Focused Physical Assessment
Respiratory, Cardiac, Vascular and GI
Cabrillo College
Karen Merchant, RN, MSN
February 13, 2007
Tips for Physical Exams
♦ Ensure patient comfort and explain plan
♦ Compare right and left sides of body
♦ Assess areas of concern first
♦ Save painful procedures for last
♦ Develop own systematic approach
– Example: head to toe
– System to system
Five Methods of Physical
Assessment
♦ Inspection
♦ Auscultation
♦ Percussion
♦ Palpation
♦ Olfactory
Respiratory Assessment
♦ Respiratory rate, rhythm, depth, effort
– Use of accessory muscles
– Shallow or deep breathing
– Count rate for 30 seconds, X2 for rate
♦ Inspection
– Symmetry
– Shape of chest
• Barrel chest associated with chronic lung disease
Auscultation- Normal breath sounds
♦ Bronchial: over trachea
– Loud, high-pitched, hollow
– Expiratory: Inspiratory is 3:2 ratio
♦ Bronchiovesicular: posterior fields with large
airflow
– Blowing, medium-pitched, tubular
– Inspiration = Expiration
♦ Vesicular: peripheral lung fields (except near
scapula)
– Soft, breezy, low-pitched
– Inspiration 3x longer than expiration
Posterior Stethoscope placement
Lateral Stethoscope placement
Anterior Stethoscope placement
Abnormal Breath Sounds
♦ Crackles/Rales
– “crackly” high-pitched sounds
– Not relieved with coughing
– Usually in lung bases
♦ Rhonchi
– Mucous and thick fluid movement
– Usually in larger airways
– May clear up with coughing
– Coarse
Abnormal Breath Sounds
♦ Wheezing
– May be on inspiration, expiration or both
– May be present in any lung fields
– High-pitched, “musical” sounding
– High velocity flow through narrowed bronchi
♦ Pleural friction rub
– Dry grating sound from inflamed pleura
– Anterior lateral lung field
Palpation and Percussion
♦ Palpate for tenderness, symmetry,
deformities
– Tracheal deviation
♦ Percussion via hands
– Side to side as in auscultation
– Dull or flat due to collapsed lung field
(atelectasis)
– Hyperresonant sounds with asthma
• Due to hyperinflation of lungs
Cardiac Assessment
♦ Ensure patient calm
– No exercise, smoking, eating before exam
♦ Ask about symptoms
– Chest Pain
– Fatigue
– Edema (fluid build up in extremities)
– Palpitations (pounding or racing heartbeats)
– Shortness of breath
Cardiac Assessment
♦ Know important landmarks
– PMI (point of maximal impulse)
– Base of heart is upper portion
– Apex is the bottom tip
♦ Inspect and Palpate at each landmark
– Look for visible heart movement
– Feel for “thrill” from murmer
Cardiac Landmarks
Cardiac Auscultation
♦ S1: “lub” from systole
– Strongest at tricuspid and mitral valves
♦ S2: “dub” from pre-diastole
– Strongest at aortic and pulmonic valves
♦ Listen for rate, rhythm and regularity
♦ Apical heart rate for full 1 minute
Vascular Assessment
♦ Check pulses for rate, rhythm and quality
– Scale
• 0 = absent
• + 1 = thready/weak
• + 2 = normal
• + 3 = bounding
– Peripheral pulses
• Check for variations between locations
• Know locations for all pulses
♦ Inspect for cyanosis of skin, nails
♦ Measure capillary refill
Dorsalis pedis pulse
Vascular Insufficiency in Legs
Assessment
Criteria
Venous
Arterial
Color
Normal-elevated
cyanotic-down
Pale-elevated
dark red-down
Temperature
Normal
Cool
Pulse
Normal
Decreased or
absent
Edema
Often marked
Absent or mild
Skin Changes
Brown ankles,
ulcers at ankle
region
Thin, shiny,
hairless, thick
nails, necrosis
Severe Arterial Insufficiency
Vascular Auscultation and Palpation
♦ Auscultate for bruits
– May indicate arterial blockage
– Use bell of stethescope on carotid arteries
– Listen for blowing or rushing sounds
♦ Palpate for Pitting Edema
– 0 = no pitting
– +1 = to ¼ inch pitting (mild)
– + 2 = ¼ to ½ inch pitting (moderate)
– + 3 = ½ to 1 inch pitting (severe)
– + 4 = > 1 inch pitting (very severe)
Pitting Edema Examples
Abdominal Assessment
♦ Four quadrants in Anterior Abdomen
– RUQ- liver, transverse colon, gallbladder
– LUQ- stomach, body of pancreas, portion of
ascending colon
– RLQ- appendix, ascending colon
– LLQ- small intestine, sigmoid colon
♦ Posterior
– Kidneys, diaphragm, bladder
Abdominal Assessment
♦ Important to assess in correct order
– Inspection
– Auscultation
• Normal, hypoactive, hyperactive or absent sounds
• All 4 quadrants
• Listen 5 minutes before reporting absent bowel sounds
– Percussion
• Dullness may indicate mass
– Palpation
• Light is 1-2 cm
• Deep is 2-4 cm