Week 5: Head to Toe Assessment - Lungs, Heart, PVS

Assessment

• ROS: review of systems - subjective data through interview

• Physical examination of body systems: objective data - inspection, palpation, precussion, auscultation

  • Respiratory system: resp rate, rhythm, effort, lung sounds

  • Cardiac system: systolic BP, apical HR (rate/rhythm), heart sounds (S1 & S2-aortic, pulmonary, tricuspid, mitral)

  • Peripheral vascular system: arterial pulses (carotid, brachial, radial, femoral, popliteal, post tibial, dorsalis pedis), capillary refill, edema

respiratory system: anatomy - review

• Lungs: right & left

  • right: upper lobe, middle lobe, lower lobe

  • left: upper lobe, cardiac notch, lower lobe

• trachea —> primary bronchi —> secondary bronchi —> tertiary bronchi —> bronchioles —> alveoli

• Thorax: lungs, rib cage, cartilage, intercostal muscles

  • Suprasternal notch: U shaped depression above sternum btw clavicle

  • Sternal angle: continuous with second rib

  • Costal angle: right and left costal margins meet at xiphoid process - 90 degree

• Apex of lung: highest point 3-4 cm above inner third of clavicle

  • Posterior: C7

• Base of lung: rest on diaphragm

  • Posterior: T10

respiratory system: anatomy -landmarks

• Anterior anatomical landmarks:

  • midsternal line: middle of the sternum

  • midclavicular line: middle of the clavicle - left and right

  • axillary line: armpit - left and right

• Posterior anatomical landmarks:

  • vertebral line: middle of vertebra

  • scapular line: down scapula - left and right

respiratory assessment: components

• ROS: review of systems - subjective data

• Exam: objective data

  • respirations: rate, rhythm, effort, depth, SPO2- inspection

  • lung: skin/thorax (inspection/palpation/percussion), breath sounds (auscultation)

respiratory assessment: ROS

• Review of systems: subjective data - gather through interview

  • Symptom analysis: any positive symptom - PQRSTU

    • PQRSTU: provocation/palliation, quality, radiation, severity, timing, understanding

• Respiratory ROS:

  • Shortness of breath (SOB): do you experience SOB, dyspnea, changes in breathing patterns

  • Cough: two types

    • Productive: wet cough - mucus, phlegm, substance produced by cough

      • Sputum: color, consistency, amount

    • Nonproductive: no substance - irritating/dry  

  • Chest pain/ pain with breathing

respiratory assessment: respirations

• basic respiratory rate: driven by CO2 levels - ventilation

  • technique: inspection - watch respiratory cycles (inspiration and expirations) —> measure in cycles per minute

    • rate: 12-20 breaths per minute

      • bradypnea: less than 12

      • tachypnea: more than 20

    • rhythm: regular v irregular

    • effort: relaxed (unlabored) v forced (labored)

    • depth: shallow, normal, deep

    • pulse oximetry: SPO2- 94%-100%

• factors influence RR:

  • Increase: exercise, acute pain, anxiety, body position, hb function

  • Decrease: medications (depresses breathing)

respiratory assessment: lungs

• Takes time: use all four assessment techniques - chest/thorax

  • Inspection: symmetry, deformities, note work of breathing 

    • Visualize rise/ fall of chest

  • Palpation: assess for abnormal vibrations (fremitus)

    • Place hand on areas of chest and feel during inspiration/expiration 

  • Percussion: assess for consolidation - hollow

    • Tapping over posterior/anterior surfaces to elicit hollow sounds (replaced by ultrasound)

  • Auscultation: assess ventilation, symmetric sounds bilaterally, note adventitious sounds, note diminished sounds

    • Place diaphragm of stethoscope systematically posteriorly and anteriorly

    • Listening each point during respiratory cycle: inspiration/expiration

respiratory assessment: lungs - breath sounds (auscultation)

• 3 types of breath sounds in healthy adults: sounds come from different-sized tubes

  • Bronchial (B)

  • Bronchovesicular (BV)

  • Vesicular (V)

    • Adventitious: abnormal breath sounds

• Auscultate anteriorly & posteriorly (not over scapula -no sound)

  • Auscultation sequence: snake across chest (side to side) - symmetry

    • Anterior: 1-5

    • Posterior 1-9

respiratory assessment: breath sounds - bronchial

• location: trachea and larynx

• sound: hollow, tubular, blowing

• pitch: high pitch, loud

• duration: sound on expiration longer than inspiration

respiratory assessment: breath sounds - bronchovesicular

• location: major bronchi, upper third of the chest, ICS 1 & 2, btw scapulae

• sound: normal breath sounds

• pitch: medium

• duration: inspiration = expiration

respiratory assessment: breath sounds - vesicular

• location: peripheral lung fields where air flows through smaller bronchioles and alveoli

• sound: soft, whisper

• pitch: low

• duration: inspiration longer than expiration - 3:1

respiratory assessment: lungs - adventitious sounds (abnormal)

• Wheeze: squeak or high-pitched whistle, pronounced on expiration 

  • Constriction of bronchioles: asthma - air pass through narrow airway

• Crackles: popping, crackling, bubbling - discontinuous

  • Consolidation: not cleared by coughing - air is pass though inflamed or wet area 

• Stridor: high pitch, noted over trachea, can be life-threatening 

  • Obstruction/constriction/swelling of upper airways: anaphylaxis, epiglottitis

• Diminished: struggling to hear any air movement - symmetry 

  • Low effort of pt: not deep enough breaths

  • Larger body habitus: larger pt - more adipose btw lungs and stethoscope

respiratory assessment: older adult consideration

• Increased anteroposterior diameter: round/barrel shape or kyphosis of thoracic spine

  • Decreased subcutaneous fat: bony prominences pronounced 

  • Chest expansion decreased: still symmetric 

  • Costal cartilages calcify - less mobile thorax 

  • Tired during deep breathing of auscultation: allow brief rest periods

respiratory assessment: documentation

• Rate: 12-20 respirations/ min 

• Rhythm: regular/irregular 

• Effort: labored, unlabored, even, shallow, deep 

• Lung sounds: clear to auscultation (CTA) all 4 lung fields OR adventitious sounds/ diminished sounds noted (where)

  • EX: pt resp rate is 16/min, even/unlabored, lungs CTA all 4 fields, pt no sign of resp distress (interpretation)

  • EX: pt with labored respirations, tachypnic at 24 resp per min with increased effort, adventitious sounds noted over bronchioles

cardiovascular system: anatomy - review

• Heart: 2nd-5th intercostal space from right border of sternum to left midclavicular line

  • 4 chambers

    • Atria: right and left

    • Ventricles: right and left (bigger)

• Valves: 4 valves

  • Atrioventricular: right (tricuspid) and left (bicuspid) - open during diastole

  • Semilunar: right (pulmonary) and left (aortic) - open during systole

• Precordium: area around the heart - anterior chest overlying heart

  • Base: top of the heart - 2 ICS or sternal angle

  • Apex: bottom of heart - 4/5th ICS

• Cardiac cycle: 

  • Diastole: ventricles relax/fill with blood, AV valves open

    • AV valves closes: first heart sound (s1): beginning of systole 

  • Systole: ventricles fill, blood ejected 

    • SL valves close: second heart sound (s2): end of systole

• Blood flow: vena cava —> right atrium —> tricuspid valve (AV) —> right ventricle —> pulmonary valve (SL) —> pulmonary arteries —> lungs —> pulmonary veins —> left atrium —> bicuspid valve (AV) —> left ventricle —> aortic valve (SL) —> aorta —> body tissues

cardiovascular assessment: components

• ROS: review of systems - subjective data

• Exam: objective data - inspection, palpation, and auscultation (percussion not used)

  • Systolic BP by palpation

  • Apical heart rate & rhythm

  • Heart sounds: S1 & S2 - aortic, pulmonic, mitral, tricuspid, erb’s point

cardiovascular assessment: ROS

• Review of systems: subjective data - gather through interview

  • Symptom analysis: any positive symptom - PQRSTU

    • PQRSTU: provocation/palliation, quality, radiation, severity, timing, understanding

• Cardiovascular ROS

  • Chest pain

  • Shortness of breath (SOB/dyspnea) 

  • Orthopnea: difficulty breathing in supine (laying down)

  • Fatigue

  • Edema (leg swelling)

  • Nocturia: urinary frequency at night

cardiovascular assessment: inspection, palpation, auscultation

• Inspection: skin color, signs of distress (diaphoresis, dyspnea, pain) 

  • Note skin color to extremities/lips - pallor (paleness), cyanosis (blue tinge), observe other signs of distress

• Palpation: systolic BP

• Auscultation: heart sounds (S1 and S2- 4 locations over valves), apical heart rate/rhythm

  • Placing diaphragm of stethoscope on selected points over the precordium 

cardiovascular assessment: systolic - palpation

• Systolic blood pressure: palpation + cuff

  • Palpate radial artery while inflating cuff until pulse disappears: note pressure (110mmHg)

  • Deflate, wait, reinflate to 30 mmHg over pulse pressure (140)

  • Deflate slowly, palpating radial artery until first pulsation (systolic) is palpated

    • Document as #/palp (120/p or 110/p)

• CANNOT assess diastolic only by palpation, ONLY systolic

• USe: identify baseline systolic necessary for perfusion (90/p or 90/systolic)

  • Hypotension (less than 90): fluid, trendelenberg

cardiovascular assessment; apical heart rate

• Apical heart (HR): auscultate 4th intercostal space, medial to the midclavicular line 

  • Document: time, rate (60-100bpm), rhythm (regular, irregular)

• apical impulse (HR): palpable - only ½ of adults

cardiovascular assessment: heart sounds - types

• heart sounds: created by the closing of the heart valves

  • Lub: S1 

    • First heart sound

    • Signals beginning of systole

    • Closure of AV valves causes sound

    • Corresponds with each carotid pulsation

    • Loudest at the apex of the heart

  • Dub: S2

    • Second heart sound

    • Signals start of diastole

    • Closure of SL valves causes sound

    • Loudest at the base of the heart 

  • DON'T want S3/S4: indicative of issues

    • S3: mitral area - normal in children/young adults but abnormal in adults 

    • S4: before S1 - normal in older adults but abnormal in children and adults

    • Murmur: extra sound caused by disruption of flow through heart

cardiovascular assessment: heart sounds - auscultation

• 4 auscultation areas: best hear the heart sound - S1 and S2 in each spot

  • Aortic valve area (SL): 2 intercostal space (ICS) at the right sternal border (base of heart)

  • Pulmonary valve area (SL): 2 intercostal space (ICS) at the left sternal border (base of heart)

  • Tricuspid valve area: (AV): 4th intercostal space at the left lower sternal border

  • Mitral valve area (AV): 5th intercostal space at or sound the left midclavicular line (apex of the heart)

• Pneumonic: APEToMan

  • aortic, pulmonary, erbs, tricuspid, mitral

cardiovascular assessment: older adult considerations

• Rise in systolic BP

  • Orthostatic hypotension: drop in BP when rising to sit/stand 

  • Chest increases in anteroposterior diameter

  • S4 sound 

  • Ectopic beats

cardiovascular assessment: documentation

• Systolic BP: systolic BP < 120 over palpation 

• Rate: apical heart rate (counter for 30 sec regular, 1 min if irregular) 

• Rhythm: regular, irregular 

• S 1 & S2: sounds noted in all 4 quadrants 

  • EX: SBP 110/p, apical heart rate 74 bpm and regular, S1/S2 sounds auscultated over aortic arch, pulmonic, mitral, and tricuspid valves, no additional heart sounds noted 

peripheral vascular assessment: components

• ROS: review of systems - subjective data

• Exam: objective data - inspection and palpation

  • Arterial pulse: carotid, brachial, radial, femoral, popliteal, post tibial, dorsalis pedis —> force

  • Capillary refill: time

  • Edema: extrmemties —> grade

peripheral vascular assessment: ROS

• Review of systems: subjective data - gather through interview

  • Symptom analysis: any positive symptom - PQRSTU

    • PQRSTU: provocation/palliation, quality, radiation, severity, timing, understanding

• Peripheral vasculature ROS:

  • Leg pain or leg cramps

  • Edema (swelling)

  • Color changes

  • History of clots

peripheral vascular assessment: inspection and palpation

• Arms, legs, extremities:

  • Color: pink (perfusion) - rubor/erythema, cyanosis, pallor (pale)

    • Erythema: redness: inflammation 

    • Cyanosis: dusky blue - lips, finger tips

  • Temperature: warm - cool, hot (use back of hands for temp!)

  • Moisture: dry - excessive dryness (flaky), excessive moisture (weeping, diaphoresis) 

  • Texture: smooth/even - flaking, scaling, taut, shiny, symmetrical

  • Integrity: open wounds, lesions, cracks, indurations

peripheral vascular assessment: arterial pulse - location

• Pulses are palpated at locations close to the surface and over a bone: index and middle fingers

  • Carotid: central - need to have

  • Brachial

  • Radial

  • Femoral: central - need to have

  • Popliteal

  • Post tibial

  • Dorsalis pedis

• Pulse: location, strength/amplitude, symmetry

peripheral vascular assessment: arterial pulse - strength grading

• Pulse documentation: location, strength, symmetry

  • 3+  bounding, feels forceful - hypertension, anxiety, exercise 

  • 2+: average, normal finding and what you feel most often - adequate perfusion

  • 1+: weak, thready - hypotension, partial occlusion, blood loss

  • 0: absent - occlusion due to trauma or constriction of vessels, absent pulse = emergency

peripheral vascular assessment: arterial pulse - older adults

• Peripheral vessels harden

  • Rigid with age: resulting in a condition called arteriosclerosis

    • Arteriosclerosis restricts blood flow

• Weaker peripheral pulses

  • Dorsalis pedis/ posterior tibial pulses: more difficult to palpate

peripheral vascular assessment: capillary refil

• Important for orthopedic injury

  • Assess peripheral perfusion

  • Depress and blanch the nail bed (fingers and toes)

  • Release: note time color returns

  • < 2 seconds is expected

peripheral vascular assessment: edema - palpation

• Edema: fluid accumulation in the intercellular spaces - not an expected finding (poor circulation)

  • Affects dependent extremities: immobility 

• Palpate for edema: press and release

  • Depress skin over tibia or medial malleolus for 5 seconds

  • Pitting edema: indentation left behind 

• Grade edema

peripheral vascular assessment: edema - grading

• Grade pitting edema: press 5 seconds

  • 1+  mild pitting, slight indentation, no perceptible swelling in the leg

  • 2+  moderate pitting, indentation subsides rapidly

  • 3+  deep pitting, indentation remains for a short time, leg looks swollen

  • 4+  very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

peripheral vascular assessment: documentation

• inspection of extremities - skni color, temperature, moisture, texture, integrity

• Pulse: 

  • Location: radial, brachial, carotid, femoral, popliteal, tibial, dorsalis pedis 

  • Strength: 3+, 2+, 1+, absent - 2+ expected

  • Symmetry: assess for differences - symmetry expected

• Capillary refill: 

  • Duration: fingertips and toes - <2 seconds expected 

  • Symmetry: assess bilaterally - symmetry expected 

• Edema: 

  • Location: shins 

  • Grade: 1+, 2+, 3+, 4+ - no edema expected

• EX: documentation of expected findings

  • Systolic palpated at 135/P. Consistent with previous blood pressure readings and patient reporting no distress at this time (if abnormal value - indicate concern)

  • Patient with apical heart rate of 78 bpm, regular. S1 and S2 sounds auscultated over 4 quadrants. No additional heart sounds or aberrant beats noted.

  • On inspection BLEs are warm, pink and dry with even skin tone. No edema is noted. Cap refill < 2 seconds. Peripheral pulses 2+, symmetrical and regular.