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.
Crackles
ADVENTITIOUS LUNG SOUNDS
Characteristics
Popping, crackling, bubbling, moist sounds
on inspiration
Rhonchi
Rumbling sound on expiration
Pneumonia, emphysema, bronchitis,
bronchiectasis
High-pitched musical sound during both
inspiration and expiration (louder)
Emphysema, asthma, foreign bodies
Wheezes
Dry, grating sound on both inspiration and
expiration
Pleurisy, pneumonia, pleural infarct
Sound
Pleural Friction Rub
Lung Problem
Pneumonia, pulmonary edema, pulmonary
fibrosis
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.
EDEMA: Assess by placing thumb over
Grading Murmurs
dorsum of the foot or tibia for 5 seconds
Grade I
Faint; heard with concentration
0
No edema
Grade II
Faint murmur heard immediately
1+
Barely discernible depression
Grade III Moderately loud, not associated with thrill
2+
A deeper depression (< 5 mm) w/
normal foot & leg contours
Grade IV Loud and may be associated with a thrill
3+
Deep depression (5-10 mm) w/ foot &
Grade V
Very loud; associated with a thrill
leg swelling
Grade VI Very loud; heard w/stethoscope off chest, associate w/a thrill
4+
Deeper depression (> 1 cm) w/ severe
foot and leg swelling
Normal B/P for all <120/<80; Prehypertension 120-139/80-89
Guidelines/education site for adult B/P http://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017
For children & adolescents: http://pediatrics.aappublications.org/content/pediatrics/140/3/e20171904.full.pdf
Formula to convert from Fahrenheit to Celsius: (5/9)*(deg F-32)
PULSES: Peripheral pulses
to convert from Celsius to Fahrenheit: (1.8*deg C)+32
should be compared for rate,
95º F = 35ºC
96ºF = 35.5ºC
98.6ºF = 37ºC
100ºF = 37.7ºC 101ºF = 38.3ºC
rhythm, and quality.
102ºF = 38.8ºC 103ºF = 39.4ºC 104ºF = 40ºC
105ºF = 40.5ºC
0
Absent
Symptom Analysis: This assists the client in describing the problem.
+1
Weak and thready
P Provocate/Palliative: What caused it? What makes it better/worse?
+2
Normal
Q Quality/Quantity: How does it feel, sound, look, how much?
R Region/Radiation: Where is it and does it spread?
+3
Full
S Severity Scale: Rate on appropriate pain scale. Does it interfere with ADLs?
+4
Bounding
T Timing: When did it start? Sudden/gradual? How often? How long does it last?
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5 P’s of Circulatory
Checks
Pain
Pallor
Paralysis
Paresthesia
Pulse
AGE
Preemie
Term NB
6 Months
1 yr
3 yrs
5 yrs
6 yrs
8 yrs
12 yrs
16 yrs
Adult Female
Adult Male
Averages for Age Grouping
WGT (kg)
PULSE
RESP
1-2
140
< 60
3
125
< 60
7
120
24-36
10
120
22-30
15
110
20-26
18
100
20-24
20
100
20-24
25
90
18-22
40
85-90
16-22
> 50
75-80
14-20
50-75
60-100
12-20
75-100
60-100
12-20
B/P (syst.)
50-60
70
90 ± 30
96 ± 30
100 ± 25
100 ± 20
100 ± 15
105 ± 15
115 ± 20
120 ± 20
90 + age
100 + age
Symptom Analysis: This assists the client in describing the problem.
Provocate/Palliative: What caused it? What makes it better/worse?
Quality/Quantity: How does it feel, sound, look, how much?
Region/Radiation: Where is it and does it spread?
Severity Scale: Rate on appropriate pain scale. Does it interfere with ADLs?
Timing: When did it start? Sudden/gradual? How often? How long does it last?
P
Q
R
S
T
4 Primary Assessment Techniques: INSPECT, PALPATE, PERCUSS, AUSCULATE
What to Observe
General appearance and behavior, mood, affect, posture, gait, hygiene, speech, mental status,
height, weight, hearing and visual acuity, VS, nutritional status
Head and Neck
Skull size, shape, symmetry, hair & scalp, clenched jaws, puff cheeks, inspect teeth and gums,
swallowing, PERRLA, inspect ROM neck, shrug shoulders, palpate trachea for symmetry, palpate
carotid pulses
Upper Extremities
Inspect skin, cap refill, fingernails, palpate peripheral pulses, rate muscle strength, assess ROM
Assessment Area
General Survey
Posterior Thorax
Inspect spine for alignment, inspect skin especially at boney prominences, assess anteroposterior to
lateral diameter, assess thoracic expansion, auscultate breath sounds
Anterior Thorax
Observe respirations. Effort, pattern, excursion, auscultate breath sounds, auscultate heart sounds,
inspect jugular veins,
Abdomen
Inspect, auscultate for bowel sounds, light palpation for tenderness, palpate the kidneys, blunt
percussion over CVA (posterior thorax) for tenderness
Lower Extremities
Inspect skin, palpate peripheral pulses, inspect and palpate joints for swelling, assess for pedal and
ankle edema, assess ROM
General Neurologic
Inspect gait and balance, assess recent and remote memory, Assess alertness and orientation x 4
(person, place, time and situation), Glasgow Coma Scale
Wound/Skin abnormality Documentation:
1. Location of the abnormality. Use your anatomical terms (lateral, medial, ventral, distal, etc… to olecranon process, ischium, patella, etc…)
and each abnormality is addressed separately.
2. Surgical lines (approximated) length documented in cm.
a. List the # of sutures or staples if present.
b. Redness, Swelling, Warmth, Induration, Drainage. Be specific where.
3. Any open area. Length X width documented in cm. Depth in cm if applicable.
a. Wound Bed: Color, Slough/Eschar, Drainage, Tunneling if present: Use percentages and clock face if appropriate.
4. Staging (if pressure) *cannot downstage a wound nor stage a wound that the wound bed cannot be seen.
5. Surrounding Skin: Redness, Swelling, Warmth, Induration, Drainage.
Glasgow Coma Scale
Eye
Verbal
Motor
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1
Does not
open eyes
Makes no
sounds
Makes no
movements
2
Opens eyes in response to
painful stimuli
Incomprehensible sounds
3
Opens eyes in response to
voice
Utters incoherent words
4
Opens eyes
spontaneously
Confused, disoriented
Extension to painful stimuli
(decerebrate response)
Abnormal flexion to painful
stimuli (decorticate response)
Flexion / Withdrawal
to painful stimuli
5
N/A
6
N/A
Oriented,
converses normally
Localizes to
painful stimuli
N/A
Obeys
commands