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  • When you auscutate a patient’s chest and hear the familiar lub-dub , you are hearing the first heart sound S1 ad the second heart sound S2. When the valves close, the heart muscle can be heard through the chest wall. Contraction of the ventricles- ventricular pressure rises, closing the mitral and tricuspid valves (to prevent backflow) and causes vibrations heard as S1. Ventrcles relax- ventricular pressure falls and the aortic and pulmonic valves close, causing vibrations heard as S2 Identify S1 and S2 and ten listen for any extra heart sounds such as S3 and S4 or any murmurs
  • S3- rapid ventricualr filling; called a ventricular gallop in adults.. Frequently heard in children and in pts with high cardiac output. Ken-tuc-ky
  • S4 – Atria contract and eject blood into resistant ventricles( slow ventricular contraction); called an atrial gallop. heard over the tricuspid and mitral areas. You may hear it in elderly patients or in pts with a previous MI. occurs just before S1 and sounds like Ten-nes-see.
  • Depress pretibial for 5 seconds
  • or cystic fibrosis; not associated with asthma, or chronic smoking
  • Palpating the abdomen before you auscultate can change the character of the patient’s bowel sounds and lead to an inaccurate assessment. Perform the assessment in a private, quiet, warm and well-lit room. Warm your hand and stethoscope before touching the patient.

Assessment of the Heart, Great vessels of the neck, and ... Assessment of the Heart, Great vessels of the neck, and ... Presentation Transcript

  • Basic Physical Assessment Head-to-toe assessment Major body systems assessment
  • Purpose
    • Gather baseline data
    • Supplement, confirm, or refute data in nursing hx
    • Confirm and identify nursing diagnosis
    • Make clinical judgments about changing status
    • Evaluate the physiological outcomes of care
  • Health History
    • Provides baseline subjective information
    • Guides and directs your physical assessment
    • Identifies
      • Strengths
      • Actual or potential health problems
      • Support system
      • Teaching needs
      • Discharge and referral needs
    • Use of effective communications skills
    • Family history
    • Life patterns
    • Sociocultural history
    • Spiritual health
    • Mental reactions
    • Emotional reactions
  • PHYSICAL ASSESSMENT
    • Validates the patient’s complaints related to health
    • Assists in formulating nursing diagnoses and interventions
    • Monitors current health problems
    • Obtains baseline information for future assessments
  • Assessment techniques
    • Inspection …Always first!!!
    • Palpation
    • Percussion
    • Auscultation
  • Assessment techniques Palpation
    • Temperature
    • Texture
    • Moisture
    • Organ size and location
    • Rigidity or spasticity
    • Crepitation, Vibration
    • Position
    • Size
    • Presence of lumps or masses
    • Tenderness, or pain
  • Assessment techniques Percussion
    • Assess underlying structures for location, size, density of underlying organs.
    • Direct – sinus tenderness
    • Indirect- lung percussion
    • Blunt percussion- organ tenderness (CVA tenderness )
  • Assessment techniques Percussion sounds
    • Flatness – bone or muscle
    • Dullness – heart, liver, spleen
    • Resonance – air filled lungs (hollow)
    • Hyperresonance – emphysematous lung (hyperinflated)
    • Tympany – air-filled stomach (drumlike)
  • Assessment techniques Auscultation
    • Listening to sounds produced by the body:
    • Heart
    • Blood vessels
    • Lungs
    • Abdomen
    • Instrument: stethoscope
      • Diaphragm – high pitched sounds
      • Bell – low pitched sounds
  • Assessment techniques Auscultation
    • Avoid Interruptions
    • Start with a general inspection first
    • Proceed for specific observation of the system
    • Expose only the part being examined
    • Examine the unaffected area or parts first
    • Examine external parts first, then internal
    • Compare one side to the other side
    • Proceed from head to toe
  • Eyes - PERRLA
    • Shine light through pupil onto retina
      • Cranial nerve III stimulated
        • Observe for pupillary constriction
        • Observe for accomodation
    • Pupils: black, round, regular, equal in size, 3-7 mm
      • PERRLA = Pupils equal, round, reactive to light, accommodation
  • Pupils
    • Cloudy pupil : cataracts
    • Dilated pupil : glaucoma, trauma, neurologic disorder
    • Constricted pupil : drug use
    • Pinpoint pupil : opioid intoxication
  • Great vessels of the neck
    • Jugular veins
      • Empty unoxugenated blood directly into the superior vena cava, which empties into the right side of the heart
    • Carotid arteries
      • Reflects cardiac systole and is timed with S1, Palpate only one at a time
    • Carotid artery pulse – correlates with first heart sound
  • Assessment
    • Position client supine
    • Then head elevated at 45 degrees
    • INSPECTION:
    • Lifts, heaves
    • PMI (assess location)
  • General Reference Lines
    • Sternal Line
    • Midclavicular Line
    • Apical /PMI – left 5 th iCS midclavicular line
    • Axillary Line
  • Heart Auscultatory Sites
    • When auscultating sounds, place the stethoscpe over the four different site
    • All physicians take money- APTM
    • Aortic, Pulmonic, Trisuspic, Mitral
    • The sites are identified by the names of heart valves… but they are not located directly over the valves.
    • Rather, these sites are located along the pathway blood takes as it flows throught the heart’s chambers and valves.
  • Heart
    • Review: heart is in the center of the chest, behind and to left of the sternum
    • Base is at top, apex is the bottom tip
    • Apex touches anterior chest wall at 5 th intercostal space medial to left midclavicular line
    • Heart pumps blood through 4 chambers
    • Events on left side occurs just before those on right
    • Valves open and close, pressures within rise and fall and chambers contract as blood flows though each chamber
  • Cardiac Cycle
    • Systole : ventricles contract and eject blood from left ventricle into aorta and from right ventricle into pulmonary system
    • Diastole : ventricles relax and atria contract to move blood into ventricles and fill coronary arteries
    • Diahragm of the stethoscpe – for highpitched sounds – heart sounds
    • Bell - for low pitched sounds – bruits, murmurs
  • Heart Sounds
    • S1: Lub: mitral valve closure
    • S2: Dub: Aortic valve closure
  • Heart Sounds – S1 & S2
    • S1:
      • Closure of mitral and tricuspid valves (M1 before T1)
    • Correlates with the carotid pulse
    • Can be split but not often
    • S2:
      • Closure of aortic and pulmonic valves
    • May have a split sound (A2 before P2)
  • Heart Sounds
    • S1 loudest at the apex (tricuspid), this sound corresponds to the closure of M1& T1
    • May be split.
    • S2 loudest at the base (aortic),
    • Physiologic S2 splitting- heard best at pulmonic area during peak inspiration
    • S2 splitting – when the pulmonic valve closes later than the aortic valve – normal during inspiration
    • Fixed split – ASHD – no variation with insp.
  • Extra Heart Sounds- S3…
    • a low-pitch vibration in early diastole immediately after S2
    • Rapid ventricular filling: ventricular gallop May be a cardinal sign of CHF in adults
    • May be normal in children, and patients with high cardiac output (athletes)
    • Pathological in adults: CHF, HTN, CAD
    • S1 -- S2-S3
    • Sounds like: Ken--tuc-ky
  • Extra Heart Sounds- S4…
    • Soft, low-pitched sound in late diastole immediately before S1
    • Atria contract and eject blood into resistant ventricles (slow ventricular contraction): atrial gallop
    • May be physiological in infants and small children
    • Common in HTN pts
    • S4-S1 — S2
    • Sounds like Ten-nes--see
  • Heart Sounds
    • Normal (Lub-dub, Lub-dub)
    • S1 Lub (Closure of AV Valves at start of systole)
    • S2 Dub – (Closure of pulmonic and aortic valves upon end diastole)
    • 3 rd Heart Sound – Middle 3 rd of diastole
    • 4 th Heart Sound – Atrial
  • S1 Systole S2 Diastole S1 Systole S2 S4 M T A P S3 S4 M T A P
  • Peripheral Pulses
    • Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse
    • Measure strength of pulse and equality
    • Assess carotid, radial, and pedal
    • Also assess brachial, posterior tibial, and dorsalis pedis
  • Peripheral Pulses
    • Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse
    • Measure strength of pulse and equality
    • Assess carotid, radial, and pedal
    • Also assess brachial, posterior tibial, and dorsalis pedis
    • Documentation of Pulses
  • Grading
    • 0 = Absent, not palpable
    • 1+- Diminished, barely palpable
    • 2+- Easily palpable, normal pulse
    • 3+ - Full pulse, increased
    • 4+ - Strong, bounding, cannot be obliterated
  • Lower Extremities
    • Pedal pulses
    • Foot strength bilaterally
    • Homan’s Sign
    • Capillary refill (see next slide)
    • Edema
    • Pain
  • Capillary Refill
    • Should test fingers and toes
    • Press down on nail to compress capillaries
    • Color goes white, then release
    • Color should return briskly; < 3 seconds
    • Document “sluggish” if > 3 seconds
  • Assessing for Edema
    • Depress
    • pretibial area & medial malleolus for 5 seconds
    • Grade pitting edema
      • 1+ to 4+
  • Lungs – Anatomy and Landmarks
    • Lungs are paired but not symmetrical (see next slide)
    • right lung = 3 lobes RUL, RML, RLL
    • left lung=2 lobes LUL , LLL
    • Lung border locations :
    • Apices – 1 inch above the clavicles
    • Bases – located at the level of the 6 th rib (T10)
    • Lateral chest – extend from the apex of the axilla to the 7 th or 8 th rib.
  • Lungs
    • Inspection
    • Color, Size and shape of chest, any deformities or lesions
    • Resp. rate and depth
    • Pattern of respiration – regular rhythm
    • Abnormal patterns
      • Hyperventilation-fast rate and deep breathing
      • Tachypnea >28 vs. bradypnea <10
      • Stertorous -“death rattle” –seen in comatose patient
  • Lungs
    • Inspection
      • Check size, shape, symmetry
        • Altered shape ex., COPD, barrel chest
        • Altered symmetry ex., kyphosis (hunchback), scoliosis (S)
        • Altered breathing ex., rib fractures, pneumothorax
        • Altered color ex., hypoxia
        • Retractions from airway obstruction, respiratory distress
        • Scars from lung surgery, trauma
  • Looking at related structures
    • Skin: cyanosis, pallor
    • Nails: Clubbing
      • Spongy nail matrix and nail angle of greater than 160 degrees
      • Associated with congenital heart disease
  • AP Diameter Anterior Posterior Diameter
    • The diameter of the chest from front to back should half the width of the chest.
    • AP-Transverse/Lateral diameter= 1:2 ;
    • Transverse/Lateral should twice as wide as front to back
    • Barrel chest – emphesyma pts (alveoli lost its eleasticity so lung tissue does not recoil back to normal
    • COPD / Emphysema classically produces the &quot;Barrel Chest Deformity&quot; Lungs are overinflated, and pushing the chest wall out
    • Pectus carinatum (Pigeon chest)– sternum protrudes out beyond the front of the abdomen– may be related to Rickkets
    • Pectus excavatum (funnel chest)– sternum pushed in; depressed on all or part of the sternum
  • Normal Breath Sounds
    • Bronchial over trachea
    • Bronchiovescular over main bronchi
    • Vesicular over lesser bronchi, bronchioles, and lobes
  • Adventitious/Abnormal Breath Sounds Note whether the sound occur during inhalation or exhalation, or both.
    • Continuous sounds
    • Wheezes
    • Rhonchi
    • Discontinuous sounds
    • Crackles (Rales)
      • Fine
      • Course
      • *Atelectic crackles
      • Pleural friction rub
  • Wheeze & Rhonchi Continuous Sound
    • Wheeze
    • high-pitched musical sounds heard first when a patient exhales
    • Partial blockage in airflow
    • Severe blockage – wheezes also heard when patient inhales
    • Asthma, CHF, or foreign body obstruction, tumors
    • Rhonchi
    • low pitched – snoring , rattling sound
    • heard primarily when the pt exhales
    • may also be heard on inhalation
    • disappears with coughing
    • Uncleared secretions, bronchitis, pneumonia,
  • Crackles Discontinuous Sound
    • Crackles (Rales) -Caused by collapsed or fluid-filled alveoli popping open.
    • FINE Crackles –
      • usually heard in the lung bases;
      • CHF, Pneumonia, restrictive diseases – pulm fibrosis, asbestosis, atelectasis (early CHF)
    • COURSE Crackles
      • during inhalation and may be present in exhalation
      • Sounds like bubbling or gurgling as air moves through secretions in the larger airways
      • COPD, pulm edema
  • Crackles Discontinuous Sound
    • Crackles (Rales) -Caused by collapsed or fluid-filled alveoli popping open.
    • Atelectic crackles
      • common in elderly, disappears after several deep breaths
    • Pleural friction rub – pericarditis
      • fluid in the pericardial space due to inflamed pleura
      • pain on deep inspiration.
  • Pulmonary Edema
    • Accumulation of fluid in the air sacks (aveoli) of the lungs
  • Abnormal Breath Sounds
    • Diminished breath sounds
      • Obese, muscular chest wall
      • poor inspiratory effort
      • pleural effusion
    • Absent breath sounds
      • Missing lung/lobe
      • airway obstruction, pneumothorax
  • Lungs - Palpation
    • Crepitus – SQ air pockets = abnormal
      • Indicates subcutaneous air in the chest
      • Feels like puffed rice cereal crackling under the skin and indicates air is leaking from the airways or lungs due to chest tube or open wound
    • Tactile fremitus – increased fluid accumulation = abnormal
    • A palpable vibration that is caused by the transmission of air through the broncho pulmunary system
      • Decreased fremitus – over areas where pleural fluid collects (effusion, and pneumothorax, atelectasis, emphysema)
      • Increased fremitus – abnormally seen in areas in which alveoli are filled with fluid and exudate, occurs with consolidation of lung tissue (pneumonia). You will feel more vibration.
  • Objective Data
    • Respiratory
        • Rate : 18 resp/min
        • Depth : deep, even, shallow
        • Effort : labored, unlabored
      • Breath Sounds
        • Describe : clear, rhonchi, inspiratory/expiratory wheezes, crackles
        • Location : all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat.
        • Cough : present/not present
          • Describe : productive, moist, nonproductive
        • Sputum : large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.
  • Interventions
    • Position , Turn, Cough, Deep breathe
    • O2 Method : nc, venti mask, rebreathing mask
      • Flow rate: 2L/min; 3l/min
      • Humidity: yes/no
    • Pulse Oximeter : continuous, spot monitoring
    • Incentive Spirometer : in use, n/a
      • Time used: 10 am, 11 am, 1 pm, 3 pm
      • Volume: 500 cc, 500 cc, 600 cc, 800 cc
    • Oropharyngeal Suctioning : Describe- moderate amount thick tan secretions
    • Med List: Albuterol inhaler, Prednisone, Theophylline
  • Abdomen
    • Sounds, masses, tenderness
    • Divide into four quadrants: RUQ, RLQ, LUQ, LLQ
    • Inspect then auscultate
    • Bowel sounds: absent, hypoactive, hyperactive
    • Listen continuously for 5 minutes to determine absence
    • Palpate and/or percuss after listening
    • Abdomen should be soft, non-tender, non-distended
  • Abdomen
    • RUQ – liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of colon, ascending /transverse colon, right kidney
    • LUQ – stomach, spleen, body of pancreas, left kidney, splenic flexure of colon, transverse/descending colon
    • RLQ – cecum, appendix, right ovary, tube, ureter, and spermatic cord
    • Midline – aorta, uterus, bladder
    • Epigastric, umbilical, suprapubic
  • Different Sequence of Assessment
    • Inspect
    • Auscultate
    • Percuss
    • Palpate
    • Procedure:
      • Have patient empty bladder
      • Position patient supine with knees slightly flexed
    • Note the abdominal shape and contour.
    • The abdomen should be flat to rounded in people of average weight.
    • A protruding abdomen may be due to obesity, pregnancy, ascites, or abdominal distention.
    • A slender person may have a slightly concave abdomen
  • Abdomen - Inspection
    • Lesions – benign, scars from sx or trauma, striae, etc.
    •   Distention - can be from fluid, air, mass, or obstruction
    •   Pulsations - or movement of abdominal wall from peristalsis, pulsations and respiratory movement
      • Peristalsis usually can’t be seen. If seen, slight wavelike motions.
      • Visible rippling waves may indicate bowel obstruction -reported immediately.
      • In thin pts, abdominal aortic pulsations may be seen in the epigastric area.
      • Marked pulsations may indicate HTN, Aortic insuff, AAA, or other condition causing widening pulse pressure (see next slide)
  • Aneurysm
    • Note vascular sounds – presence of bruits over aorta, renal, iliac, femoral
    • Normally no bruits noted
    • Abdominal aortic aneurysm – surg emerg.-tx immed to prevent hemorrhage, shock, and death
    • If you see bounding pulsation on abd wall, feel for pulsations, and measure (greater than 6 cm- most likely aneurysm) report.
  • Auscultation of Bowel Sounds
    • Absent
      • no BS for 5 min
    • Hypoactive
      • less than 5/min
    • Active
      • 5-30 per min
    • Hyperactive
      • > 30 /min
  • Abdomen - procedure
    • BOWEL SOUNDS
    • VENOUS HUMS
    • RENAL BRUITS
    • INGUINAL BRUITS
    • Use diaphragm of stethoscope lightly on skin to prevent stimulating bowel sounds
    • Start in RLQ (BS often present here) then proceed all four quadrants
    • Listen for 3-5 minutes
    • Note character and frequency of BS
  • Bowel Sounds
    • Normal BS are high-pitched, gurgling noises caused be air mixing with fluid during peristalsis. The noises vary in frequency and pitch, and intensity. They are loudest before meal times. Normal BS – 5-30 per minute
    • Borborygmus, or stomach growling – are the loud, gurgling, splashing bowel sound heard over the large intesting as gas passes through it.
    • Hyperactive BS - > 30 /min – loud, high pitch, tinkling that occur frequently – may occur with diarrhea, constipation, and laxative use
    • Hypoactive < 5 per min ; - occur infrequently – assoc. with bowel obstruction, ileus, peritonitis, and indicate diminished peristalsis. (paralytic ileus, use of narc meds can decrease peristalsis)
    • Absent, no BS for 5 minutes.
    • Be sure to allow enough time for listing in each quadrant before you decide that bowel sounds are absent. If NGT to suction, turn off suction as to not obscure or mimic sounds
  • Percussion
    •     To assess
    • -Density of abdominal contents
    • -Locate organs
    • -Screen for abnormal fluid or masses
    •  
    •    Tympany – predominantly over the abdomen – gas-filled
    •  
    •    Dull over organs in the abdominal cavity (liver, spleen)
    • CVA tenderness Costovertebral Angle CVA tenderness – positive in pyelonephritis
  • Abdomen - Palpate
    • Palpate all four quadrants:
    • To check for muscle resistance or rigidity; masses, fluid, tenderness.
      • To palpate, put finger of one hand close together and make gentle rotating movements as you depress ½ inch (1.3 cm) Light palpation – depress 1 cm:Relaxation; Tenderness; Masses
    •     Palpate areas of pain and tenderness last
    •   Normal : the abd should be soft and nontender. As you palpate, note any
    • Abnormal findings : tenderness, masses, and rigidity
  • Palpation
    • Light Palpation
    • TENDERNESS, MASSES, RIGIDITY
    • Deep Palpation
    • Deep palpation - depress 5-8 cm; that’s about 2-3 inches.
    • In obese, patient, put one hand over the other and push down.
    • Palpate the entire abd on a clockwise direction and not any: Tenderness;  Masses; Enlarged organs
  • Normally Palpable Structures
    • Know what is underneath so you can determine what can be expected from normal to abnormal
      • Ex. suprapubic distention, full bladder or tumor?
      • Sigmoid colon, stool can be palpated there
    • Liver – should not be able to palpate liver way below the rib = enlarged
  • Rebound Tenderness
    • Use when found abdominal pain or tenderness
    • Hold hand at 90 deg angle & push slowly & deeply
    • Lift hand quickly
    • Norm. response is no pain on release of pressure
    • Perform at end
  • ABDOMEN (summary)
    • INSPECT-SKIN, PULSATION
    • AUSCULTATE FOR BOWEL SOUNDS IN 4 QUADRANTS FOR 2-5 MIN & DETERMINE IF AUDIBLE, ABSENT, HYPOACTIVE, HYPERACTIVE
    • PERCUSS FOR TYMPANY & LIVER DULLNESS
    • PALPATE LIGHTLY FOR TENDERNESS, MASSES, RIGIDITY
  • References
    • ASSESSMENT OF HEAD & NECK http://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20HEAD%20&%20NECK_SP%2004.ppt
    • Health History and Physical Assessment http://e-courses.cerritos.edu/rsantiago/My%20Webs/PowerPoint%20Presentations.htm
    • Physical Assessment http://webteach.mc.uky.edu/nursing/nur869/webquests/lab1/Presentationphysical%20assessment.ppt
  • References
    • Rachel S. Natividad, RN,MSN: Assessment of the Abdomen http://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20THE%20ABDOMEN%20N212_n251%20SP04.ppt
    • Rachel S. Natividad, RN,MSN: Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system http://e-courses.cerritos.edu/rsantiago/My%20Webs/Cardiovascular%20Assessment%20_N212_N251%20SP04.ppt
    • Rachel S. Natividad, RN, MSN:The Respiratory System, Thorax and Lungs
    • http://e-courses.cerritos.edu/rsantiago/My%20Webs/Resp%20Assess%20N212_251%20SP04.ppt