Assessing Lung Sounds

(3) Normal Breath Sounds

Bronchial breath sounds: loud, harsh and high pitched. Heard over the trachea, bronchi—between clavicles and midsternum, and
over main bronchus.
Bronchovesicular breath sounds: blowing sounds, moderate intensity and pitch. Heard over large airways, either side of sternum, at
the Angle of Louis, and between scapulae.
Vesicular breath sounds: soft breezy quality, low pitched. Heard over the peripheral lung area, heard best at the base of the lungs.

ADVENTITIOUS LUNG SOUNDS

Sound Characteristics Lung Problem
Popping, crackling, bubbling, moist sounds Pneumonia, pulmonary edema, pulmonary
Crackles on inspiration fibrosis

Rhonchi Rumbling sound on expiration Pneumonia, emphysema, bronchitis,

bronchiectasis
High-pitched musical sound during both Emphysema, asthma, foreign bodies
Wheezes inspiration and expiration (louder)

Pleural Friction Rub Dry, grating sound on both inspiration and Pleurisy, pneumonia, pleural infarct
expiration

Assessing Heart Sounds

These tones are produced by the closing of valves and are best heard over 5 points:
1.) Second intercostals space along the right sternal boarder. AORTIC AREA
2.) Second intercostals space at the left sternal boarder. PULMONIC AREA
3.) Third intercostals space at the left sternal boarder. ERB’S POINT
4.) Fifth intercostals space along the left sternal boarder. TRICUSPID AREA
5.) Fifth intercostals space, midclavicular line. MITRAL AREA—APEX
This is where the Point of Maximal Impulse (PMI) is found—document location (note: with enlarged hearts mitral area may present at
anterior axillary line)
S1 (“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 (“dub”) end of ventricular systole and beginning of diastole. Aortic and pulmonic valves close.
S3 (“Kentucky”) 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 bell of stethoscope and have pt in the left lateral position.
S4 (“Tennessee”) 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.

Grading Murmurs
Grade I Faint; heard with concentration EDEMA: Assess by placing thumb over
Grade II Faint murmur heard immediately dorsum of the foot or tibia for 5 seconds
Grade III Moderately loud, not associated with thrill 0 No edema
Grade IV Loud and may be associated with a thrill 1+ Barely discernible depression
Grade V Very loud; associated with a thrill 2+ A deeper depression (< 5 mm) w/
Grade VI Very loud; heard w/stethoscope off chest, associate w/a thrill normal foot & leg contours
3+ Deep depression (5-10 mm) w/ foot &
Normal B/P for all <120/<80; Prehypertension 120-139/80-89
leg swelling
Guidelines and education site for adult B/P.
4+ Deeper depression (> 1 cm) w/ severe
http://www.nhlbi.nih.gov/hbp/index.html
foot and leg swelling
For children & adolescents:
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

Sawall RN, MS, MPH, CNS 1

Health Assessment 2005
Note to students: the chart should be used as an organized reference guide and memory refresher and not substituted for assigned class work or a replacement for
medical or nursing references. The chart should not be relied upon to provide any medical or nursing care.
 5 P’s of Circulatory Averages for Age Grouping
Checks AGE WGT (kg) PULSE RESP B/P (syst.)
Pain Preemie 1-2 140 < 60 50-60
Term NB 3 125 < 60 70
Pallor 6 Months 7 120 24-36 90 ± 30
1 yr 10 120 22-30 96 ± 30
Paralysis 3 yrs 15 110 20-26 100 ± 25
5 yrs 18 100 20-24 100 ± 20
Paresthesia 6 yrs 20 100 20-24 100 ± 15
8 yrs 25 90 18-22 105 ± 15
Pulse 12 yrs 40 85-90 16-22 115 ± 20
16 yrs > 50 75-80 14-20 120 ± 20
Adult Female 50-75 60-100 12-20 90 + age
Adult Male 75-100 60-100 12-20 100 + age

PULSES: Peripheral pulses

should be compared for rate,
rhythm, and quality. Formula to convert from Fahrenheit to Celsius: (5/9)*(deg F-32)
0 Absent to convert from Celsius to Fahrenheit: (1.8*deg C)+32
95º F = 35ºC 96ºF = 35.5ºC 98.6ºF = 37ºC
+1 Weak and thready
110ºF = 37.7ºC 101ºF = 38.3ºC 102ºF = 38.8ºC
+2 Normal 103ºF = 39.4ºC 104ºF = 40ºC 105ºF = 40.5ºC
+3 Full
+4 Bounding

Symptom Analysis: This assists the client in describing the problem.

P Provocate/Palliative: What caused it? What makes it better/worse?
Q Quality/Quantity: How does it feel, sound, look, how much?
R Region/Radiation: Where is it and does it spread?
S Severity Scale: Rate on appropriate pain scale. Does it interfere with ADLs?
T Timing: When did it start? Sudden/gradual? How often? How long does it last?

4 Primary Assessment Techniques: INSPECT, PALPATE, PERCUSS, AUSCULATE

Assessment Area What To Observe
General Survey General appearance and behavior, posture, gait, hygiene, speech, mental status, height, weight,
hearing and visual acuity, VS, nutritional status
Head and Neck Skull size, shape, symmetry, hair & scalp, auscultate for carotid bruits, clenched jaws, puff cheeks,
palpate TMJ, use cotton swab for facial sensations, test EOMs, cover/uncover test, corneal light
reflex, Weber and Rinne test, use ophthalmoscope and otoscope, inspect and palpate teeth and
gums, test rise of uvula, test gag reflex, test sense of smell and taste, inspect ROM neck, shrug
shoulders, palpate all cervical lymph nodes, palpate trachea for symmetry, palpate thyroid gland

Sawall RN, MS, MPH, CNS 2

Health Assessment 2005
Note to students: the chart should be used as an organized reference guide and memory refresher and not substituted for assigned class work or a replacement for
medical or nursing references. The chart should not be relied upon to provide any medical or nursing care.
Upper Extremities Inspect skin, blanche fingernails, palpate peripheral pulses, rate muscle strength, assess ROM, test
deep tendon reflexes (DTRs)
Posterior Thorax Inspect spine for alignment, assess anteroposterior to lateral diameter, assess thoracic expansion,
palpate tactile fremitus, auscultate breath sounds
Anterior Thorax Observe respirations. pattern, palpate respirations, excursion, auscultate breath sounds, auscultate
heart sounds, inspect jugular veins, perform breast exam
Abdomen Auscultate for bowel sounds, inspect, light and deep palpation, percuss for masses and tenderness,
percuss the liver, palpate the kidneys, blunt percussion over CVA (posterior thorax) for tenderness
Lower Extremities Inspect skin, palpate peripheral pulses, assess for Homan’s sign, inspect and palpate joints for
swelling, assess for pedal and ankle edema, assess ROM
General Neurologic Test stereognosis-object identification in hands, test graphesthesia-writing on body with closed
pen, test two point discrimination, assess temp perception, inspect gait and balance, assess recent
and remote memory, test cerebellar function by finger to nose test for upper extreme, and running
each heel down opposite shin of lower extremity, test the Babinski reflex.

Sawall RN, MS, MPH, CNS 3

Health Assessment 2005
Note to students: the chart should be used as an organized reference guide and memory refresher and not substituted for assigned class work or a replacement for
medical or nursing references. The chart should not be relied upon to provide any medical or nursing care.