Cardio-pulmonary assessment Flashcards
Preparation
wash hands introduce self ID patient explain procedure provide privacy don gloves (can remove to percuss)
Vital signs/ LOC
Temp- 98.6F or 37C HR- 60-100- count for 30 sec x2 RR- 12-20- count for 30 sec BP- 120/80-140/90 Pulse ox- 94% LOC- person, place, time, purpose
Subjective data
Respiratory: Cough/sputum Shortness of breath Pain with breathing Hx of respiratory infections/conditions Smoking hx Calculates pack per year Environmental exposures to airborne toxins Hx of chest trauma/surgeries Use of oxygen
Cardiac: Hx of cardiac problems Chest pain Palpations Dizziness/fainting Fatigue Edema
Respiratory assessment
Skin color- pink, warm, dry, intact
Respiratory pattern- effortless, relaxed breathing, even and regular
Chest contour- elliptical in shape, barrel, pectus excavatum, pectus carinatum
Is trachea midline
Anterior chest:
Check chest expansion
Palpate for fremitus upper and lower lobes- vibrations are present bilaterally- 4
Percuss upper and lower lobes- resonance is present-5
Auscultate upper and lower lobes
Auscultating through full inhale and exhale
Identify abnormal lung sounds if present
Posterior chest: Check chest expansion Palpate fr fremitus- all locations Percuss posterior chest-all locations Auscultate posterior chest-all locations Auscultate through full inhale and exhale Identify abnormal lung sounds if present
Cardiac assessment
Ask pt to lie down
Locate right and left jugular veins/pulsations
Note jugular distention (present or absent)
Palpate carotid pulses
Auscultate full length of carotid arteries using bell
Elevate puts head 45 degree angle Auscultate heart sounds with diaphragm at aortic valve area Pulmonic valve Erbs point Tricuspid valve Mitral valve (apex)
Auscultate heart sounds with bell at aortic valve area Pulmonic valve area Erbs point Tricuspid valve Mitral valve (apex)
Confirm profusion of apical pulse
Check brachial and radial pulses bilaterally
Check popliteal and pedal or post-tibial pulses bilaterally
Note presence/absence of edema in lower extremities bilaterally
Closing
Make patient comfortable and safe
wash hands
offer to answer any questions
order of assessment
inspection
palpation
percussion
auscultation
Crackles
Characteristics:
popping, crackling, bubbling, moist sounds, inspiration
Lung Problems:
Pneumonia, pulmonary edema, pulmonary fibrosis
Rhonchi
Characteristics:
Rumbling sound on expirations
Lung Problems:
Pneumonia, emphysema, bronchitis, bronchiectasis
Wheezes
Characteristics:
High-pitched musical sound during both inspiration and expiration (louder)
Lung Problems:
Emphysema, asthma, foreign bodies
Pleural Friction Rub
Characteristics:
Dry, grating sound on both inspiration and expiration
Lung Problems:
Pleurisy, pneumonia, pleural infarct
S1 heart sound
Lub
The start of cardiac contraction called systole
Mitral and tricuspid valves are closing and vibration of the ventricle walls due to increased pressure
S2 heart sound
dub
End of ventricular systole and beginning of diastole
Aortic and pulmonic valves close
S3 heart sound
Tennessee
A ventricular gallop heard after s2
Normal in children and young adults, pregnancy, and highly trained athletes
In older adults it is heard in heart failure
Use the bell of the stethoscope and have pt in the left lateral position
S4 heart sound
Kentucky
Atrial diastolic gallop
Resistance to ventricular filling and heard before S1
Heard in HTN and left ventricular hypertrophy
Listen at apex in left lateral position
