8/2/2019 Patient Assessment Guide

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Sawall RN, MS, MPH, CNS

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 formedical or nursing references. The chart should not be relied upon to provide any medical or nursing care.

1

Assessing Lung Sounds(3) Normal Breath Sounds

Bronchial breath sounds: loud, harsh and high pitched. Heard over the trachea, bronchibetween 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

Crackles

Popping, crackling, bubbling, moist sounds

on inspiration

Pneumonia, pulmonary edema, pulmon

fibrosis

Rhonchi Rumbling sound on expiration Pneumonia, emphysema, bronchitis,

bronchiectasis

Wheezes

High-pitched musical sound during both

inspiration and expiration (louder)

Emphysema, asthma, foreign bodies

Pleural Friction Rub Dry, grating sound on both inspiration and

expiration

Pleurisy, pneumonia, pleural infarct

Assessing Heart SoundsThese 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. ERBS POINT

4.) Fifth intercostals space along the left sternal boarder. TRICUSPID AREA

5.) Fifth intercostals space, midclavicular line. MITRAL AREAAPEX

This is where the Point of Maximal Impulse (PMI) is founddocument 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. Inolder 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

Grade II Faint murmur heard immediately

Grade III Moderately loud, not associated with thrill

Grade IV Loud and may be associated with a thrill

Grade V Very loud; associated with a thrill

Grade VI Very loud; heard w/stethoscope off chest, associate w/a thrill

Normal B/P for all

8/2/2019 Patient Assessment Guide

2/2

Sawall RN, MS, MPH, CNS

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 formedical or nursing references. The chart should not be relied upon to provide any medical or nursing care.

2

5 Ps of Circulatory

Checks

Pain

Pallor

Paralysis

Paresthesia

Pulse

Formula to convert from Fahrenheit to Celsius: (5/9)*(deg F-32)

to convert from Celsius to Fahrenheit: (1.8*deg C)+32

95 F = 35C 96F = 35.5C 98.6F = 37C

110F = 37.7C 101F = 38.3C 102F = 38.8C

103F = 39.4C 104F = 40C 105F = 40.5C

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 statusHead 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

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 Homans 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.

Averages for Age Grouping

AGE WGT (kg) PULSE RESP B/P (syst.)

Preemie 1-2 140 < 60 50-60

Term NB 3 125 < 60 70

6 Months 7 120 24-36 90 30

1 yr 10 120 22-30 96 30

3 yrs 15 110 20-26 100 25

5 yrs 18 100 20-24 100 206 yrs 20 100 20-24 100 15

8 yrs 25 90 18-22 105 15

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 + agePULSES: Peripheral pulses

should be compared for rate,

rhythm, and quality.

0 Absent

+1 Weak and thready

+2 Normal

+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?