Health/ H2T Assessment- Respiratory/ Cardiac/ Extremities Flashcards
What do you INSPECT for in respiratory assessment
Look for breathing pattern & rate (respirations, labored vs nonlabored effort)
Look at shape of the chest (normal, barrel, etc)
Flaring nostrils (in infants & children)
How do document normal chest sounds?
Lungs are clear
Good Air exchange
Adventitious Breath Sounds mean …
Examples
Abnormal breath sounds
Ex:
Wheezing (high pitch sounds from inflammation)
Bronchi (snoring sounds)
Pleural rub (grating sound)
Rails/Crackles (rice krispy/crackling sound due to fluid)
Absence of breath sounds
breathing that is difficult or requires more effort than normal
labored breathing
What do you auscultate in a respiratory assessment?
Chest sounds (anterior listening)
Breath sounds (posterior listening)
*Listen for quality and intensity(
How to auscultate anterior chest sounds
- Assist pt with sitting upright*
- Ask pt to take SLOW, DEEP BREATHS through the mouth
- Start 1 inch below R mid clavicle over the intercostal space and listen to 1 FULL inspiration and expiration. Do to L side
- Begin 1.5- 2 inches below origin point R mid clavicular and listen to 1 FULL again. Repeat on L side
-Move down to midclavicular 5th intercostal space and repeat process on both R & L sides
How to auscultate posterior chest sounds
Tell pt to lean forward and cross there arms
- Start at 2 inches below shoulder and 2 inch into the right of the spine. listen to 1 FULL inspiration and expiration. Do to L side
-Repeat on both sides about 2 inches from origin point.
-Repeat
-End just below scapula on both sides
PMI
Point of Maxium Impulse
where steth is placed to hear heart sounds the best
Where is PMI?
L mid-clavicle 5th intercostal space
Normal Heart sounds
S1 and S2 Lub Dub
Systole
Ventricular Contraction
Diastole
Ventricular Relaxation
Abdominal Assessment
Assess the abdomen in four quadrants
Pt should be laid flat
Inspect Auscultate Percuss Palpate
Why do we auscultate before palpate when assessing abdomen?
We do not want to disrupt or create sounds that did not exist prior to palpating before listening
Anything done rectally, pt should
be on their left side
Grading Scale for Pulses
0- Absent
1- Diminished, thready
2- Normal, not easily obliterated
3- Increased full volume
4- Bounding
How many arterial pulse sites are there?
12
When assessing the extremities,
always compare both sides
you inspect and palpate; check
arterial pulses
capillary refill
veins
Edema
Joint mobility/ ROM
Muscle strength
Color, Movement, Temp
CMS
Normal capillary refill documentation
Capillary refill < 3 seconds
Abnormal capillary refill documentation
Capillary refill > 3 seconds
Capillary refill is a good test to check for
circulation
How is edema measured and checked?
measured from +0-4
*Make indentation w/ finger
Count in seconds for indentation to return to normal
Hyperactive bowel sounds aka
Borborygmi
Best area to check apical pulse
The mitral area aka apical area of the heart located 5th intercostal space L mid-clavicle
Example of a Normal breath sounds that are lough and high pitched, compared to sound of air blowing through a pipe
Bronchial
Example of a Normal breath sound that is soft and breezy
vesicular
example of a normal breath sound that are medium pitched and soft
Broncho vesicular
What are some causes for adventitious breath sounds?
Inflammation of airways, air passing through fluid, and narrowed airways
How is edema measured?
pressing thumb into skin and noting how long the tissue remains indented
Edema measurement scale
+1 pitting edema- barely detectable/ immediate rebound
+2 pittind edema- a few seconds to rebound
+3 pitting edema- 10 to 12 seconds to rebound
+4 pitting edema- more than 20 seconds to rebound
+5 branwy edema- no pitting, tissue is firm; skin warm and mosit- skin discoloration
Difference between pitting and non pitting edema
Pitting edema- cause is excess water in the tissue, can usually resolve e/ diuretics and elevation
Non pitting- cause can be other than extra fluid, can be salts, proteins and drainage is more difficult
The BELL of a stethoscope is to listen to _____ ; the diaphragm of stethoscope is to listen to _____
heart murmurs; breath sounds
Dependent areas of bedridden patients;
back and sacrum.
CMS stands for
Circulation, Motion, Sensation
