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.
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 <120/<80; Prehypertension 120-139/80-89
Guidelines and education site for adult B/P.
http://www.nhlbi.nih.gov/hbp/index.html
For children & adolescents:
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
EDEMA: Assess by placing thumb over
dorsum of the foot or tibia for 5 seconds
0
No edema
1+
Barely discernible depression
2+
A deeper depression (< 5 mm) w/
normal foot & leg contours
3+
Deep depression (5-10 mm) w/ foot &
leg swelling
4+
Deeper depression (> 1 cm) w/ severe
foot and leg swelling
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 for
medical or nursing references. The chart should not be relied upon to provide any medical or nursing care.
1
5 P’s of Circulatory
Checks
Pain
Pallor
Paralysis
Paresthesia
Pulse
PULSES: Peripheral pulses
should be compared for rate,
rhythm, and quality.
0
Absent
+1
Weak and thready
+2
Normal
+3
Full
+4
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
Formula to convert from Fahrenheit to Celsius: (5/9)*(deg F-32)
to convert from Celsius to Fahrenheit: (1.8*deg C)+32
95º F = 35ºC
96ºF = 35.5ºC
98.6ºF = 37ºC
110ºF = 37.7ºC
101ºF = 38.3ºC
102ºF = 38.8ºC
103ºF = 39.4ºC
104ºF = 40ºC
105ºF = 40.5ºC
Bounding
P
Q
R
S
T
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?
4 Primary Assessment Techniques: INSPECT, PALPATE, PERCUSS, AUSCULATE
What To Observe
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
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.
Assessment Area
General Survey
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 for
medical or nursing references. The chart should not be relied upon to provide any medical or nursing care.
2