of hair by your ear) = sign of excessive secretions, like with pulmonary edema (left sided health failure). http://www.youtube.com/watch?v=9C5RFb1qWT8&feature=related Rhonchi = gurgling sounds in larger airways, indicates mucus in the larger airways associated with pneumonia https://www.youtube.com/watch?v=QPBZOohj2a0 Wheezing = whistling sound during expiration = a sign of narrowed bronchi / indicates asthma. http://www.youtube.com/watch?v=YG0-ukhU1xE http://www.youtube.com/watch?v=NnuaHGW1cwU&feature=related Process: http://www.youtube.com/watch?v=W-YrpzSgmmc&feature=r •Auscultation assesses movement of air through the tracheobronchial tree and detects mucus or obstructed airways. Normally, air flows through the airways in an unobstructed pattern. Recognizing the sounds created by normal airflow allows you to detect sounds caused by airway obstruction. When listening, follow the same systematic approach that was used for palpation. •Abnormal sounds result from air passing through moisture, mucus, or narrowed airways. They also result from alveoli suddenly reinflating or an inflammation between the pleural linings of the lung. •Adventitious sounds often occur superimposed over normal sounds. •Crackles are caused by random, sudden reinflation of groups of alveoli, or disruptive passage of air through small airways, and can be described as fine, medium, or coarse. •Rhonchi are low-pitched, continuous sounds caused by muscular spasm, fluid, or mucus in larger airways; or new growth or external pressure causing turbulence. •Wheezes are high-pitched continuous musical sounds, like a squeak heard continuously during inspiration or expiration. They usually are louder on expiration and often are heard in asthma. •A pleural friction rub has a dry, rubbing or grating quality and is caused by inflamed pleura: parietal pleura rubbing against visceral pleura. •During auscultation, note the location and characteristics of the sounds, and listen for the absence of breath sounds. [Table 30-21 (on text p. 525) provides the characteristics of normal breath sounds.] [Table 30-22 (on text p. 526) provides the characteristics of adventitious breath sounds.] [Image is Figure 30-35 (on text p. 525), Use the diaphragm of the stethoscope to auscultate breath sounds.]

Respiratory Assessment Breathing patterns are regular and unlabored. Thoracic expansion is symmetrical and no lumps, lesions, or tenderness are seen. Tactile fremitus present in all lobes. Breath sounds are vesicular over in the lower lobes and bronchovesicular in upper lobes. There were no adventitious breath sounds heard. Patient tolerated the procedure well.

Assessing the Heart Inspect for any pulsations look for pulsations Auscultate the heart listen for Lub Dub or abnormal sounds Dysrhythmia Extra heart sounds Murmurs (grade, pitch, quality) https://www.youtube.com/watch?v=Fm_AdQ4S7GE http://www.youtube.com/watch?v=QTlpb7-mwWk&feature=related http://www.youtube.com/watch?v=sXwifLyRmPc

Cardiovascular system Inspect carotid arteries and jugular veins Auscultate carotid arteries Palpate carotid arteries What would you suspect with jugular vein distention? What would you suspect with bruits at the carotid artery? Jugular vein extension = right sided heart failure Bruits at the carotid = carotid artery stenosis

Cardiovascular Even strong pulsations on the carotid arteries with no bruits heard. No jugular vein distention seen when in semi fowler position. Chest pulsations lifts or heaves are not visible. Heart sounds heard at the aortic, pulmonic, tricuspid and mitral area no murmurs, gallops, or other abnormal sounds heard.

Peripheral Vascular Assessment Temperature is one warmer than the other? Perfusion Capillary refill Pulse Pedal pulse Sensation Avoid visual queue Movement Wiggle toes Edema Lightly press, did you leave a “dent”? compare findings bilaterally What patients would have a priority for a peripheral vascular assessment? Folks with poor circulation would be a high priority for a PVA, may be diabetic, or may have a cast or dressing that can restrict circulation

Peripheral Vascular Assessment Feet warm (cool) bilaterally. Pedal pulses equal bilaterally. Capillary refill less than 3 seconds on both feet. Patient can move toes on both feet on request. Patient can feel light touch on both feet, no edema noted

Abdominal Assessment Inspection Auscultation Palpation Begin with inspection and follow with auscultation, then with palpation. Palpations can cause bowel sounds

Abdominal Assessment Inspection What can cause abdominal distention? Umbilicus Contour and symmetry Enlarged organs or masses Distention What can cause abdominal distention? Any indications of trauma or other issues? Before you assess, explain what you will be doing, properly drape the patient, place the patient in a position of comfort, control the environment, and use proper lighting. Most important, reinforce that the patient should be comfortable and should not tense the abdomen. •When examining the abdomen, look for symmetry, masses, or pulsations. Extenstion can result from

Abdominal Assessment Auscultate divide it abdomen into four quadrants listen to each quadrant for either: No bowel sounds Hypo-bowel sounds (1-5 per minute) Active/normal bowel sounds(6-30 per minute) Hyper-bowel sounds (over 30 per minute) •Peristalsis, or the movement of contents through the intestines, is a normal function of the small and large intestines. Bowel sounds represent the audible passage of air and fluid that peristalsis creates. •The best time to auscultate is between meals. •Bowel sounds generally are described as absent, hypoactive active / nomral, hyperactive •Absent sounds indicate lack of peristalsis, possibly as the result of late-stage bowel obstruction, paralytic ileus, or peritonitis. •Normally, sounds are absent after general anesthesia and abdominal surgery •Hyperactive sounds are loud, “growling” sounds called borborygmi, which indicate increased GI motility. •

Abdominal Assessment

Abdominal Assessment Palpate the abdomen Assess for any tenderness or masses Assess for rebound response What patients have a higher priority for an abdominal assessment? http://www.youtube.com/watch?v=kmLqO-NG248

Abdominal Assessment Abdomen is flat and symmetrical and non distended with no lesions, bulges, or scars. Normal bowel sounds present in all four quadrants, There was no guarding, rigidity, enlargement or masses seen upon palpation. No complaint of tenderness or discomfort

Neurological Assessment Full assessment requires time and attention to detail. Many variables must be considered during evaluation: level of consciousness (LOC), physical status, chief complaint. The bed side assessment done by the nurse is basic: Neurological assessment (5)   Assess LOC using Glasgow coma scale (including O x 3) Assess Pupil response to light Assess and compare grip strength bilaterally on upper extremities Assess and compare strength of plantar flexion and dorsa flexion on lower extremities

Neurological Assessment To assess consciousness ask the individual; "Can you tell me your name?" "Can you tell me were you are?" "Can you tell me what time of day this is?" To assess the pupils, Look at the pupils to see if they're equal in size. See how the pupils react to light

Neurological Assessment To assess for motor response, have the patient hold your hands and ask them to squeeze. Compare the two sides for strength at the same time. have the patient dorsal flex or planter flex against your hands compare the strength bilaterally For a child look for symmetry in movement of extremities / assess strength by having them push against your hand and grasp finger What patients have a higher priority for a neurological assessment ?

Neurological Assessment Patient alert and oriented to person, place and time. Pupils equal and react to light. Hand grasp is equal bilaterally. Dorsal and planter flexion of feet equal bilaterally” For a child under 3: “Child awake and alert, responds to mother’s voice and reached for toy bear when presented. Pupils equal and react to light. Moving extremities spontaneously and with equal strength. Anterior fontanel flat with no bulging or depression”

What was covered to today? Respiratory assessment Cardiovascular assessment Peripheral vascular assessment Abdominal Assessment Neurological assessment