||Observe and document the overall pattern of the patient's breathing.
- body positioning; sitting upright or hunched over?
- muscles used in breathing; accessory muscles to assist
- chest wall configuration: Does the chest move in and out
easily? Does only one side move?
Observe and document and note changes in the patient's respiratory
- use of pursed lips
- stridor - crowing sound
- abdomen and chest rising together or irregularly (chest rise,
abdomen draws in)
- slow or rapid respiration
Normal Breath Sounds
Fine Rales or Crackles
Rales or crackles is a sound that is a discontinuous sound that
is like a milkshake being sucked up through a straw, or popcorn
popping in a popcorn popper, or like aerial bombs going off on the
4th of July, or the sound that you hear when burning wood crackles
and pops in a fireplace. When fluid or mucus collects in the
peripheral portions of the lung, the alveoli collapse and the walls
of the alveoli stick together. Then, when the patient attempts to
inhale and creates a large negative, the alveolar walls are forced
to pop open and the crackle or the popping sound is created. This is
a sound heard during inspiration. If it is heard anywhere on the
chest wall, it is an ominous sound. It is indicative of a pneumonia
or an atelectatic lung.
Medium Rales or Crackles
Course Rales or Crackles
Wheezing The wheezes are
considered to be central airway sounds caused by air passing through
mucus plugs in the upper divisions of the tracheobronchial tree. The
sibilant wheeze is a high-pitched whining type of wheeze much like the
sound that hump-back whales make as they migrate. The sonorous wheeze is
a snoring type of sound.
Pleural Friction Rub Pleural
Friction Rubs are created when the visceral and parietal pleurae become
inflammed and roughened. The inflammed membranes will stick together.
- Put on your stethoscope so that the ear pieces are directed away
from you. Adjust the head of the scope so that the diaphragm is
engaged. If you're not sure, scratch lightly on the diaphragm, which
should produce a noise. If not, twist the head and try again. Gently
rub the head of the stethoscope on your shirt so that it is not too
cold prior to placing it on the patient's skin.
- Don't get in the habit of performing auscultation through
- Ask the patient to take slow, deep breaths through their mouths
while you are performing your exam. This forces the patient to move
greater volumes of air with each breath, increasing the duration,
intensity, and thus detectability of any abnormal breath sounds that
might be present.
- Sometimes it's helpful to have the patient cough a few times
prior to beginning auscultation. This clears airway secretions and
opens small atelectatic (i.e. collapsed) areas at the lung bases.
- If the patient cannot sit up (e.g. in cases of neurologic
disease, post-operative states, etc.), auscultation can be performed
while the patient is lying on their side. Get help if the patient is
unable to move on their own. In cases where even this cannot be
accomplished, a minimal examination can be performed by listening
laterally/posteriorly as the patient remains supine.
- Requesting that the patient exhale forcibly will occasionally
help to accentuate abnormal breath sounds (in particular, wheezing)
that might not be heard when they are breathing at normal flow
Summary of Breath Sounds
DRAINAGE AS A
David Woodruff reviews heart sounds. (10 min)
- Position the patient supine with the head of the table slightly
- Always examine from the patient's right side. A quiet room is
- Listen with the diaphragm at the right 2nd interspace near the
sternum (aortic area).
- Listen with the diaphragm at the left 2nd interspace near the
sternum (pulmonic area).
- Listen with the diaphragm at the left 3rd, 4th, and 5th
interspaces near the sternum (tricuspid area).
- Listen with the diaphragm at the apex (PMI) (mitral
- Listen with the bell at the apex.
- Listen with the bell at the left 4th and 5th
interspace near the sternum.
- Have the patient roll on their left side.
- Listen with the bell at the apex.
- This position brings out S3 and mitral murmurs.
- Have the patient sit up, lean forward, and hold their breath in
- Listen with the diaphragm at the left 3rd and 4th interspace
near the sternum.
- This position brings out aortic murmurs.
- Record S1, S2, (S3), (S4), as well as the grade and
configuration of any murmurs ("two over six" or "2/6", "pansystolic"
- Normal sinus rhythm (at rates of ~60, ~90, ~130, and ~180 beats per minutes).
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Observe and document:
- color (cyanosis=blue) of skin, nail beds, earlobes, and mucous
- Check the radial pulses on both sides. If the radial pulse is
absent or weak, check the brachial pulses.
- Check the posterior tibial and dorsalis pedis pulses on both
sides. If these pulses are absent or weak, check the popliteal and
- Press down firmly on the patient's finger or toe nail so it
- Release the pressure and observe how long it takes the nail bed
to "pink" up.
- Capillary refill times greater than 2 to 3 seconds suggest
peripheral vascular disease, arterial blockage, heart failure, or
- Check for the presence of edema (swelling) of the feet and lower
- Check for the presence of cyanosis (blue color) of the feet or
- Check for the presence of clubbing of the fingers.
||Think Anatomically: When looking, listening, feeling and
percussing imagine what organs live in the area that you are examining.
The abdomen is roughly divided into four quadrants: right upper, right
lower, left upper and left lower. By thinking in anatomic terms, you
will remind yourself of what resides in a particular quadrant and
therefore what might be identifiable during both normal and pathologic
What exactly are you listening for and what is its significance?
Three things should be noted:
- Are bowel sounds present?
- If present, are they frequent or sparse (i.e. quantity)?
- What is the nature of the sounds (i.e. quality)?
As food and liquid course through the intestines by means of
peristalsis noise, referred to as bowel sounds, is generated. These
sounds occur quite frequently, on the order of every 2 to 5 seconds,
although there is a lot of variability.
Percussion: The technique for percussion is the same as that
used for the lung exam. First, remember to rub your hands together and
warm them up before placing them on the patient. Then, place your left
hand firmly against the abdominal wall such that only your middle finger
is resting on the skin. Strike the distal interphalangeal joint of your
left middle finger 2 or 3 times with the tip of your right middle
finger, using the previously described floppy wrist action (see under
lung exam). There are two basic sounds which can be elicited:
- Tympanitic (drum-like) sounds produced by percussing over air
- Dull sounds that occur when a solid structure (e.g. liver) or
fluid (e.g. ascites) lies beneath the region being examined.
The major areas of the exam, covering
the most testable components of the neurological system, include:
Mental status testing (covered in a separate section
of this web site)
Muscle strength, tone and bulk
Coordination and Gait
- Ptosis (III)
- Facial Droop or Asymmetry (VII)
- Hoarse Voice (X)
- Articulation of Words (V, VII, X, XII)
- Abnormal Eye Position (III, IV, VI)
- Abnormal or Asymmetrical Pupils (II, III)
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||Find out how the patient feels about himself, his place in society, and
his life relationships with others. Ask about occupation,
education, financial status, and responsibilities.
Typical questions might include:
- How have you coped with medical and/or emotional crisis in the
- Has your life changed recently. What changes in your
personality or behavior have you noticed?
- How adequate is the emotional support you receive from your
- How often do you exercise? What types of things do you do?
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The Mental Status Exam (MSE)
In actual practice, providers (with the exception of a psychiatrist or
neurologist) do not regularly perform an examination explicitly designed
to assess a patient's mental status. During the course of the normal
interview, most of the information relevant to this assessment is
obtained indirectly. This review provides an opportunity to consciously
think of the elements contained within the MSE.
In the day to day practice of medicine (and, in fact, throughout all
of our interactions) we continually come into contact with persons who
have significantly impaired cognitive abilities, altered capacity for
memory, disordered thought processes and otherwise abnormal mental
status. First and foremost, the goal is to be able to note when these
abnormalities exist (you'd be surprised at how frequently they can be
missed) and then to categorize them as specifically as possible. If a
person seems "odd, confused or not quite right" what do we mean by this?
What about their behavior, appearance, speech, etc. has lead us to these
conclusions? In some instances, the patient's condition (e.g. markedly
depressed level of consciousness, intoxication) will preclude a
complete, ordered evaluation of mental status, so flexibility is
important. Knowing when to "cut your losses" and abandon a more detailed
examination obviously takes a bit of experience! The formulation of
actual diagnoses, the final step in this process is, for the most part,
beyond the scope of this discussion (I've included two of the most
commonly encountered ones at the end of this section as examples). In
fact, even if you had the experience and knowledge to generate
diagnoses, this still may not be possible after a single patient
encounter. The interview provides a "snap shot" of the patient, a
picture of them as they exist at one point in time. Frequently, and this
applies to the physical examination as well, several interactions are
required along with information about the patient's usual level of
function before you can come to any meaningful conclusions about their
current condition. The components of the MSE are as follows:
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|Diagnoses are made on the basis of a pattern of responses to the above
evaluation. Two commonly occurring disorders are described below:
- Delirium: Also referred to as Altered Mental Status, Delta MS,
Acute Confusional State, or Toxic Metabolic State. This is a very
common condition (particularly among hospitalized patients) notable
for an acute, global change in mental status that can be the result
of physiologic derangement anywhere within the body. Causes include:
infection, hypoxia, toxic ingestion, impaired ability of the body to
handle endogenously produced toxins (e.g. liver or kidney failure),
etc. There is a wide spectrum of presentations, ranging from
unarousable to extremely agitated. Patients may appear quite ill,
with markedly abnormal vital signs that in themselves can suggest
the cause of the delirium (e.g. hypotension, infection). They are
frequently confused, disoriented, agitated and uncooperative. Formal
evaluation of mood, affect, memory, judgment or insight can be
hopeless. Thought process is disordered and content notable for
delusions, paranoia and hallucinations. In general, the diagnosis is
suggested by the time course of the illness (i.e. the change is
acute). Treatment is dictated by the underlying insult, which can
generally be determined after a detailed history (usually with the
help of others who are familiar with the patient), review of
medications, thorough examination, and appropriate use of lab and
radiologic testing. The elderly as well as those with multiple
medical problems (conditions which frequently coexist) are at the
highest risk for developing this condition. Delirium in this patient
sub-set can be provoked by seemingly minor precipitants. Initial
presentation of psychotic disorders as well as dementia can be
mistaken for delirium (and vice versa). This can only be sorted out
with time and appropriate testing, though these distinctions are
- Dementia: A final common pathway for multiple disorders
characterized by its slow, progressive nature, taking months to
years to develop. While quite uncommon under 50, the incidence
increases markedly with age. Patient's appearance and behavior vary
with the extent of involvement. This ranges from well groomed, alert
and cooperative to agitated, unable to care for themselves and
incapable of answering even simple questions. Mood and affect can
range widely, and may or may not be appropriate for the given
situation. Thought process and content have similar variability.
Memory, judgment and higher cortical function deteriorate with time.
As this is a progressive disease, presentation will depend on the
level of advancement. Contributions from other acute, reversible
medical problems must be ruled out on the basis of history,
examination and laboratory testing.
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- Appearance: How does the patient look? Neatly dressed with clear
attention to detail? Well groomed?
- Level of alertness: Is the patient conscious? If not, can they
be aroused? Can they remain focused on your questions and
conversation? What is their attention span?
- Speech: Is it normal in tone, volume and quantity?
- Behavior: Pleasant? Cooperative? Agitated? Appropriate for the
- Awareness of environment, also referred to as orientation: Do
they know where they are and what they are doing here? Do they know
who you are? Can they tell you the day, date and year?
- Mood: How do they feel? You may ask this directly (e.g.
"Are you happy, sad, depressed, angry?"). Is it appropriate for
their current situation? Mood swings may indicate a
physiologic disorder. Medications, or disease may influence
mood changes. After childbirth and during menopause women may
experience profound depression.
- Affect: How do they appear to you? This interpretation is
based on your observation of their interactions during the
interview. Do they make eye contact? Are they excitable? Does the
tone of their voice change? Common assessments include: flat
(unchanging throughout), excitable, appropriate. Check lability of
affect (rapid dramatic fluctuation in emotions), flat affect
(unresponsive range of emotions), or inappropriate affect
(inconsistency between expression and mood).
- Thought Process: This is a description of the way in which they
think. Are their comments logical and presented in an organized
fashion? If not, how off base are they? Do they tend to stray
quickly to related topics? Are their thoughts appropriately linked
or simply all over the map?
- Thought Content: A description of what the patient is thinking
about. Are they paranoid? Delusional (i.e. hold beliefs that are
untrue)? If so, about what? Phobic? Hallucinating (you need to ask
if they see or hear things that others do not)? Fixated on a single
idea? If so, about what. Is the thought content consistent with
their affect? If there is any concern regarding possible interest in
committing suicide or homicide, the patient should be asked this
directly, including a search for details (e.g. specific plan, time
etc.). Note: These questions have never been shown to plant the
seeds for an otherwise unplanned event and may provide critical
information, so they should be asked!
- Memory: Short term memory is assessed by listing three objects,
asking the patient to repeat them to you to insure that they were
heard correctly, and then checking recall at 5 minutes. Long term
memory can be evaluated by asking about the patients job history,
where they were born and raised, family history, etc.
- Ability to perform calculations: Can they perform simple
addition, multiplication? Are the responses appropriate for their
level of education? Have they noticed any problems balancing their
check books or calculating correct change when making purchases?
This is also a test of the patient's attention span/ability to focus
on a task.
- Judgment: Provide a common scenario and ask what they would do
(e.g. "If you found a letter on the ground in front of a mailbox,
what would you do with it?").
- Higher cortical functioning and reasoning: Involves
interpretation of complex ideas. For example, you may ask them the
meaning of the phrase, "People in glass houses should not throw
stones." A few common interpretations include: concrete (e.g. "Don't
throw stones because it will break the glass"); abstract (e.g.
"Don't judge others"); or bizarre.
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|Pain and Discomfort
||No particular expression
||Occasional grimace or
frown, withdrawn, disinterested
||Frequent to constant
quivering chin, clenched jaw
||Normal position or relaxed
||Uneasy, restless, tense
||Kicking, or legs drawn up
||Lying quietly, normal
position, moves easily
||Squirming, shifting back
and forth, tense
||Arched, rigid or jerking
||No cry (awake or asleep)
||Moans or whimpers;
||Crying steadily, screams
or sobs, frequent complaints
||Reassured by occasional
touching, hugging or being talked to,
||Difficult to console or
Each of the five categories (F) Face; (L) Legs; (A) Activity;
(C) Cry; (C) Consolability is scored from 0-2, which results in
a total score between zero and ten.
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Quick Summary- 2000 Infusion Nursing Standards of
client's medical record for correct solution, additives, and
time of infusion.
- Perform hand
hygiene. Observe for patency of intravenous (IV) line and needle
client's knowledge of how positioning of IV site affects flow
- Verify with
client how venipuncture site feels.
- Check for signs or symptoms
of local complications:
prescriber's orders and follow “six rights” for correct solution
and proper additives.
appropriate flow rate.
- Follow the
procedure for infusion controller or pump: Assess patency and
integrity of system when alarm sounds.
- Document insertion and tubing
client for signs of overhydration or dehydration.
client for signs of infiltration: inflammation at site, clot in
catheter, kink or knot in infusion tubing.
and report solutions, infusion rates, use of electronic infusion
device, and client’s responses.
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See hospital Policy
Aspiration of gastric
contents results in a chemical pneumonitis
Most commonly seen in
apical segments of right lower lobe
If unrecognised or
inadequately treated it can result in a
secondary bacterial infection
Secondary infection is
usually with gram-negative and anaerobic
||Skin Risk assessment
10 Best Practices for Skin Care
Diabetic Food Pyramid
|Food intake represents a potentially important tool
in monitoring persons at risk for malnutrition in the hospital.
Unfortunately, recent studies have suggested that
the recording of the amount of food eaten in hospitals is highly
Nurse’s aides can be trained to be more accurate
in estimating the amount of food ingested, but doing so requires a
substantial time investment.
- The patient should not have had alcohol,
tobacco, caffeine, or performed vigorous exercise within 30 minutes
of the exam.
- Ideally the patient should be sitting with feet on the floor and
their back supported. The examination room should be quiet and the
- History of hypertension, slow or rapid pulse, and current
medications should always be obtained.
- Observation: Before diving in, take a minute or so to
look at the patient in their entirety, making your observations, if
possible, from an out-of-the way perch. Does the patient seem
anxious, in pain, upset? What about their dress and hygiene?
Remember, the exam begins as soon as you lay eyes on the patient.
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Temperature can be measured is several different ways:
- Oral with a glass, paper, or electronic
thermometer (normal 98.6F/37C) 
- Axillary with a glass or electronic thermometer
- Rectal or "core" with a glass or electronic
thermometer (normal 99.6F/37.7C)
- Aural (the ear) with an electronic thermometer
Of these, axillary is the least and rectal is the most accurate.
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Oxygen Saturation: Over the past decade, this
non-invasive measurement of gas exchange and red blood cell oxygen
carrying capacity has become available in all hospitals and many
clinics. While imperfect, it can provide important information about
cardio-pulmonary dysfunction and is considered by many to be a fifth
vital sign. In particular, for those suffering from either acute or
chronic cardio-pulmonary disorders, it can help quantify the degree of
- Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations.
[p129, p237] 
- Without letting go of the patients wrist begin to observe the
patient's breathing. Is it normal or labored?
- Count breaths for 15 seconds and multiply this number by 4 to
yield the breaths per minute.
- In adults, normal resting respiratory rate is between 14-20
breaths/minute. Rapid respiration is called tachypnea.
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- Sit or stand facing your patient.
- Grasp the patient's wrist with your free (non-watch bearing)
hand (patient's right with your right or patient's left with your
left). There is no reason for the patient's arm to be in an awkward
position, just imagine you're shaking hands.
- Compress the radial artery with your index and middle fingers.
- Note whether the pulse is regular or irregular:
- Regular - evenly spaced beats, may vary
slightly with respiration
- Regularly Irregular - regular pattern
overall with "skipped" beats
- Irregularly Irregular - chaotic, no real
pattern, very difficult to measure rate accurately
- Count the pulse for 15 seconds and multiply by 4.
- Count for a full minute if the pulse is irregular. 
- Record the rate and rhythm.
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Orthostatic Vital Signs
Orthostatic (a.k.a. postural) measurements of pulse and
blood pressure are part of the assessment for hypovolemia.
What is Orthostatic Hypotension?
Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person assumes a standing position. It may be caused by hypovolemia (a decreased amount of blood in the body), resulting from the excessive use of diuretics, vasodilators, or other types of drugs, dehydration, or prolonged bed rest.
1. There is controversy as
to length of wait between moving to a new position and taking
VS. Most studies and experts agree that a one minute wait
between movement is satisfactory.
2. For consistency the
same arm with the same cuff and same location of pulse
measurement should be used. This is easily accomplished by using
electronic measuring devices.
Supine- The patient
needs to lie supine, without pillows, for two to three minutes
before measuring VS. * If supine position compromises patient’s
breathing status or comfort level, assist them to a position as
flat as possible. It is a good technique to obtain two sets of
measurement while the patient is supine and use the second set
as the baseline. This is done due to the normal sympathetic
response (alerting reaction) which can cause false positives by
initially raising the systolic B/P.
measurements with the patient in this position is controversial,
some say the elevation is not significant enough to cause a
change, other say that this in-between position causes false
negatives by providing a chance for the body to adjust before
changing to the standing position. * If the patient is not able
to stand this is the next position after supine. Whenever
measuring at this position the patient should be sitting
upright, with their legs dangling at the side of the bed.
Standing- If the
patient ambulated to the treatment area, and there are no signs
of syncope, the sitting position can be avoided
Document lying; sitting; standing. You should also indicate whether the pulse was regular and if on
a monitor, document rhythm. Also include any symptoms the
patient reports as well as your clinical observations, but do
not pose leading questions like, "are you dizzy?" Lastly, if
fluid replacement is ordered, after infusion is completed,
repeat orthostatic assessment should be performed to evaluate
and document effectiveness.
When a patient stands,
gravity causes blood to pool in the large vessels of the legs
and lower trunk (up to 500ml). Normally, baroreceptors in the
aortic arch and carotids sense this change in blood
pressure/volume and stimulate an endocrine, catecholamine, renin/aldosterone
response. This response causes the peripheral blood vessels to
constrict, the heart rate and contractility to increase, and the
kidneys to hold fluids. This action pulls blood into the core
circulation to supply the primary organs (heart, lungs, kidneys,
liver and brain).
In patients who are
volume depleted (hypovolemic), there is not enough circulating
blood to be pushed into core circulation, especially when the
patient moves from the supine to sitting or standing. That is
why clinicians think a positive tilt is indicative of volume
depletion, and institute replacement while awaiting other test
There is little
agreement as to what indicates a significant orthostatic change
and what is considered a positive tilt test. The "20-10-20" rule
may be used as a guide for this. The rule refers to the expected
decrease in systolic B/P (up to 20 mm Hg), a rise in diastolic
B/P of 10 mm HG and an increase in heart rate by 20 beats per
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- A normal adult heart rate is between 60 and 100 beats per minute
(see below for children).
- A pulse greater than 100 beats/minute is defined to be
tachycardia. Pulse less than 60 beats/minute is defined to be
bradycardia. Tachycardia and bradycardia are not necessarily
abnormal. Athletes tend to be bradycardic at rest (superior
conditioning). Tachycardia is a normal response to stress or
- Position the patient's arm so the anticubital fold is level with
the heart. Support the patient's arm with your arm or a bedside
- Center the bladder of the cuff over the brachial artery
approximately 2 cm above the anticubital fold. Proper cuff
size is essential to obtain an accurate reading. Be sure
the index line falls between the size marks when you apply the cuff.
Position the patient's arm so it is slightly flexed at the elbow. 
- Palpate the radial pulse and inflate the cuff until the pulse
disappears. This is a rough estimate of the systolic pressure. 
- Place the stetescope over the brachial artery. 
- Inflate the cuff to 30 mmHg above the estimated systolic
- Release the pressure slowly, no greater than 5 mmHg per second.
- The level at which you consistantly hear beats is the systolic
- Continue to lower the pressure until the sounds muffle and
disappear. This is the diastolic pressure. 
- Record the blood pressure as systolic over diastolic ("120/70"
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- Higher blood pressures are normal during exertion or other
stress. Systolic blood pressures below 80 may be a sign of serious
illness or shock.
- Blood pressure should be taken in both arms on the first
encounter. If there is more than 10 mmHg difference between the two
arms, use the arm with the higher reading for subsequent
- It is frequently helpful to retake the blood pressure near the
end of the visit. Earlier pressures may be higher due to the "white
- Always recheck "unexpected" blood pressures yourself.
|Blood Pressure Classification in
|Isolated Systolic Hypertension
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