Check off Respiratory and Cardio

1

perform hand hygiene

2

introduce self

3

verify patient id

4

provide privacy

5

verify any allergies

6

update white board

7

today i will be checking your basic vitals and listen to your lung and heart sounds

8

the patient is not sweating, does not have a strained look, and there are no noises heard while the patient is breathing

9

the patient position is…

10

ask the patient where they are and what time of day it is - patient is oriented and conscious

11

the fingers have good perfusion, no cyanosis, pallor, or clubbing. the fingers are a warm temperature and are not cold

12

take respiration and radial pulse

• respiration - depth and rhythm

• radial - amplitude and rhythm

13

take respiration and radial pulse

• respiration - depth and rhythm

• radial - amplitude and rhythm

14

oxygen saturation

15

take blood pressure

16

perform hand hygiene

17

any difficulty breathing or problems with the lungs

18

personal or family history of respiratory problems like COPD or asthma

19

personal or family history of cardiac problems like high cholesterol, hypertension, blood clots

20

have you felt any shortness of breath or any chest pain

21

do you have a cough? does it have sputum?

22

have you experienced any episodes of dizziness or felt like your heart is racing

23

have you noticed any changes in skin color, temperature, or edema in extremities

24

do you drink alcohol or smoke? how frequent?

25

have you noticed any weight or energy level changes

26

how often do you exercise and what activities do you do

27

chest looks symmetrical and costal angle is less than 90 degrees. both sides of the chest are expanding symmetrically with respirations

28

perform chest expansion assessment

• expansion was symmetrical

• the respirations have good depth and regular rhythm

29

skin color on the chest is consistent with the patient background and is symmetrical. there are no wounds or lesions present

30

inspect jugular vein and carotid artery on RIGHT side

• the jugular vein is not swollen or enlarged and i can not see the carotid artery pulsing

31

color is good and equal, symmetrical and there is no edema present in the upper extremities

32

color is normal with patient background, is symmetrical and there is no edema present in the lower extremities

33

palpate chest - there is no tenderness or cracking present

34

assess capillary refill on fingers and toes - refill is less than 2 secs

35

palpate following at the same time

• carotid - DO NOT palpate at the same time

• brachial

• radial - USE DOPPLER

• dorsalis pedis

• posterior tibial

36

locate and identify:

• trachea

• suprasternal notch

• midsternal line

• midclavicular lines

• anterior, posterior, and midaxillary lines

• vertebral and scapular lines

37

clean stethoscope

38

auscultate 5 cardiac valves with the BELL and say name and location and that presence of s1 and s2

• aortic - 2nd ICS RSB

• pulmonic - 2nd ICS LSB

• erbs point - 3rd ICS LSB

• tricuspid - 4th ICS LSB

• mitral - 5th ICS midclavicular line

39

obtain apical pulse for 30 secs

• breath sounds are regular, good rhythm, and did not hear any abnormalities like crackles or rhonchi. apical pulse has good rhythm

40

auscultate 12 anterior positions. breath sounds are normal, no abnormalities heard. rhythm of the breaths are normal

41

auscultate 16 posterior positions. breath sounds are normal, no abnormalities heard. rhythm of the breaths are normal

42

clean stethoscope

43

thank patient and all results are good and normal and no abnormalities

44

lower bed, brakes locked, side rails up, call light in reach

45

perform hand hygiene