ARELLANO UNIVERSITY College of Nursing 2600 Legarda, Sampaloc. Manila PACUCOA Level Il RE-Accredited Status wwwarellano.edu.ph = Nursing assessment is an important step of the whole nursing process. Assessment can be called the “base or foundation’ ofthe nursing process. With a weak orincorrect assessment, nurses can create an incorrect nursing diagnosis and plans there ore creating wrong interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet that you and print and use to guide you throughout the first step of the nursing process. Physical Assessment Integument Skin: The client's skin is uniform in color. unblemished and no presence ofany foul odor. He has 1a good skin turgor and skin's temperature is within normal limit. Hair: The hair ofthe client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are alsonc signs of infection and infestation observed. Nails: The client has a light brown nails and has the shape ofconvex curve. itis smocth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds. Head ‘+ Head: The head ofthe clert is rounded: nommocephalic and symmetrical ‘© Skull: There are no nodules or masses and depressions when palpated ‘+ Face. The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses. Eyes and Vision ‘+ Eyebrows: Hair is evenly distibuted. The clent's eyebrows are symmetrically aligned and. showed equal movement when asked to raise and lower eyebrows. ‘+ Eyelashes: Eyelashes appzared to be equally distributed and curled slightly outward, ‘+ Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute + Eyes © The Bulbar conjunctiva appeared transparent with few capillaries evident ‘The sclera appeared white ‘The palpebral conjunctiva appeared shiny, smooth and pink. ‘There is no edema ortearing ofthe lacrimal gland, ‘Comeais transparent, smooth and shiny and the details ofthe iis are visible. The ccliant binks when the comea was touched. c The pupils ofthe eyes are black and equal in size. The irs is flat and round, PERRLA (pupils equally round respond tolight accommodation), iluminated and rnon-iluminated pupils constricts. Pupils constrict when looking at near object and. dilate at far object. Pupils converge when object is movedtowards the nose. © When assessing the peripheral visual field, the client can see objects in the periphery when looking straight zhead. JOANNE MARIE S. HARCIA, RN, MAN2 When testing for the Extraccular Muscle, beth eyes of the client coordinately ‘moved in unison wah paralle! alignment. © The client was able to read the newsprint held at a cistance of 14 inches Ears and Hearing * Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned wih the outer canthus of eye. When palpating for the texture, the auricles are mobilo, firm and not tender. The pinna recoils when folded. During the ascescment of Watch tick test, the client was able to hear ticking in both ears. Nose and Sinus + Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or faring. When lightly palpated, there were no tendemess and lesions Mou = The Ipsofthe cient are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his lips when asked to whistle. c Teeth and Gums: There are no discoloration ofthe enamels, no retraction of gums, pinkish in color of gums ‘© The buccal mucosa of the client appeared as uniformly pink; moist, soft glistening and with elastic texture, ‘© The tongue ofthe client is centrally positioned. itis pink in color, moist end slightly rough. There is a presence ofthin whitish coating © The smooth palates are light pink and smocth while the hard palate has a more ire gular texture. c The uvula of he client is positioned in the midline ofthe softpalate. © The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort. c The Iymph nodes of the client are not palpable © The trachea is placedin the midline ofthe neck. ‘© The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible. Thorax, Lungs, and Abdomen ‘+ Lungs /Chest: The chest wall is intact with notendemess and masses. There's a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing forthe respiratory excursion. The client manifested quiet, mhythmic and effortless respirations. ‘+The spine is vertically aligned. The right and let shoulders and hips are ofthe same height. ‘+ Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence ofheaves or lfs. ‘+ Abdomen: The abdomen ofthe client has an unblemished skin and is uniform in color. The abdomen has a symmetric contour. There were symmetric movements caused associated with client's respiration = The jugular veins are not visite © When nails pressed between the fingers (Blanch Test), the nails return to usual colorin less than 4 seconds Exiromities © The extremities are symmetrical in size and length ‘© Muscles: The muscles are not palpable with the absence oftremors. They are normally firm and chowed smooth, coordinated movements. «Bones: There were no presence ofbore deformities, tendemess and swelling. ‘* Joints: There were no swelling, tendemess and joints move smocthly. JOANNE MARIE S. HARCIA, RN, MANNursing Assessment in Tabular Form Assessment Integumentary © Skin + Hair © Nails Skull Face Eyes and Vision © Eyebrows © Eyelashes © Eyelids © Bulbar conjunctiva ¢ Palpebral Conjunctiva © Sdera + Lacrimal gland, Lacrimal sac, Nasolacrimal duct Comea + Clarity and texture Normal Findings Abnomnal Findings When skinis pinched i goes to previous state immediately (2 seconds). With fair complexion with dry moist skin Evenly cistibuted hair With shor. blackand shiny nai. With presence of pediculosis, Capitis ‘Smooth and has intact epidermis With short and clean fingernails and toenails Convex and with good capillary ‘efill ime of2 seconds. Rounded, normocephalic and symmetrical, smooth and has uniform consistency Absence of nodules or masses. ‘Symmetical facial movement, palpebral fissures equal in size, symmetric nasolabial folds Hair evenly distributed with skin intact. Eyebrows are symmetrically aligned and have equal movement. Equally distributed and curled slightly outward. Skin intact with no discharges and no discoloration. Lids close symmetrically and blinks involuntary. Transparent with capillaries slighty visible Shiny. smooth, pink Appears white No edema or tendemess over the lacrimal gland and ne tearing. Transparent, smooth and shiny upon inspection by the use ofa Penlight which is held in an ‘oblique angle ofthe eye and JOANNE MARIE S. HARCIA, RN, MANAssessment ‘© Comeal sensitivity Pupils Visual Fields Visual Acuity Ear and Hearing © Auricies © Extemal Ear Canal © Hearing Acuity Test + Watch Tick Test Nose and sinuses * Extemal Nose Normal Findings ‘Abnormal Findings moving the light slowly across the eye. Has [brown] eyes Blinks when the comea is touched through a cotton wisp from the back ofthe client. Black, equal in sze with consensual and direct reaction, pupils equelly rounded and reactive tolight and accommodation, pupils constrict when looking at near objects, dlilates at fer objects, converge when object is movedtoward the ‘nose at four inches distance and by using penlight When looking straight ahead, the client can see objects at the periphery which is done by having the client sit directly facing the nurse at a cistance of 23 feet The right eye is covered with a card and asked to look directly at the student nurse's nose. Hold penlight in the periphery and ask the client when the moving object, is spotted Able to identify letter/read in the newsprints ata distance of fourteen inches. Patient was able toread the newsprint at a distance of 8 inches. Color ofthe auricles is same as facial skin. symmetrical, auricle is aligned with the outer canthus of the eye, mobile, firm, non-tender, and pina recoils afterit is being folded, Without impacted cerumen. Voice sound audible. Able to hear ticking on right ear at a distance of one inch and was able tohear the ticking on the left ear at the same distance ‘Symmetiic and straight, no JOANNE MARIE S. HARCIA, RN, MANAssessment + Nasal Cavity Mouth and Oropharynx = Teoth ‘+ Tongue and fioor of the mouth ‘* Tongue movernent Uvula Gag Reflex Neck Head movement Muscle strength Lymph Nodes + Thyroid Gland Thorax and lungs Posterior thorax + Spinal alignment Breath Sounds © Anterior Thorax Abdomen Abdominal movements Normal Findings ‘Abnormal Findings flaring. uniform in color. ait moves freely as the clients breathes through the nares. Mucosa is pink, no lesions and ‘nasal septum intact and in middle with no tendemess. ‘Symmetical, pale lips, brown gums and able to purse lips. With dental caries and decayed ower molars Central position, pink but with whitish coating which is normal, with veins prominent in the for ofthe mouth. Moves when askedto move without diffcuty and without tendemess upon palpation Positioned midline of soft palate, Present which is elicited through the use ofa tongue depressor. Positioned at the midline without tendemess and flexes easily. No masses palpated. Coordinated, smooth movement with no discomfort, head laterally flexes, head laterally rotates and hyperextends With equal strength Non-palpable, non tender Not visible on inspection, glands ascend butnot visible in female during swallowing and visible in males, Chest symmetrical Spine vertically aligned, spinal colurnn is straight, leftand right shoulders and hips are at the same height. With normal breath sounds without dyspnea. Quiet, rhythmic and effortless respiration Unblemished skin, uniform in color, symmetric contour, not distended. ‘Symmettical movements cause JOANNE MARIE S. HARCIA, RN, MANAssessment ‘© Auscultation of bowel sounds Upper Extremities Lower Extremities Muscles Bones and Joints Mental Status Language Orientation Attention span Level of Consciousness Motor Function Gross Moter and Balance © Walking gait Stancing on one foot with eyes closed Heel toe walking Tos orhael walking Fine motortest for Upper Exiremities Finger to nose test Alternating supination and, pronation ofhands on knees Finger to nose and to the nurse's finger Fingers to fingers Normal Findings ‘Abnormal Findings by respirations. With audible sounds of 23 bowel sounds/minute, Without scars and lesions on both extremities With mirimal scars onlower extremities Equal in size both sides of the body, smooth coordinated movements, 100% of normal full movement against gravity and, {ull resistance No deformities or sweling, joints move smoothly. Can express oneself by speech or sign Oriented toa person. place. date or time, Able to concentrate as evidence by answering the questions appropriately. A total of 15 points indicative of complete orientation and alertness Has upright posture and steady. gait with oppesing arm swing unaidedand maintaining balance. Maintained stance forat least five (6) seconds Maintains @ hee! toe walking along a straight ine Able towalk several steps in toesheels. Repeatedly and shythmically touches the nose. Can altemetely supinete and pronate hands at rapid pace Perform with coordinating and rapidity. Perform with accuracy and rapidity. JOANNE MARIE S. HARCIA, RN, MANAssessment Normal Findings Abnormal Findings Rapidy touches each fingerto Fingers to thumb thumb with each hand. Fine motortest for the Lower Extremities Able to discriminate between Pain sensation sharp and dull sensation when touched with needle and cotton ‘Skin Assessment Color Vitiligo. Jaundice Pallor Cyanosis Erythema Melanin Vascular Lesions Ecchymosis Petechiae ‘Spider Angiomas Venous Star Moisture Temperature Texture MobiityTurgor Skin Lesions Color Type Pattern, grouping, or arrangements Location Size ‘Mobility/Consistency Assessment of the Eye L.Health History A. Current Health Status Problems JOANNE MARIE S. HARCIA, RN, MANCorrective lenses B. Past Health Status Lens change Blurred vision Spats, floaters, halos Infections or inflammations ofthe eyes Eye surgery orinjury Styes (hordeolums) High blood pressure Diabetes Eye medications C. Family health status I Exami of the Eye A. Vision Distance vision a Snellen char ‘SNELLEN CHART 1. Keep area well it 2. Client stands 20 feet from chart. 3. Test one eye at atime and then both eyes 4. Read smallest line of print possible, 5. Record visual acuity as a fraction (20/20). Alterations on visual acuity - Emmetropia - Hyperopia - Myopia - Presbyopia Neer vision Color vision B. Extracccular Muscle Function 4. Postion and alignment 2. Six cardinal positions of gaze Failure oflid closure Failure oflid opening (ptosis) -Nystagmus 3. Coverluncover test 4. Comesl light reflex test C. Peripheral Vision JOANNE MARIE S. HARCIA, RN, MAN1. Visual Fields ‘The visual feldisthe entire area seen by an eye when its gaze is fixed on a central point. Visual fields are limited by the eyebrows, the cheeks, and by the nose. To test visual fields by confrontation you need to face the subject directly at about 2 feet aivay with eyes at the same level. Test one eye at a time. Slowly bringa pencil in from the periphery into the field ofvision. Do this in eight cifferent directions D. Inspection Position and alignment ofthe eyes ‘a. Abnormalties - Exophthalmos -Lid lag, Eyebrows ‘a Abnormalities - Seborrheic dermatitis Loss of lateral 1/3 of eyebrows Eyelids a. Inspect for -Edema ~Color Lesions Lashes (condition and direction) - Adequacy of closure b. Abnormalities -Blephartis (inflammation ofthe eye lids) ~Ectropion (margin of lid tumed outward) -Ertropion (inward turring of id margin) -Periorbital edema (seen in inflammation, myxedema nephrotic syndrome -Hemiated fat involves lower lids) -Piosis (droopng of upper lid) - Sty (hordeolum: infection around hair follcte) ~Chalazion (chronic infammatory lesion of Meibomian gland) -Xenthelasma (raised yellowish plaques that appear on nasal portion of eyelids -Failure oflid closure -Epicenthal fold Laciimal apparatus a Observe for - Swelling ~Tearing (may occur from conjunctival inflammation, comeal initation, inadequate drainage [ectropion}, ornaso- lacrimal duct obstruction - Dryness ofthe eyes b. Abnormalities - Dacryocysitis (inflammation of the lacrimal sac) Conjunctiva ‘a Inspect lower lids b. Inspect upper palpebral conjunctiva ¢ Subconjunctival hemorrhage . Chemosis (edema) e. Finguecula - is a common type of conjunctival degeneration in the eye Pterygium - refers to any winglike triangular membrane occurring in the neck, eyes, knees, elbows, ankles or cigits. in the eye, a pinguecula is called a pterygium ifit invades the comea The tem comes fromthe Greek word pterygion meaning “wing” JOANNE MARIE S. HARCIA, RN, MAN. Conjunctivitis - infammation of the conjunctiva commonly due to an infection or an allergic reaction Sclera Comea ‘a Comeal reflex b. Inspect with light a Shape Pupils a Size Anisocoria - is a condition where the pupil of one eye differs in size from the pupil ofthe other. Your pupilis the black circle in the center of your eye. The pupils ofyour eyes are usualy the same size. b. Shape Reaction to light - PERRLA -Direct reaction. Consensual reaction Pupillary Responses (CN It Il) direct response, meaning constriction ofthe illuminated pupil, as well as the consensual response, meaning constriction ofthe opposite pupil E. Palpation Palpate eyelids for swelling and tendemess Palpate eyeball Palpate lacrimal sac F. Ophthalmoscopic examination Increase light intensity by tuming rheostat clockwise ‘a Large round beam b. Small round beam Slittike beam . Green (red-fee) e. Grid Lens +40 to-20 a Positive diopters (black) b. Negative diopters (red) Ophthalmoscope exam a Redreflex b. Optic fundus Optic disk -Size - Shape -Color -Margns Cup . Blood vessels | [Arterioles \Veins JOANNE MARIE S. HARCIA, RN, MANfeolor _fightrad [dark purple| size [small farge light reflex erat sent [pulsations [none prevent ©. Maculs £ Periphery g. Vitreous/lens 1h. Abnormalities retinal disorders hypertensive retinopathy — burst blood vesse's, due to long-term high bloodpressure. jabetic retinopathy — damage to the retine caused by complications of diabetes melitus, which could eventually lead to binchess Retinopathy — general term referring to non.inflammatory damage to the retina Retinopathy of prematurity — scarring and retinal detachment in premature babies Age-related macular degeneration — the photosensitive cells in the macula malfunction and over time cease to work ‘Macular degeneration — loss of central vision, due to macular degeneration Peripheral retinal degeneration Retinitis pigmentosa — genetic disorder, tunnel vision preceded by night-blindness Retinal haemorrhage Disorders of ocular muscles, binocular movement, accommodation and refraction Strabismus (Crossed eye/Wandering eye/Walleye) — the eyes co not paint in the same direction ‘Ophthalmoparesis — the partial ortotal paralysis ofthe eve muscles Progressive external ophthaloplegia — weakness of the external eye muscles Esotropia — the tendency for ayes o become crosseved Exotropia — the tendency for eyes to look outward Disorders of refraction and accommodation Hypermetropia (Farsightedness) — the ability to focus on near objects (and in extreme cases, any objects) ‘Myopia (Nearsightedness) — cistant objects appear blurred Astigrratism — the comes or the lens ofthe eye is not perfectly spherical, resulting in different focal points in ‘ifferent planes ‘Anisometropia —the lenses ofthe two eyes have different focal lengths Presbyopia — a condition that occurs wth growing age and resutts in the inabilty to focus on close objects Disorders of accommodation Intemal ophthalmoplegia Visual disturbances and blindness ‘Amblyopia (lazy eye) — poor or blurry vision due to either no transmission or poor transmission ofthe visual image to the brain Leber's congenital amaurosis — genetic disorder, appears at birth, charactensed by sluggsh or no pupillary responses: Scatoma (bind pol) — an aves imparment of vison surounded by field of latvely well-preserved vision See also Anopsia. Color blindness — the inability to perceive differences between some orall colors that other people can ‘istnguish Achromatopsia / Maskun — a low cone count or lack of function in cone cells Nyctalopia (Nightblindness) — a condition making it difficult orimpossible to see in the dark Blindness — the brain does not receive optical information, through various causes River blindness — blindness caused by long-erm infection by a parasitic worm (rare in westem societies) Micropihalmia/coloboma — a disconnection between the optic nerve and the brain andlor spinal cord Other disorders of eye and adnexa Red eye — conjunctiva appears red typically due to illness or injury Argyll Robertson pupil — small, unequal, irregularly shaped pupils Excohihalmos (also called exophihalmus, exoprthalmia, proptosis, oroxorbitism) is a bulging of the eye anteriorly out of the orbit. Exophthalmos can be either bilateral (as is often seen in Graves" JOANNE MARIE S. HARCIA, RN, MANdisease) or unilateral (as is often seen in an orbital tumor). Glaucoma is a term for a group of eye disorders which result in damage to the optic nerve Papilledema refers to swelling of the optic disc from increased intracranial pressure (ICP) CNs & Muscles That Control Extra Occular Movements ‘$04, LR'G, Al The Rest 'S eye movement. GLAUCOMA, ASSESSMENT OF THE EAR Anatomy and Physiology I Heath History A. Current Health Status 1. Change in hearing 2 Ear pain 3. Cerumen 6. Past Health Status 1. Injury 2 Tinnitus 3. History of ear infections JOANNE MARIE S. HARCIA, RN, MAN4 Drainage 5 Problems with balance, dizziness, or vertigo. 6 Mecications . Family History D. Health Promotion and Protection Ill Examination of the Ear A. Inspection 4. Color 2 Size 3. Drainage Nodules Lesions B. Palpation 1. Palpate extemal ear (tragus) 2. Palpate mastoid process 3. Pullhelix backward . Aucitory Function Screening Gross hearing screening Whisper Watch tick test Weber's test Rinne test Conduction deafness ‘Sensorineural deafness D. Otoscopic Examination Examine the extemal canal Cerumen color ‘Tympenic membrane Pearly gray Annulus (white and dense) Light reflex (anterior inferior quadrant) * Right tympanic membrane (5 o'clock position) * Left tympanic membrane (7 o'clock position) 4 Malleus (dense whitish streak) ‘5. Umbo (center oftympanic membrane) EXAMINATION OF THE HEAD AND NECK JOANNE MARIE S. HARCIA, RN, MAN| Anatomy & Physiology I Health History A History ofHead Trauma B Headaches C. Swelling of face, jaws, and mastoid process 1D. Sinus infections E Nasal discharge (post nasal drip) F Prolonged nosebleeds G Medication use +H. Mouth lesions |. Difficulty swallowing/chewing 4J.Voice hoarseness K Allergies L.Neckinjury/neck surcery M Use oftobacco N. Bruxism (0. Mouth care IIL Examination ofthe Head and Face A Head 1.Inspect a. Erect and midline b Hair distribution cc Symmetry and contour 2 Palpate a Palpate scalp and hair texture B Face 1. Inspection ‘a. Spontaneous facial expression b. Color (pallor & cyanosis) cc. Facial lesions, rash, swelling, and redness Abnormal movement 2.Palpation a. Palpate face for skin tone, muscle tone, and contours, b. Temporal artery pulses cc Palpate the temporomandibular joints 3. Auscuttate a. Temporal arteries C Nose 4. Inspect ‘a. Symmetry and contour b Deformity, swelling, discoloration c.Flaring of nares d Drect inspection with nasal speculum and perlight 2.Palpate Tenderness b. Nasal patency D. Sinuses 4. Inspect frontal and maxilary sinuses forinflammation and edema 2.Palpate for tendemess JOANNE MARIE S. HARCIA, RN, MAN3.Percuss fortenderness 4.Transillumination E Mouth and Oropharynx 1 Inspect a. Unusual breath odors b Oral mucosa cc Gingval surfaces d.Condition of teeth e. Tongue pink, rough, midline depression ~Hypoglossal nerve function (CN 12) ~ Examine underside = Lingual frenulum f.Herdand softpellets g Tonsils (Graded0to | 4 0 tonsils behind the pillars At fonsis ere peaking frompiliars lo fonsis are between pilars and ule iB fonsiss are touching uvula fea tonsil ere extending io midline 2. Palpate a. Palpate upper and lower lips and tongue to evaluate muscle tone and surface structure 3. Examine oropharynx with tongue depressor and penlight (glossopharyngeal vagus nerves) F. Neck 1. Inspect a. Symmetry b Masses . Scars Ability to swallow (aryny, trachea, and thyroid will all rise) 2. Lymph Nodes a Inspectand palpate, noting size, shape, delimtation, mobility, consistency, and tendemess 3. Trachea- inspect and palpate 4, Thyroid gland- inspect, palpate, and auscultate 5. Carotid arteries- inspect palpate, and auscultate 6. Jugular venous distention ASSESSMENT OF THORAX AND LUNGS JOANNE MARIE S. HARCIA, RN, MANCARDIAC ASSESSMENT Hoalth History 1. Current Health Status - chest pain fangina {nyocardial infarction post-myocarcial syndrome pericarditis issecting aortic aneurysm pulmonary artery hypertension [pneumothorax pneumonia ‘ib fracture lesophageal reflux esophageal spasm esophageal rupture - shortness ofbreath = syncope - swelling ofankles orfeet - heart palpitations - fatigue 2. Past Health History - congenital heart disease = rheumatic fever = heart murmur - high blood pressure, high cholesterol, diabetes melitus ~ confusion + fatigue - dental work 3. Family History 4, Personal Habits - smoking - alcohol - sloop & rest ~ nutrition - stress & coping Techniques of Exemination The patient should be supine with upper body elevated at a 15-30E angle. The room must be quiet, warm, and have good lichting. You should stand to the right of the patient being examined. Inspection and Palpation of the Heart inspection and palpation reinforce each other and are time saving when done together. ‘Tangential lighting helps you detect pulsations The ball of the hand (at the base of the fingers) is the most sensitive at detecting thei. The finger pads are more sensitive in detecting pulsetions Inspect and Palpate for: Pulsations-these are more visible when patients are thin. A thick chest wall or increased AP diameter can obscure them. Pulsations may indicate increased blood JOANNE MARIE S. HARCIA, RN, MANvolume or pressure. Lift orheaves- these ae forceful cardiac contractions that cause a slight to vigorous movement of stemum and ribs. Thills- these are the vibrations ofloud cardiac murmurs. They feel like the throat ofa purring cat. Thrills cccur with turbulent blcod flow. You should inspect and palpate at the following areas: 1. Aortic Area (second interspace to the right of the stemum), ‘a pulsation could indicate an aortic aneurysm. a thrill could indicate aortic stenosis. 2. Pulmonic Area (second interspace tothe lett of the sternum). «a pulsation could indicate pulmonary hypertension a thrill could indicate pulmonic stenosis. 3. ERB's Point (third interspace to the left ofthe stemum). Erb’s points a site at the upper trunk ofthe brachial plexus located 2~3 cm above the clavicle. findings similar to that ofaortic and pulmonic areas. 4. Tricuspid Area Right Ventricular Area) (4-5th interspace: lower half of the sternurr), ‘a sustained systolic lift could indicate right ventricular enlargement. ‘a systolic thrill could indicate a ventricular septal defect. in patients with anemia, anxiety, hyperthyroidiam, fever, pregnancy, or increased ‘cardiac output, a brief pulsation may be felt. 5. Mitral Area (Left Ventiicular Area) (6th intercostal apace at the midclavicular line). This is where you can find the Apical Pulse and usually can find the Point of Maximum Intensity (PM). ‘identify the PMI by location, diameter, amplitude, duration, and rate. To help identify ‘t, have patient exhale completely and hold breath orhave the patient lean forward. Normal is a light tap, 1-2 cmin diameter at the Sth interspace at the left midclavicular line. PMI could be displaced down and tothe left with ventricular hypertrophy, pregnancy, and CHF. ‘nommally seen in less than half the population. increased pulsation could indicate increased cardiac output, anemia, anxiety, fever, or pregnancy. a thril could indicate mitral regurgitation, or mitral stenosis 6. Epigastric Ara (below xyphoid process), increased sortic pulsation could indicate AAA, and aortic regurgitation or right ventricular pulsation ofright ventricular enlargement. 7. Ectopic Area (2-3rd interspace ai the LMCL) increased pulsations in this area seen in patients with MI's arcoronary heart disease. 8. Sternoc! cular Area (top of stemum at junction of clavicles pulsation of aortic arch may be felt in a thin client, Auscultation of the Heart JOANNE MARIE S. HARCIA, RN, MAN1. Aortic Area 2nd right interspace close to the sternum 2.Pulmonic Area 2nd leftinterspace. 3. ERB's Point 4rd left interspace. 4. Tricuspid Area _5th left interspace close to the stermum. 5. Mitral Area (Apical) 5th left interspace medial tothe MCL 1. With your stethoscope, identifyths first and second heart sounds ($1 and $2). at the aortic and pulmonic arees (base). $2 is normally louder than S1. $2 is considered the dub of lub-DUB." $2 is caused by the closure of the aortic and pulmonic valves. at the tricuspid and mitral area (apex) $1 is often, but not always louder than $2. $1 | considered the lub of 'LUB-dub’’ $1 is caused by the closure ofthe mitral and ‘cuspid valves. ‘S1is synchronous with the onset ofthe apical impulse. 2. Identity the heart rate. tachycardia bradycardia 3. Identify the rhythm, ifitisiregular. try to identify the pattem Do early beats appear on a regular shythm? Does the ire gularty vary consistently with respiration? | rhythm totally regular? 4, Listen to S1 first, then S2 at the previously mentioned areas using the Glaphragm and then the bell ‘note its intensty. are there any spitting sounds check during inspiration where S2 usually splits at pulmonic and ERB's point a thick chest wall orincreased AP diameter may make $2 inaudible. Alterations in St a. $1 is accentuated in exercise, anemia, hyperthyroidiem, and mitral stenosis, b. Sis diminished in frst degree heart block . $1 spittis most audible in tricuspid area (T-Iub-dub). Alterations in $2 a. Normal physiolagicel splitting of $2 is best heard at pulmonic area. It ‘occurs on inspiration (lub-T-dub, lub-dub). b. Splting of $2 can indicate pulmonic stenosis, airial sepial defect, right vertricular failure, and left bundle branch block (lub-T-dub). 5. Listen for $3 (ventricular gallop). JOANNE MARIE S. HARCIA, RN, MAN1a physiclogic 83 is frequently heard in children and in pregnant wamen |t occurs early in diastole during rapid ventricular filing. lis heard best at the apex in the lef lateral decubitus position ‘Lis heard best using the bell ‘a pathologic $3 ocaurs in people over the age of40. Cause is usually myocardial failure sounds like lub-cub-dee (or’Kentucky). 6. Listen for an S4 (atrial gallop). ‘t occurs before $1 ‘tis low pitched and bestheard wth the bell ‘often normal in older aduits ‘tis heard best at the apex in the left lateral decubitus position ‘t may be caused by coronary artery disease, hypertension, myocardiopathy, or sortic stenosis sounds ike dee-tub-dub (or'Tennessee'). 7. Listen for murmurs, CHECK TIMING. Are they sysiolic or diastolic? (systolic murmurs may be benign. Diastolic murmurs are never benign). LOCATION OF MAXIMAL INTENSITY. Where isthe murmur bestheard? FREQUENCY (pitch). This vanes fromlow-pitched, caused by siow veloaty of biood flow, to high pitched, caused bya rapid velocity of blood tow. INTENSITY. the loudness of a murmur is descnbed on a scale of to6: [Grade lintensity! Sounds 1 ery faint, easly missed (quiet, barely aucible [3 moderately loud but easily heard. Same intensity 2s $1 or S2. ia id but usually no thril present [5 very loud-thril present (6 heard with stethoscope offof chest. Thrill present. RADIATION. some murmurs radiate in the direction of the blood stream by which they are produced. Listen overneck, back, shoulders. and lef axilla. - QUALITY. musical [blowing [rarsh | ‘aortic murmurs are heard bestin full expiration with patient leaning foward JOANNE MARIE S. HARCIA, RN, MANmival murmurs are heard best afler exercise in left side lying position. Assessment of Extra Heart Sounds - ejection click - opening snap «= mridsystolie lick ASSESSMENT OF THE LUNGS AND THORAX ‘These same steps are very popular today in assessment of all systems ofthe body. These stepsare designed tottake the nurse through the assessment in a logcal and organized sequence. You first start with a very general inspection and history ofthe patient: then your ‘exam becomes more detailed as you begin to examine the interaction of all body systems. Visual Inspection - isthe first step of the examination. Thisis a very important part of the exam, since mary abnormalities can be detected by merely inspecting the thorax as the pationt is breathing. Palpation - is the first step of the assessment, where we will touch the patient. Many breathing cifficuties can be seen during this step. Some systemic problems can be detected during this part of the exam as well as just mechanical broathing problems. Percussing -is usually helpful only in a limited capacity to the examiner, as we will discuss later. Ausculation - is the process of listening to the breath sounds with the use of stethoscope. In this text, we will describe the characteristics of normal and common abnormal breath sounds. PATIENT HISTORY Following is a guide to the history-taking process. (Lever, 1990). The history is very important to obtain before you begin your examination. The nursing history may repeat some ofthe same items that the medical history has obtained but the nurse will have different objectives in mind when asking questions and gathering data, The fallowing guide can be used to obiain information fiom the patient and nursingrrelated information. ‘+ Reason forHospitalization (medical diagnosis from chart) ‘© Family Mecical History ‘© Family history (TB, allergy, asthma, smoking) © Soda history of family ‘© Occupational history ‘0 Type of work patient is engaged in, are they exposed to air or chemical pollutants © Exposure to exotic animals, birds: pigeons, parrots, parakeets © Consider the part ofthe country they are fom; some diseases are endogenous ‘+ General Patient Medical History ‘2 Major medical problems; heart, Gl, GU, respiratory surgery, ete. © Allergy © Childhood diseases ‘+ Specific Medical History (specificto this hospitalization) ‘© Pain - pulmonary pain. pleural pain. muscular pain. cardiac pain, describe in detail Cough —type of cough, type and character of sputum, bloodin sputum Hemoptysis Dyspnea — ask circumstances surrounding trouble breathing Hoarseness Wheezing oo000 THE LUNGS AND THORAX ‘The lungs are the cone-shaped orgens locatedin the pleural spaces in the right and left sides ofthe bony thorax. The right lungis dividedinto three separate and distinct lobes by deep fissures. The left lung has only two lobes. The purpose ofthe lungs is mostimportantly the exchange of gasesin the body. Air is moved into the lungs through the air passages by the JOANNE MARIE S. HARCIA, RN, MANUse ofthe respiratory muscles. In this text, we will net go into detail about these structures, because most nurses are already quite familiar with the respiratory muscles, primary and. secondary. Ifyou need a refresher. you may use any basic anatomy test. In this text, we wish to update you on assessment of the lungs and thorax. Following is an ilustration of the thorax and the major landmarks necessary for proper localization of ndings The first consideration is being able to accurately count and localize the ribs. The round and curved rib shown on the very top ofthe thorax is the frst rib. It is at the level ofthe clavicle. t's location behind the clavicleand the manubrium, makes it diffcult to palate this rib.. The space immeciately below this 1st rib is the frst intercostal space. If the examiner finds the suprastemmal notch (which the manubrum joins the body of the sternum, slide the finger down just a few centimeters, the 2nd rb will be found. The interspace just below this rib is the second intercostals space. Note also each ‘bis attachedto the stemum by a length of costal cartilage. Only the first seven ribs actualy articulate with the sternum, as the 8th, 3th and 10th nbs articulate with the costal cartilage from the nb directly above it,. The “floating-rbs”, the 11th and 12th nibs, have free anterior tips. lease review all above structures named in the text. Count the number of ribs and their location Terminology: + Tidal volume The volume ofair in and out ofthe lungs with a normal breath, approx. 500 mi) © Residual Volume Volume of air which remains in the lungs after a forced expiration (approx. 1200 ml) ‘+ Insosiratory reserve volume This term is the extra volume of air which can be inhaled after the person has taken in a nomal breath (“forced inspiration’) approx. 3000 mi © Expiratory reserve volume Is the extra amount ofair that can be expired by forceful expiration after the personhas, expired a normal breath of air, (forced expiration") approx 1100 rl of ar. ‘+ Insosiratory capacity The sum of tidal volume + inspiratory reserve volume: amount of air you can breathe when you forcefully inspire, after taking normal breath (tidal volume) (3500 mi). + Functional residual capacity Is the sum of: expiratory reserve volume + residual volume. This volume is the amount { air leftin lungs ater a normal expration. approx 2300 ml + Vital capacity The sum of ingpirstory reserve volume + tidal volume + expiratory reserve volume, This volume is the maximum amount of air thai a person can expel from the lungs after frst filing JOANNE MARIE S. HARCIA, RN, MANlungs to maximum and then expel air to maximum extent approx. 4600 mi + Total lung capacity Is the sum ofthe maximum volume to which the lungs can be expandedwith the greatest possible inspiratory force. approx. $800 rl EXAMINATION OF THE THORAX In the clinical setting, examination ofthe thorax first includes a gross examination of the patient. The patient will be comfortably seated on the edge ofthe bed, ifpossible, to best visualize the thorax and breathing pattems. Keeping in mind the structures ofthe bony thorax, visually inspect the thorax. Assess the following: ¢ Respiratory rate and rhythm © Gross deformities; curvatures, scars, d'scolorations, etc. * Abnormal breathing pattems (retractions included) Keep in mind, ifthere is any gross breathing difficulty, or any other condition which may compromise the patient: emergency first aid should be administered. We will not try to Continue the entre respiratory examination it another emergency condition exists. However, for our “outine” examination, the first step is visual inspecion. Pethaps during this part of the exam, the nurse shouldmake a mental note of any abnormality which will need tobe further assessed by some other method, such as palpation During the time ofthe visual inspection, the nurse will be aware ofany mental status changes in the patient such as restlessness or lethargy or confusion. These changes may be indicative ofrespiratory cifficully. Vital signs should be taken prior to the examination fora baseline, Taking all of the above information, the nurse may now continue to the next piiase of our examination. Remember to make notes on paper ofany abnormal findings as well as the nomal fndings ofthe exam. These netes will help you later for charting the findings on the patient's chart. Accurate information is always important when documerting the patient's condition Observing Respirations: The normal respiratory rate is 12 - 18 breaths per minute in adults DEFORMITIES OF THE THORAX Funnel chest Barrel ches There are many possible deformities ofthe thorax. The illustration shows two common deformities Funnel Chest and Barrel Chest. While performing your examination you may be unsure as tothe proper term or name ofthe particular deformity. If you are unsure aboutthe correct torm, just describe the problem in detail and describe the subjective and/or objective symptoms that may be present. Funnel Chest may be desorbed as a deformity where the stemum is depressed and results in pressure placed upon the underlying organs. This may cause a change in the blood pressure or pulse: chart these changes ifpresent. JOANNE MARIE S. HARCIA, RN, MANBarrel Chest may be described as a deformity which causes a rounded chest where ribs are elevated and separated more than normal. The slope ofthe ribsis also changed, they are almost completely horzontal. PALPATION. Expose the patient's thorax providing for as much comfort and privacy as possible. Use the fingertips and flat ofthe hand in order to palpate the thorax. Use firm but gantle pressure to assess the breathing and movements of the thorax. Next, palpate any abnormalities vhich you noticed from the first step of this assessment the inspection phase. Palpate the fellowing: Size and shape ofthe thorax during respirations intercostal spaces (for bulging or retractions) Any scars or other skin abnormalities (skin temperature as well) Tenderness or pain (palpate gently) Palpation should be done in an orderly method. First start at either the top or boitom and palpate through the ertire thorax surface. Next observe and palpate the posterior thorax. Use the same methodical approach. As with the previous findings, take notes and carefully chart any abnormal findings. Locations Describe the location ofyour abnormal findings according to the way your hospital requires. A general method ofdesciibing location isto use landmarks such as nipples, nippl line, the midstemal line, etc. Indicate anterior or posterior thorax, and use the midaxillary line location when applicable. When charting your findings, especially abnormal ones, be very desciiptive as to specific types ofabnormality. If the breathing is abnormal, describe the cate and rhythm. Ifthere is an abnormal node or mass, describe its lacation and size and whether tender or non- tender. These locations will apply to the posterior thorax aa well as to the anterior. Additional landmarks: * Midstemal tine A line extending downward from the stema notch * Midclavicular line A vertical line parallel o the midstemal line and extending downward from the midpoint of each clavicle. © Anterior Axillary Line A line extending downward from the anterior axillary fold ‘+ Posterior Axillary Line A line parallel tothe anterior axillary line beginning at the posterior axillary fold. © Midaxitlary Line A vertical line starting at a point midway between the anterior and posterior axillary lines. ‘+ Midspinal Line A vertical line in the center ofthe back running along the spinal process. ‘+ Midscapular Lines Vertical lines on the back, parallel tothe midspinal line, extending through the apices ofthe scapulae. JOANNE MARIE S. HARCIA, RN, MAN+ infrascapular Area Area of the pestericr thorax lying below the scapulac + interscapular Area Area of the posterior thorax lying between the scapulae. PERCUSSION Percussions oflimited use tomost nurses. The technique can reveal abnormalities which might be better assessed by palpation ofauscultation. Use percussion in conjunction with these other methods of assessment in order to confirm suspicions of underiying pathology. The technique ofpercussion, striking the chest wall, sets up soundwaves. These waves set the underlying tissues in motion, producing audible and palpable vibrations. Using this, method is effective for only a depth of about 5 to 7 cm. into the chest wal tissues. Therefore, deeper problems are virtually undetectable by this method. Percussion will be help to indicate the presence of air or fluids in underlying tissues. c F As shown in the illustration: ‘+ Hyperextend the fingers as shown. pressingthe middle distal phalanx firmly on the surface ofthe chestwall. (Do not et the hand rest upon the area as it will decrease the sounds heard). ‘+ Hold the opposite hand close to the handon the patient Flex the middle finger 2s shown, retract and strike the area shown by the arrow. Use 2 quick motion ofthe wrist + After striking at a right angle, quickly withdraw the finger (the striking finger), soas nat todampen the sounds ‘+ Strke an area twice, in order to gata clear sound. Move on to next spot quickly, using a uniform blow each time for comparison, Always use a quickwrist motion and listen carefully to the pitch of the resulting vibrations set up by the blow. Use this chart for comparison: . FLAT High piteh solid tissue beneath © DULL Medium pitch firm tissue beneath «RESONANT Low pitch normal resounding lung tissue (semi-hollow or “fu‘fy” sound) © HYPERRESONANT — very low pitch _very hollow sound. (emphysema) + TYMPANY musical very hollow sound (air bubble) JOANNE MARIE S. HARCIA, RN, MANPercuss across the tops of both shoulders (apex of each lung). Next, move down and move across the thorax, striking each spot as you proceed and notingthe sounds produced. Normal healthy lung tissue should resound with a resonant and full sound, as there is normal “fuffy” lung tissue beneath. If there is ahemothorax or pneumonia with fluid present, the sound will be flatter or duller as described in chart cbove. Remember to percuss anterior and posterior thorax ifyyou decide to use this technique. AUSCULTATION This technique has many indications and is widely used today. tt will incicate that there is oral air flow through the trachea and the bronchi, and into the lungs. It can indicate the presence of fluid and/or other obstructionin the air passages. Also the condition ofthe surrounding tissues can be assessed by this method, Just 2s with the other methods of assessment, have the patient sit comfortably andhave them breath just slightly deeper than normal through an open mouth,. Listen at each spot (described in the folowing paragraphs) for at least one full breath. Compare the symmetry of, the sounds (each side ofthe thorax). Ifthe patient becomes faint (from hyperventilation during the exam), stop temporarily, and then proceed. You vill be listening for: ‘© Quality and intensity are they fulland easily audible, rate, rhythm, are they ‘diminished? '* Adventitious sounds abnormal breath sounds; these sounds are distinguished from the variations of normal breath sounds which can occur due to hypoventilation or hyperventilation. SOUND: Before we discuss auscultation of breath sounds, we will ciscuss some ofthe characteristics of sound. Sound has three basic characteristics; intensity frequency, and duration Frequency refers tothe number of vibrations per unit oftime; and itis measured in cycles per second, orHz (Hertz). What is called 2 high frequency sound wil have a large number of vibrations per second. Wheezes can be of high frequency or low fecuency, or can be described as high-pitched or low-pitched. The “quality” of sound is also known a3 its “timbre.” Itisa result of the component frequencies that will make up a particular sound. The quality ofa sound will alow us to recogrize if musical note was played ona guitar or a violin or a piano. You may play the exect same note on all instruments, but that note will have a difforent quality on each instrument. This quality is important when listering to breath sounds and in noting changes in the spcken voice through the stethoscope. The intensity is described simply as the loudness of the sound. Intensity is affected by these factors: Amplitude Energy source Distance the sound travels Medium through which the sound travels The above factors will determine ifthe sound is loud or faint or distant. For example, iTyou are listening to lung sounds through lung tissue that is full of Muid, the sound will be louder, JOANNE MARIE S. HARCIA, RN, MANbecause fluid conducts sound better Sound travels better through material that is denser Our ears usually hear scunds using normal air conduction of scunds, In a vacuum, no sound is transmitted. Duration of vibrations of sound will determine if our ears interpret sounds as short or long sounds. For example. a patient can have short or long, wheezes. The average adult can hear vibrations with frequencies from 16 to 16,000 Hz. Our ‘maximum sensitivity is between 1,000 and 2.000 Hz. Below 1,000 Hz our sensitivity falls off rapidly. Most breath sounds are below 500 Hz, therefore we must listen carefully to all breath sounds, as our ears are not very sensitive tothese frequencies, NORMAL AND ABNORMAL BREATH SOUNDS: Normally. it is difficult to hear breath sounds. Normal breath sounds will seem faint or distant when auscultating. This is @ normal feature of breath sourds. Many authorities have described abnormal breath sounds using varied terminology. The Joint Committee on Pulmonary Nomenclature ofthe American College of Chest Physicians-American Thoracic Society renamed abnormal breath sounds into two main categoties in 1875. These two categories are: + Rales for a discontinuous sound (crackie) ‘© Rhonchus: fora continuous sound (wheezes) In 1980, they further categorized the sounds as: | Crackles (course and fine) 2. Wheeze 3. Rhonchus Cugel, in 1978, and Hudson, et al, in 1976 coined terms such as dry rales, sticky rales, bubbling rales, and others. Stil other authorties use further derivations of these terms. Each nurse must follow their own hospital pdlicy when they attempt to describe breath sounds In this text, we use the defiritions below for broath sounds feral PEscuctar [iow pitch jneard over most ofnormal lung [Neral PRONCRO-VESICULAR [medium pitch [heard over mainstream bronchi aa RONCHALTRACHEAD high pitcr normally heard over trachea ‘SOUNDS tubular (like wind tunnel) [ABNORMAL| RALES —_discrete nor-continuous sound, produced by moisture in the lung tissues; can be fine in quaity orcoarse. [ABNORMAL RHONCRI [continuous sounds produced by air being foreed through Inarrowed passages, narrowed by secretions and/or [constriction ofthe air passage. [ABNORMAL WHEEZES continuous musical sounds produced as ar is forced Ithrough narrowed passages, like rhonchi, can occur in linspiration or expiration; with rales, may change character lafter coughing [ABNORMAL STRIDOR loud musical sound ofconstant pitch, most prominent [during inspiration can be heard very well at a distance due {to its loud intensity; sound is produced by obstruction ofthe lairway, laryngeal tumors, tracheal stenosis or aspirated foreign body, [ABNORMAL PLEURAL |non-musical sound, usually longer and lower pitch than lung FRICTION RUB |crackles, sounds like the oreaking ofold leather, etiology: [coarsened surface ofthe normal pleura, due to fibrin [deposits thickened or inflamed or with neoplastic cells, [ABNORMAL MEDIASTINAL |Clarman's Sign) This is @ coarse, crackling sound CRUNCH or vibration that is synchronous with systole and is |fequently heard over the precordium in the presence of Imediastinal emphysema. This distinctive popping or [cruncking sound is thought to crignate from air |separating the parietal and visceral pericardium during the JOANNE MARIE S. HARCIA, RN, MAN[contraction ofthe heart [ABNORMAL | BRONCHIAL This is heard in patients with bronchopleurocutane ous LEAK SQUEAK fistula: a high-pitched squeak over the affected chest area \during sustained Valsaiva maneuver, the pitch being higher jin smaller fistules than in larger ones [ABNORMAL | INSPIRATORY [A musical sound, Squawk found in some patients with SQUAWK diffuse pulmonary fibrosis, this squawk is usually laccompanied by rales (crackles) and also predisposed by Ihypersensitivity pneumonitis caused by inhaling antigens. Other abnormal sounds will also be presented in this course. They are sounds which can be helpful in diagnosing certain conditions of the lungs (diagnosis here refers to assessing possible abnormal conditions of the lungs....nursing diagnosis). Always place the diaphragm. ofthe stethoscope firmly over the area ofthe thorax and move it from right to lettin order to assess symmetry ofthe sounds your wil hear (refer tothe diagram). Terms relating to the formation ofbreath sounds: + Turbulence Sound that is caused by the uneven flow of air in the human airway: turbulence is thought to be the source for all normal breath sounds. + Laminar Flow Air flow in a straight, smooth pipe; ifit fows unobstructed, the pressure will gradually decrease and no sound ill be created, bacause there is no turbulence. + Turbulent Flow Sound is created by this type of air fow. In the alway, the laminar air flow is broken, and currents form. Currents cause uneven air flow and produce sounds. © Vottices This is a whirlpool of air that is started when air enters @ wider channel from a narrow one. Vortices are created in the airway and will help to form some ofthe lung sounds heard when airis also turbulent When auscultating or performing each par ofthe assessment on the lungs, follow a similar pattem as shown in the below diagram. You should proceed in an orderly manner, from top. to bottom. Begin at the apex ofthe lung; go right to left side. Next, place the stethoscope on the chest wall, going from side to side, in the same spot on each side. Proceed down the length ofthe chest wall and using several different spots in the lung field. Remember to be symmetrical, “compare on side, same spot, to other side of chest, same ‘pot. Perform same for posterior thorax. Rightlung: 3lobes_-—— a. RUL rightupper lobe JOANNE MARIE S. HARCIA, RN, MAN. RML right middle lobe . RLL fight lower lobe Left lung: 2iobes a. LUL left upper lote . LLL left lower lobe When performing any of he proceding assessments, be cure to assess all lobes ofthe lungs. Note that anterior only, a small part of the leftlower lobe is able to be assessed. The same holds true forthe right lower lobe. ADDITIONAL BREATH SOUNDS Hfyou are unsure ofwhat you are hearingthrough the stethoscope, orif breath sounds are diminished, ask him/her to breathe deeper and/or open the mouth wider. Perhaps ask him to breath faster; that may enhance the quality of the sounds you are hearing. Bronchophony This term represents a test to perform on the patient which may indicate that there is consolidation of the lung. Consolidation refers to increased density of the lung tissue, due to it being filled with fluid and/or blood or mucus. Askthe patient to say the words: “ninety- nino” while you listen through the stethoscope. Normally the sound of rinety-nino” will sound very faint and muffled. When you listen through normal lung tissue, sounds are normally muffed. Ifit sounds clear through the stethoscope, there is probably consolidation ofthe lung and Bronchopheny is present. This occurs because sound transmission through consolidated tissues will be greater and clearer because danse tissue transmits sound better, than normal “fuffy’ lung tissue. Eqophony This is a term that indicates that there is consolidstion ofthe lung or possible collapse ofthe lung. Ask the patient to repeatedly say the sound“ee” while you listen with the stethoscope. Normally, it will sound muffled, but it will remain wih the long sound of “ee” when you listen over most ofthe lung feld. If the sound changes to “ay” sound, while the patient is saying “ee” then egoohony is present. This indicates consclidation. or that there is fluid in the lungs. Whispered Pectoriloquy This is another term to determine the presence of consdlication ofthe lungs. You will ask the patient to whisper a number or short phrase and repeatit: such as counting. “1. 2, 3° “1. 2. 3°. etc. and listen through the stethoscope. Normally the whispered voice will be distant and very muffied through the stethoscope. If consdiidation is present in a section ofthe lung field. the whispered voice will sound unusually clear and loud instead of muffed and distant. Consolidation ofthe lung tissue causes filing of the air spaces of te alveoli and Voice transmission through that part ofthe lung will be unusually clear and louder than normal. Thus if pectorloquy is present, itindicates consolidation of some portion ofthe lung field. COMMON PULMONARY DISORDERS AND PHYSICAL ASSESSMENT FINDINGS USUALLY PRESENT © Bronchial Asthma: hyperinflation of lungs, impaired expansion, use of accessory muscles ofrespiration, prolonged expiration and wheezes present. + Pneumothorax decreased expansion on affected sido, hyper resonant or tympanic sounds or even absent sounds in affected areas. + Pleural Effusion decreased expansion of affected sice, trachea & heart shifled away from affected side, dullness or flatness or absent breath sounds. © Atelectasis: JOANNE MARIE S. HARCIA, RN, MANdecreased expansion an affected side, dull or flat sound or absent breath sounds, trachea and heat shifled toward affected side. ‘+ Consolidation: bronchial breath sounds, bronchephony, pectoriloquy, possitle splinting on the (pneumonia) affected side. ‘Summary of Assessment factors: © When Inspecting Look forthe slope ofthe ribs, bilateral and symmetrical chest wall expansion, abnormal breathing pattems, thoracic orabdominal breathing, Look forthe shape of the thorax; evaluate anteroposterior diameter relative to lateral Giameter of chest wall, pectus cannatum (pigeon breast), pectus excevatum (funnel chest), kyphosis (spine curvature), scoliosis (leteral spne curvature), kyphoscoliosis, and note tracheal position Look forbreathlessness wheezing, sputum, cough, cyanosis, pallor, eruptions, nodules, Scars, neck vein distention, fingers for tobacco stains, finger and toes for clubbing, which can bea sign of chronic resprratory disease. When Palpating Feel formasses, nodules, pain, tendemess, examine the: neck, aiillae, supraclavicular Tossae for lymph nodes, palpate trachea for midline placement. Feel forskin temperature and moisture Eeel forother mentioned in the text. © When Percussing Listen for symmetry of sounds from each sie. Listen to patient to tell you of pain ortendemess when percussing, © When Auscuttating Listen for intensity of sounds one each side ofthe thorax (symmetry) Listen for normal and abnormal breath sounds. Following, we will present detailed outlines ofthe method for assessment. Today, nurses are taking increased responsiblity for assessment of lungs, including auscultation. However, there are still many differences in levels of responsibilities among nurses in different hospitals. Some hospitals do not allow any nurses to char any Dreath sounds at all. Other facilites want all nurses to listen and record all patients’ breath sounds. There is also every situation in between these two extremes We will present guidelines for those nurses who will have this responsibilty oflistening and. charting breath sounds. If youare in a facility that does not allow youto record breath Sounds, you may still isten to the lungs and at least chart that you notified someone that the patient sounds “congested.” In most facilities around the country, you may atleast chart “cengesied’ lungs ifyou are not ellowed to chart terms like: “rales,” ete. CHARTING THE EXAMINATION FINDINGS When chaning the normal exam, most nurses, for brevity, will chant only that respirations are “normal” and there is no “SOB.” In most cases, that is acceptable fora routine or normal examination. However, itis very possible tobe brief and thorough. 1. Inspection observe: shape of chest; include deformities width or costal angle, movements ofiniercostal spaces during respirations use of accessory muscles of respirations local impairment of respiraiory movements rate and rhythm of respirations. JOANNE MARIE S. HARCIA, RN, MANCharting ofthese normal findings might be: resp rate-20/min, regular. no SOB1 ». 1. Palpation a. identify areas oftendemnoss. ‘agcees any observed areas of abnormality ‘assess respiratory excursion (expansive movements of the chest during breathing) b. «. ‘assess skin condition (temperature, etc) 4. Poreu: a. ascoss any areas of dullness, flatness, tympany assess areas foundto be abnormal fom previous examinations. 4. Auscultation a assess quality and intensity of breath sounds ‘assess patient for abnormal breath sounds ‘assess patient for areas of consolidation When chaning your findings, you may not be sure asto exactly what you are hearing. Most hospitals donot equire trat palpation and percussion results be charled. Ifthe nurse carefully assesses the breath sounds, those others may not need to be chatted, but are still used to confirm the nurse’s assessment of the patiert’s problem. Ifthe nurse is unfamiliar with naming the individual breath sounds, you should be very descriptive when charting. For example: chart the location and sound that you hear moist respirations in LLL and RLL......or fine rales in LLL and RLL (cither is corect) Donot feel that you must ahvays tag a name tothe type of abnormal respirations that you hear. Itis sufficient to accurately describe the abnormal breathing. Another important function is to follow up the results ofyour examif there is an abnormality. Your nursing diagnosis will include nursing orders totum the patient more frequently or to suggest that respiratory therapy be performed on tho pationt. Therefore, communications is important, but s0is the nursing follow-up on your findings. GUIDE TO ASSESSMENT OF LUNGS AND THORAX, Assemble Equipment History-taking Explains Procedure tothe pationt Washes hands Gowns or drapes patientto prevent unnecessary exposure Provides a quiet place for patient comfort and for auscuitation Provide adequate lighting Use of proper Techniques: inspection, oaipation, percussion, auscultation ‘compares symmetry of thorax (each hemathorax) starts at neck, then posterior, right and lef lateral, then anterior thorax Respiratory rate determination Rhythm determination Depth determination Abnormalities: ‘defines boundanes of abnormality is found; describes accurately {do not allow patient to hyperventilate during the exam. avoids bony pominences during the exam (poor sound conduction) tecords findings accurately @YomawNe Noepens RoNe POSTERIOR THORAX EXAMINATION 4. Patient seated wth arms folded across chest 2. Inspects symmetry, contour, color, skin concition 3. Palpales posterior interspaces for masses, lesions, etc. 4. Palpates ribs and scapulae for masses, breaks, etc. 5. Evaluates tactile fremitus 6. Evaluates respiratory excursion 7. Percussion — 5 cm intervals from apex to base contra laterally 8 Diaphragmatic excursion 9. Ausculate breath sound 40. Ausculate voice and whispered sounds JOANNE MARIE S. HARCIA, RN, MANRIGHT AND LEFT LATERAL THORAX Patient seated wih arms on head Bogin in the axillae and proceed downward contra laterally using at least 4 or 5 sites for comparison Inspects for symmetry, color, condition of skin Palpate ribs for masses or bulges Palpates tactile fremitus Percusses lateral thoraces Auscultates breath sounds Auscultates voice and whispered sounds eNOnRwY Re ANTERIOR THORAX Patient is supine with arms abducted: child is placed totally lat and head isnot allowed to turn Inspect anterior chest for symmetry. contour, color, skin condition Palpate ribs and interspaces for bulges and masses, Palpate fortactile fremitus Palpate trachea Percuss anterior chest at 5 cmintervals Auscuitate for breath sounds Auscultate for voice and whispered sounds. SN OMRON CHARTING EXERCISE: This is not part of Posttest forthis course: for practice oniy. Chart a briefnarrative ofa “normal” lung assessment Chart ona patient who has COPD with an acute attack. General -- Rate, rhythm, depth (difficulty) - Pere 4. Auscultation results - S- (subjective) 0- (objective) A- (assessment) P- (plan --nursing orders) ADVENTITIOUS SOUNDS: RALES: (or crackles) Definition: Clusters or showers of sounds Produced ky bubbling ir through the alveoli, bronchioles bronchi Non-continuous Variable quality: Pere Types Fine rales: terminal bronchioles and alveoli, sounds like hair being rubbed between fingers Medium rales: larger air passages, bubbling sound of opening 2 carbonated beverage. Coarse rales louder and lower-pitched from larger passages RHONCHI Definition: 4. Produced by air travelling through narrowed passages or through mucus in the passages. 2. Varying sound quality 3° Continucus sound Sibilant chonchi (wheezes) FRICTION RUB: JOANNE MARIE S. HARCIA, RN, MANDefinition: 4. Coarse grating sound 2. inflamed surfaces ofthe ploura rub together during respirations 3° Usually over anterolateral thorax In the figure, the posterior view is seen, and the largest mass ofthe LLL can only be assessed by carefully examining the posterior of the chest wall. The nurse must then be sure that the lung felds are auscultated to the lowest point on the posterior ofthe thorax in order to assess the lower lobes completely Many disorders such 2s pneumonia will vtually go undetected ifthe examiner does not carefully look at and assess the lower posterior borders ofthe lungs. Also, patients who will lie for long times on their backs may develop fluid collecting in these lobes: another reason for the careful assessment of these lower lobes. JOANNE MARIE S. HARCIA, RN, MANThis figure shows a lateral view ofthe lower lobes: pointing out how the buk ofthe mass of the lower lobes is toward the posterior ofthe thorax. Assessment of the Abdomen |. Health History A. Current Status 1. Describe chief complaint 2 Pain 3. Ability towalk upright 4. Nutritional Assessment ‘a. 24 nour recall b. Food preferences and dislikes ©. Cultural and religious values Access to food . Eating behaviors {Appetite changes 5. Indigestion 2 Fullness, b Heartburn Discomfort Excessive belching e. Flatulence {Loss of appetite 9. Pain 6. Heartburn - usually substemal ‘a. Body positions b. Food imtants c. Time of day T. Nausea 8. Vomiting a. Appeerance of emesisiodor b. Hemateme sis 9. Stool 1. Diathea - watery or loose stool b. Tenesmus - cramping pain with strained, ineffectual evacuation ©. Steatorrhea - frothy, greasy, and foul-smelling stool wlundigested fat d. Melaena - black, tary stool ©. Bloody red stcol ¥ Occult blood 9. Constipation hy. Abilty to pass flatus 10. Alcohol intake 11. Fever 12. Difficulty breathing 13. Swelling oflymph nodes in neck, axilla, and groin B. Past Health Status 1. Have you had any problems with your mouth, throat, abdomen, or rectum that have lasted for along time? JOANNE MARIE S. HARCIA, RN, MAN2. Have you had any nerve problems, such as weakness or numbness in your hands and fingers? 3. Have you ever had surgery on your mouth, throat. abdomen, or rectum? 4. Doyou have any allergies such as to milk products? 5. Doyou use laxatives or enemas? If so, how often? 5. Doyou take any prescription or overthe-counter medications? If so, which drugs and at what dosages? . Health Status 1 Has anyone in your family had colorectal cancer or polyps? 2. Has anyone in your family had colts? I, Physical Examination of the Abdomen A. General Approach Patient must be warm and relaxed. Goodllghting Full exposure of abdomen from xyphoid process to groin, Patient should net have full bladder. Position in supine position with pillow under head and knees, ‘Arms should be held across chest or be at sides Have warm hands and a warm stethoscope. Avoid quick, unexpected movements. Distract the patient with questions. 10. Monitor your examination by watching patient's face B. Inspection of the Abdomen’ 1. Contour and Symmetry a. Flat b. Scaphoid- seen in school-aged children and wasting diseases ‘c. Round - pot belly: normal in infants and todders Protuberant &. Disiended 2 Scars ‘a Location b. Length ©. Color 3. Striae - prolonged stretching ofthe skin; seen in ascites, obesity, tumor, pregnancy, and Cushing's Syndrome Color whitelsitver red/pink/tue purple 4. Rashes and Lesions ‘a. Spider nevi (cutaneous angiomas) 5. Umbilicus a. Contour b. Location . Signs of hemia - lifting head or coughing - considered normal in white skinned children until age 2 and in black skinned children until age 7 Cullen's sign - bluish discoloration - suggests intrapentoneal hemorhage 6. Enlarged organs ‘2. Assess curing deep breath b. Differentiate between masses in the abdominal wall and intra-abdominal masses by having patient voluntaily tense abdominal muscles. 7. Masses - note size and location during deep inspiration 8. Peristalsis ‘a. Thin individuals b. Intestinal obstruction 9. Dilated veins - seen with increased collateral circulation 410. Distribution of Pubic Hair (Escutcheon) ‘a. Female cistibution - trangle with base above the symphysis b. Male distribution - diamond with upper vertex extending as high as the umbilicus 11. Tumer's sign - blue discoloration ofthe flanks - indicates gastrointestinal hemorrhage. There is extravasation of blood fromintra-abdominal organs to extraperitoneal sites (for example, hemorthagic pancreatitis). C. Auscultation of the Abdomen You must auscultate before you percuss or palpate abdomen because these maneuvers may alter the frequency of bowel sounds. Enhanced peristaltic sounds may mask other abnormal abdominal sounds such as bruits and fiction rubs. 1. Bowel sounds -lisien and note frequency and character (normal sounds consist of clicks and gurgles and occur 5 to 34 per minute). ‘a. Frequency JOANNE MARIE S. HARCIA, RN, MAN