well being a nurse you have to do all this stuff to be a nurse you have to do assessments you have to do body exams on the patients you have to do a lot that's alright for me because I want to be a nurse
Assessment of the Cardiovascular and Respiratory Systems
• During the Physical Assessment the following key system are examined as follows;
• The Respiratory System
• The Cardiovascular System
• Gastrointestinal System
• Genitourinary Assessment
This lesson will provide the learner with an overview of the techniques and procedures applied in conducting a Physical Assessment of the Respiratory, Cardiovascular, Gastrointestinal and Genitourinary Systems respectively.
On completion of this lesson, the learner should;
Understand the techniques and procedures used to perform a Physical Assessment of the Respiratory System.
Identify the different types of breathing sounds and Respiratory Rate.
Understand the techniques and procedures applied in performing a Cardiovascular Assessment.
Identify Heart sounds and determine Body Pulse.
Understand the techniques and procedures applied in performing a Gastrointestinal Assessment.
Understand the techniques applied in performing a Genitourinary and Intestinal Assessment on Male and Female Patients.
Respiration. Respiration is assessed using inspection, palpation, and auscultation. Have the patient remove all clothing to the waist and assume a sitting position. Inspect the chest for posture, shape, and symmetry of expansion. Warm the diaphragm of the stethoscope in the palms of your hands and place it firmly against the patient's chest wall. Ask the patient to breath quietly with the mouth open.
• There are three types of normal breath sounds: vesicular, bronchial, and bronchovesicular. Vesicular sounds are soft, like a quiet rustle or swish. Bronchial sounds are loud, harsh, hollow blowing sounds usually heard over the trachea and major bronchi. Bronchial sounds are louder during expiration. Bronchovesicular sounds are a combination of the other two and are heard in the upper anterior chest on each side of the sternum and posteriorly between the scapulae. Deep breathing converts vesicular sounds into bronchovesicular sounds.
• Assess the respirations for rhythm. Note whether the patient's breathing is regular, irregular, labored, or non-labored.
• Respiratory rate is the number of breaths in one minute. Bradypnea is less than 10 breaths per minute. Dyspnea is difficult or painful breathing. Orthopnea is difficult breathing except in an upright position.
• Lung sounds include breath sounds, voice sounds, and abnormal sounds. Assess lung sounds by auscultation, using a stethoscope. Auscultate the anterior and posterior upper, middle and lower lobes. Rales are crackling, tinkling sounds that occur when fluid or secretions are trapped in the smaller bronchioles or alveoli. Rhonchi are the rumbling, rattling, or snoring sounds due to mucous and secretions in the bronchial tree. A wheeze is the raspy whistling or high-pitched sound that occurs as air moves through a constricted or obstructed passage in the upper airway or bronchioles.
• Note whether the patient has a cough and whether it is persistent, occasional, productive or nonproductive. If the cough is productive, note the amount and character of the secretions.
Cardiovascular Assessment. Palpation and auscultation are used in assessment of the cardiovascular system, which includes blood pressure, peripheral pulses, heart sounds, and circulatory perfusion. The patient's blood pressure is usually taken at the onset of the assessment and the pulses are palpated while the skin is being examined.
• To obtain an accurate blood pressure reading, you will need a stethoscope, a blood pressure cuff, and a sphygmomanometer. Be sure that the patient is relaxed and use a cuff that is not more than 20 percent wider than the diameter of the patient's limb and long enough to completely encircle it. If the patient is very obese, it may be necessary to use a thigh cuff on his arm. If possible, take the blood pressure in two positions, supine or seated and standing. Wrap the cuff around the arm so that it is about one inch above the bend of the elbow. Palpate the brachial artery and place the diaphragm of the stethoscope over the artery below, but not underneath, the cuff. Inflate the cuff 30 to 40ºmmºHg above the point at which the last sound is heard. Release the pressure slowly. Observe the pressure readings on the manometer and relate these to the sounds heard through the stethoscope. The systolic pressure is the point where the first tapping sound is heard. The diastolic pressure is the point where the sound disappears.
• Take the peripheral pulses with the patient in the supine position, using your index and middle finger. Palpate the apical, radial, dorsalis pedis, and posterior tibial pulses. The posterior tibial pulse is palpable behind and below the protuberance on the inside of the ankle. See figure 4-2 for arterial pulse sites.
• Several heart sounds can be heard by auscultation (see figure 6-7). The first two heart sounds are produced by closure of the valves of the heart. The first heart sound (S1) occurs when the ventricles have been sufficiently filled and the right and left atrioventricular (A-V) valves close. S1 is heard as one dull, low-pitched sound. After the ventricles empty their blood into the aorta and pulmonary arteries, the semilunar valves close, producing the second heart sound (S2). The second heart sound is shorter and has a higher pitch than S1. The two sounds occur within one second or less, depending on the heart rate. Systoleis the period in which the ventricles are contracted. It begins with the first heart sound and ends at the second heart sound. Diastole is the period in which the ventricles are relaxed. Normally no sounds are heard during this period. The two heart sounds are audible anywhere in the region over the heart, but are best heard over specific valve areas. Rhythm is the pattern of the heartbeats and the intervals between the beats. It may be regular or irregular. Normally, equal time elapses between heartbeats. Any deviation from the normal pattern is arrhythmia. Murmurs, produced by turbulent blood flow, may occur at any cardiac auscultation site. The volume of blood flow, the force of the contraction, and the degree of valve compromise all contribute to murmur quality. Descriptive terms are used to give the murmur character. Murmurs are "whooshing" sounds. Although the mitral sound is usually loudest, a stenotic mitral valve that moves very little may produce a muffled sound.
• Circulatory perfusion is blood flow through the vessels of a specific organ or tissue. Arteries carry blood away from the heart, the capillaries serve as in-between channels, and the veins carry blood toward the heart. Close examination of the extremities will indicate the quality of the arterial and venous systems. Capillaries are the smallest blood vessels. It is through their walls that oxygen and food are supplied to the individual cells. To test capillary refill to extremities, press on a toe or fingertip, observe blanching and the time it takes the area to return to its original color. Document the time in seconds.
Figure 6-7. Areas to auscultate for heart sounds. Transmission of sounds with the closure of the heart valves.
A = Aortic
P = Pulmonic
T = Tricuspid
M = Mitral
Gastrointestinal Assessment. Inspection, palpation, and auscultation are used in gastrointestinal (GI) assessment. The GI system comprises two major components: the alimentary canal and the accessory organs. The alimentary canal includes the pharynx, esophagus, stomach, small intestine, and large intestine. Accessory organs aiding GI function include the salivary glands, liver, gallbladder and bile ducts, and the pancreas. Assessment of the gastrointestinal system includes inspection of the oral cavity (during HEENT evaluation), auscultation and palpation of the abdomen, and examination of the rectum.
(1) To ensure accurate abdominal assessment and consistent documentation of your findings, mentally divide the patient's abdomen into four quadrants (figure 6-8). Begin by inspecting the patient's entire abdomen, noting overall contour (flat, round, concave, protruding), skin integrity, appearance of the umbilicus, and any visible pulsations. Note any localized distention or irregular contours, rashes, dilated veins, and scars.
Figure 6-8. Abdominal regions.
(2) After inspecting the patient's abdomen, use a stethoscope to auscultate for bowel and vascular sounds. Lightly press the stethoscope diaphragm on the abdominal skin in all four quadrants. The bowel may be active, hyperactive, or hypoactive. Normally, air and fluid moving through the bowel by peristalsis create soft, bubbling sounds, mixed with clicks and gurgles, every 5 to 20 seconds. Loud, gurgling irregular sounds heard about every three seconds are hyperactive and may occur normally in a hungry person. Following, or when the colon is filled with feces, hypoactive bowel sounds may occur at a rate of one every minute or longer. Abdominal auscultation should be performed before percussion and palpation, because intestinal activity and bowel sounds may be altered by the motion of percussion and palpation.
(3) Palpation elicits useful clues about the character of the abdominal wall; the size, condition, and consistency of abdominal organs; the presence and nature of abdominal masses; and the presence, degree, and location of any abdominal pain. Gently press your fingertips about ½ inch into the abdominal wall. Move your hands in a slightly circular fashion so that the abdominal wall moves over the underlying structures. Note the character of the abdomen (soft, rigid, firm, tender, or nontender). Assess for organ location, masses, and areas of tenderness or increased muscle resistance. If you detect a mass, note its location, size, shape, degree of tenderness and mobility, and the presence of pulsations. When assessing a patient with abdominal pain, always auscultate and palpate in the painful quadrant last, touching the painful area may cause the patient to tense the abdominal muscles, making further assessment difficult.
Note: Do not palpate a pulsating midline mass; it may be a dissecting aneurysm, which can rupture under the pressure of palpation. Report the mass to a doctor.
(4) Gather information about the patient's appetite during the interview. Ask the patient if he has lost weight.
(5) Gather information about the patient's elimination patterns and the character of his stools. Ask the patient when he had his last bowel movement and if he has nausea, vomiting, diarrhea, or constipation.
(6) A routine rectal examination is performed if the patient is over age 40, if the patient has a history of bowel elimination changes or anal discomfort, and for an adult male with a urinary problem.
(7) If the patient is ambulatory, ask him to stand and bend his body forward over the examination table. If the patient is unable to stand, place him in a left lateral Sims' position with the knees drawn up and the buttocks near the edge of the bed or examination table.
(8) Put on a glove and spread the patient's buttocks to expose the anus and surrounding area. Asks the patient to strain as though defecating. Inspect for inflammation, discharge, lesions, scars, rectal prolapse, skin tags, and external hemorrhoids. Apply lubricant to your index finger. Explain to the patient that you will insert your gloved, lubricated finger a short distance into the rectum. Have the patient breathe through the mouth and relax.
(9) Once you have inserted your finger, rotate it to palpate all aspects of the rectal wall for nodules, tenderness, and fecal impaction. The rectal wall should feel smooth and soft. In a male patient, assess the prostate gland when palpating the anterior rectal wall; the prostate should feel firm and smooth.
Genitourinary Assessment. The male genitalia may be examined with the patient either standing or supine. However, the patient should stand as you check for hernias or varicoceles. Examine the female genitalia with the patient in a dorsal recumbent position.
1. When assessing the urinary system, check for and evaluate edema. Press firmly over a bony surface for 5 to 10 seconds, and then remove you finger. Note how long the depression remains. Document your observation on a scale from +1 (barely detectable) to +4 (a persistent pit as deep as 1 inch). When associated with fluid retention and electrolyte imbalance, edema may indicate renal dysfunction, such as nephritis.
2. Palpate the bladder for distention and tenderness. Press deeply in the midline about 1 to 2 inches above the symphysis pubis. During deep palpation, the patient may feel the need to urinate; this is a normal response. Note the size and location of the bladder. Check for lumps and masses. The bladder normally feels firm and relatively smooth.
3. Ask the patient about urinary patterns such as retention, urgency and frequency. Ask the patient if he has noticed blood in his urine or if he has pain when urinating. Ask the patient to urinate into a specimen cup. Assess the sample for color, odor, and clarity.
4. Provide the patient with a gown. and drape appropriately. Be sure to wear gloves. Expose the genitalia and inguinal areas and proceed with the examination.
5. Inspect the inguinal and femoral areas carefully for bulges. A bulge that appears on straining suggests a hernia.
6. Look for nits or lice at the bases of the pubic hairs.
7. Have the male patient assume a supine position. Begin assessment of the male genital system by inspecting the penis. Look for ulcers, scars, nodules, or signs of inflammation. Compress the glans gently between your index finger and thumb to open the urethral meatus and inspect it for discharge.
8. Inspect the scrotum. Note any swelling, lumps, or veins. Palpate each testis and epididymis. Note their size, shape, consistency, and tenderness.
Note: During the examination, the male patient may have an erection and probably be embarrassed about it. Explain to him that this is a normal response, and finish your examination in an unruffled manner.
9. Ask the female patient to empty her bladder before you begin the examination. To assess the perineal area, position her in a dorsal recumbent position with her head and shoulders slightly elevated to relax the abdominal muscles and so that both you and the patient can see each other's face. Explain in advance what you are about to do.
10. Assess the perineal area for character of skin and abnormal masses or discharge. Spread her labia with a gloved hand and inspect the urethral meatus; it should appear pink and free of swelling or discharge. In any patient, inflammation and discharge may signal urethral infection. Ulceration usually indicates a sexually transmitted disease.
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