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8/2/2019 Patient Assessment Guide
1/2
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.
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?