Nursing Process

● Definition: A systematic, patient-centered, and evidence-based method for

providing nursing care.
● Steps:
1. Assessment: Collecting and validating data.
2. Diagnosis: Identifying patient health problems.
3. Planning: Setting goals and desired outcomes.
4. Implementation: Executing planned nursing interventions.
5. Evaluation: Determining the effectiveness of interventions.

Key Terms and Concepts

● Patient-Centered Approach: Recognizes the patient as the control source in their

care, focusing on values, preferences, and needs.
● Dynamic: Reflects the evolving nature of the process.
● Critical Thinking: Applied at each step to make informed decisions.
● Cyclical: The process repeats as patient needs change.

Steps and Definitions

1. Assessment

● Definition: Collecting, interpreting, and validating information about the patient’s

health.
● Activities:
○ Collect data from primary and secondary sources.
○ Validate data to ensure completeness.
○ Organize and document data systematically.
● Types:
○ Initial: On admission, to form a baseline.
○ Problem-Focused: To monitor specific issues.
○ Emergency: During crises to identify urgent needs.
○ Time-Lapsed: For comparison with earlier data.

2. Diagnosis

● Definition: Clinical judgment about the patient’s responses to health conditions.

● Activities:
○ Analyze collected data.
○ Identify health problems, risks, and strengths.
○ Formulate nursing diagnoses using NANDA-I taxonomy.
● Types:
 ○ Problem-Focused: Current issues (e.g., Anxiety).
○ Risk: Potential issues (e.g., Risk for Infection).
○ Health Promotion: Opportunities for improved well-being (e.g., Readiness
for Enhanced Nutrition).

3. Planning

● Definition: Developing goals and strategies to address the identified nursing

diagnoses.
● Activities:
○ Prioritize problems.
○ Set goals and expected outcomes.
○ Select nursing interventions.
○ Write care plans (individualized or standardized).
● SMART Goals:
○ Specific, Measurable, Attainable, Realistic, Time-bound.

4. Implementation

● Definition: Performing nursing interventions to achieve goals.

● Activities:
○ Reassess the patient to confirm appropriateness of interventions.
○ Perform interventions (direct or indirect care).
○ Delegate and supervise appropriately.
○ Document interventions performed.
● Types of Interventions:
○ Direct Care: Hands-on (e.g., administering medication).
○ Indirect Care: Away from the patient (e.g., infection control measures).

5. Evaluation

● Definition: Assessing whether goals were met and modifying care as needed.
● Activities:
○ Compare actual outcomes with expected outcomes.
○ Identify errors or unmet goals.
○ Revise the care plan if necessary.
● Types of Evaluation:
○ Structure: Evaluating the care setting.
○ Process: Evaluating how care was provided.
○ Outcome: Evaluating patient health results.

Tools and Frameworks

Maslow’s Hierarchy of Needs

 ● Definition: A prioritization tool that ranks needs based on their urgency and
importance.
● Levels:
1. Physiological Needs: Basic survival requirements (e.g., air, food, water).
2. Safety Needs: Protection from harm or illness.
3. Love and Belonging: Emotional needs (e.g., relationships, support).
4. Esteem: Confidence and self-respect.
5. Self-Actualization: Achieving personal potential.
● Application: Addresses physiological needs first before moving to higher-order
needs.

PICOT Framework

● Definition: A structured format for formulating clinical research questions.

● Components:
○ P: Population/Patient Problem (e.g., disease, age, gender).
○ I: Intervention (e.g., therapy, medication).
○ C: Comparison (e.g., alternative treatments).
○ O: Outcome (e.g., improved health).
○ T: Time (optional; duration of observation or treatment).
● Use: Helps in creating evidence-based practice guidelines.

SBAR Communication

● Definition: A standardized framework for communicating critical patient

information.
● Components:
○ S: Situation – Describe the patient’s current issue.
○ B: Background – Provide context and relevant history.
○ A: Assessment – Share clinical findings.
○ R: Recommendation – Suggest actions or interventions.
● Use: Ensures clear and concise communication, especially in emergencies.

Standardized Care Plans

● Definition: Prewritten guides that outline care for common medical conditions.
● Examples: Protocols for myocardial infarction or diabetes management.
● Purpose: Save time, ensure consistency, and meet minimum care standards.

Nursing Outcome Classification (NOC)

● Definition: A standardized system to evaluate patient outcomes related to nursing

interventions.
● Use: Assists in linking outcomes with nursing care for measurable improvement.

A nursing audit is a systematic review and evaluation of nursing care provided to patients.
It involves assessing the quality, effectiveness, and efficiency of nursing services by
examining patient records, nursing documentation, and care practices. The goal is to
ensure adherence to established standards and identify areas for improvement.

Types of Nursing Audits:

1. Concurrent Audit:
○ Conducted while the patient is still receiving care.
○ Allows real-time identification and correction of issues in care delivery.
2. Retrospective Audit:
○ Performed after the patient has been discharged.
○ Focuses on reviewing documentation and care outcomes to evaluate past
nursing practices.

Purpose of a Nursing Audit:

● Improve the quality of patient care.

● Ensure compliance with institutional policies and nursing standards.
● Identify gaps or inconsistencies in documentation and care delivery.
● Provide data for training, policy-making, and accreditation.

Quality Assurance (QA) in healthcare is a process that ensures patients receive the best
possible care by checking if services meet established standards. It involves reviewing and
improving practices to ensure safety, effectiveness, and consistency in patient care.

Key Points:

● QA focuses on identifying areas for improvement in healthcare delivery.

● It ensures that all services are performed according to professional standards and
guidelines.
● Regular evaluations, like audits and feedback systems, are used to maintain
high-quality care.

Example: A hospital might review how quickly nurses respond to patient call bells. If
delays are identified, they may introduce new protocols to improve response times.

Comprehensive Reviewer for Basic Nursing Procedures

1. Wound Care

Purpose:
 ● Promote healing
● Prevent infection

Steps:

1. Perform hand hygiene and wear gloves.

2. Prepare and assemble all necessary materials (e.g., sterile gauze, saline, antiseptic
solution, bandages).
3. Position the patient comfortably and expose the wound area.
4. Clean the wound from the least contaminated to the most contaminated area:
○ Use a sterile solution and gauze.
○ Discard used gauze appropriately.
5. Apply a prescribed ointment if necessary.
6. Cover the wound with a sterile dressing.
7. Secure the dressing with tape or bandages.
8. Dispose of used materials and gloves properly.
9. Perform hand hygiene.

Tips:

● Always assess the wound for signs of infection: redness, swelling, heat, pain, and
discharge.
● Document the procedure and any observations.

2. Body Mechanics

Purpose:

● Prevent injury to the nurse and the patient.

● Maintain proper body alignment and posture.

Principles:

1. Keep the back straight and avoid twisting.

2. Bend at the hips and knees, not the waist.
3. Use leg muscles to lift heavy objects.
4. Keep the load close to the body.
5. Avoid lifting objects above shoulder level.
6. Use assistive devices (e.g., gait belts, slide boards) when necessary.

Tips:

● Always assess the environment for potential hazards.

● Educate the patient on safe movement techniques.
3. Range of Motion (ROM) Exercises

Purpose:

● Maintain or improve joint flexibility and muscle strength.

● Prevent contractures and stiffness.

Types of ROM Exercises:

1. Passive ROM: Performed by the nurse for patients unable to move independently.
2. Active ROM: Performed by the patient independently.
3. Active-Assisted ROM: A combination of patient and nurse efforts.

Steps:

1. Explain the procedure to the patient.

2. Support the joint being exercised.
3. Move the joint slowly and gently through its full range.
4. Avoid forcing the joint beyond its natural range.
5. Repeat each movement 5-10 times.

Tips:

● Stop the exercise if the patient experiences pain.

● Document the patient’s tolerance and any limitations.

4. Use of Assistive Devices

Purpose:

● Enhance mobility.
● Provide support and balance.

Common Devices:

● Canes: Used on the strong side of the body.

● Walkers: Provide maximum stability.
● Crutches: For non-weight-bearing or partial weight-bearing patients.

Tips:

● Teach patients to check the condition of the device regularly.

● Ensure proper height adjustment for comfort and effectiveness.
● Instruct on proper gait patterns (e.g., two-point, three-point, four-point).
5. Urinary Catheterization

Purpose:

● Drain urine from the bladder.

● Monitor urinary output.

Steps:

1. Perform hand hygiene and wear sterile gloves.

2. Prepare the patient and explain the procedure.
3. Position the patient appropriately (e.g., supine for females, supine with legs
extended for males).
4. Clean the urethral opening using antiseptic solution.
5. Insert the catheter gently into the urethra until urine flows.
6. Inflate the catheter balloon (if using an indwelling catheter).
7. Secure the catheter to the patient’s thigh or abdomen.
8. Attach the drainage bag below bladder level.
9. Dispose of used materials and gloves properly.
10. Document the procedure and findings.

Tips:

● Maintain sterile technique to prevent infection.

● Monitor for signs of discomfort or complications.

6. Managing Urinary Incontinence and Urinary Retention

Purpose:

● Promote comfort and dignity.

● Prevent skin breakdown and infection.

Incontinence Management:

1. Encourage scheduled toileting.

2. Use absorbent pads or briefs if necessary.
3. Perform regular perineal care.
4. Teach pelvic floor exercises.

Retention Management:

1. Encourage fluid intake.

2. Provide a warm environment to promote relaxation.
3. Use techniques like running water or placing warm compresses over the bladder.
4. Catheterize only if necessary and as prescribed.
7. Enema Administration

Purpose:

● Relieve constipation.
● Prepare the bowel for diagnostic procedures.

Steps:

1. Perform hand hygiene and wear gloves.

2. Prepare the enema solution as prescribed.
3. Position the patient in the left lateral (Sims’) position.
4. Lubricate the enema tip and insert it gently into the rectum (2-3 inches for adults).
5. Slowly instill the solution while monitoring the patient.
6. Encourage the patient to retain the solution for 5-10 minutes.
7. Assist the patient to the bathroom or provide a bedpan.
8. Document the procedure and results.

Tips:

● Monitor the patient for signs of discomfort.

● Do not force insertion if resistance is met.

8. Colostomy Care

Purpose:

● Maintain cleanliness and prevent infection.

● Ensure proper functioning of the colostomy.

Steps:

1. Perform hand hygiene and wear gloves.

2. Remove the old pouch carefully and dispose of it.
3. Clean the stoma and surrounding skin with warm water and mild soap.
4. Pat the area dry with a clean towel.
5. Assess the stoma for color, size, and any signs of irritation.
6. Apply a skin barrier around the stoma.
7. Attach a new colostomy pouch securely.
8. Dispose of used materials properly.

Tips:

● Empty the pouch when it is one-third full.

● Educate the patient on self-care techniques and dietary adjustments.
1. Pharmacokinetics

Definition:

The study of how drugs move through the body.

Processes:

1. Absorption:
○ Movement of a drug from its site of administration into the bloodstream.
○ Factors affecting absorption: route of administration, drug formulation,
blood flow, and gastrointestinal (GI) motility.
2. Distribution:
○ Transport of drugs throughout the body.
○ Factors: blood flow to tissues, protein binding, and drug solubility.
3. Metabolism (Biotransformation):
○ Chemical alteration of the drug, primarily in the liver.
○ Involves enzymes such as cytochrome P450.
○ First-pass effect: significant metabolism before reaching systemic
circulation.
4. Excretion:
○ Removal of drugs from the body.
○ Main organs: kidneys (urine), liver (bile), lungs (exhalation).

Tips:

● Understand drug half-life and its impact on dosing frequency.

● Monitor for organ impairment that affects metabolism or excretion.

2. Pharmacodynamics

Definition:

The study of the effects of drugs on the body.

Key Concepts:

1. Mechanism of Action (MOA): How the drug produces its effects.

○ Example: Agonists activate receptors, while antagonists block them.
2. Therapeutic Effects: Desired outcomes of drug therapy.
3. Adverse Effects: Unintended and potentially harmful effects.
4. Dose-Response Relationship: Relationship between drug dose and its effect.
5. Therapeutic Index (TI):
○ Ratio of toxic dose to therapeutic dose.
 ○ Narrow TI = greater need for monitoring (e.g., warfarin).

3. Medication Administration

Rights of Medication Administration:

1. Right patient
2. Right medication
3. Right dose
4. Right route
5. Right time
6. Right documentation
7. Right reason
8. Right response
9. Right to refuse

Steps:

1. Verify the doctor’s order.

2. Check for patient allergies.
3. Perform hand hygiene.
4. Double-check medication labels and expiration dates.
5. Administer the drug using the correct technique for the route.
6. Observe the patient for adverse reactions.

4. Intravenous (IV) Computation

Formula for Flow Rate (mL/hr):

● Flow rate = Total volume (mL) / Time (hr)

Formula for Drops per Minute (gtt/min):

● Flow rate = (Total volume × Drop factor) / Time (min)

Tips:

● Always double-check calculations.

● Use infusion pumps for accuracy.
● Monitor the IV site for complications (e.g., infiltration, phlebitis).

5. Thrombolytic Drugs
Definition:

● Drugs that dissolve blood clots.

Examples:

● Alteplase, reteplase, tenecteplase.

Indications:

● Acute myocardial infarction (MI)

● Pulmonary embolism
● Ischemic stroke

Nursing Considerations:

● Monitor for bleeding (e.g., gums, stool, urine).

● Avoid invasive procedures during therapy.
● Assess for contraindications (e.g., recent surgery, active bleeding).

6. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Definition:

● Drugs that reduce inflammation, pain, and fever.

Examples:

● Ibuprofen, naproxen, aspirin, celecoxib.

Adverse Effects:

● GI irritation and bleeding

● Kidney damage
● Increased risk of cardiovascular events

Nursing Considerations:

● Administer with food to reduce GI upset.

● Monitor for signs of bleeding.
● Educate patients to avoid alcohol and other NSAIDs.

7. Anti-Gout Medications

Definition:
 ● Drugs used to manage gout by reducing uric acid levels.

Examples:

● Allopurinol (prevents uric acid production)

● Colchicine (reduces inflammation)
● Probenecid (increases uric acid excretion)

Nursing Considerations:

● Encourage increased fluid intake.

● Monitor renal function.
● Avoid purine-rich foods (e.g., red meat, seafood).

8. Analgesics

Definition:

● Drugs that relieve pain.

Categories:

1. Non-Opioid Analgesics:
○ Examples: Acetaminophen, NSAIDs.
○ Used for mild to moderate pain.
2. Opioid Analgesics:
○ Examples: Morphine, fentanyl, hydrocodone.
○ Used for moderate to severe pain.
3. Adjuvant Analgesics:
○ Examples: Antidepressants, anticonvulsants.
○ Used in chronic pain or neuropathic pain.

Nursing Considerations:

● Assess pain level before and after administration.

● Monitor for side effects (e.g., respiratory depression with opioids).
● Educate patients on proper use and potential risks of addiction.
Health assessment is a comprehensive process performed by nurses to collect, analyze, and
interpret patient information to determine their health status and identify any actual or
potential health problems. It is a cornerstone of nursing practice and involves several
components:

1. Types of Health Assessments

● Comprehensive Health Assessment: A detailed and thorough evaluation, usually

performed during admission or at the first encounter. Includes history-taking and a
head-to-toe physical examination.
● Focused Assessment: Targeted evaluation of a specific issue or system, based on
the patient’s complaints or condition (e.g., assessing chest pain or abdominal
discomfort).
● Ongoing/Periodic Assessment: Regular evaluations to monitor changes or progress
in a patient’s condition.
● Emergency Assessment: Rapid assessment done in urgent or life-threatening
situations, focusing on critical systems.

2. Components of Health Assessment

A. Health History

● Biographical Data: Name, age, gender, occupation, and contact information.

● Chief Complaint (CC): The main reason for seeking care.
● History of Present Illness (HPI): Detailed account of the symptoms, including
onset, duration, location, quality, and intensity.
● Past Medical History (PMH): Information about previous illnesses, surgeries,
hospitalizations, and treatments.
● Family History: Genetic predispositions or familial illnesses.
● Social History: Lifestyle, habits (e.g., smoking, alcohol use), occupation, and living
conditions.
● Review of Systems (ROS): Systematic inquiry about symptoms related to all major
body systems.

B. Physical Examination

Uses the following techniques:

1. Inspection: Visual observation of the patient for signs of illness, injury, or

abnormalities.
2. Palpation: Using hands to feel for lumps, tenderness, or other physical
abnormalities.
3. Percussion: Tapping on body areas to detect fluid, air, or solid masses.
 4. Auscultation: Listening to sounds made by internal organs (e.g., heart, lungs, and
bowel) using a stethoscope.

C. Vital Signs

Measurement of key indicators of health:

● Temperature
● Pulse rate
● Respiratory rate
● Blood pressure
● Oxygen saturation
● Pain assessment (considered the "fifth vital sign").

D. Mental Status and Emotional Health

Evaluation of cognition, mood, behavior, and overall mental well-being.

E. Functional Assessment

Focuses on the patient’s ability to perform activities of daily living (ADLs) such as bathing,
dressing, eating, and mobility.

3. Tools and Frameworks Used in Health Assessment

● ABCDE Framework (Airway, Breathing, Circulation, Disability, Exposure): Used in

emergencies.
● SOAP Notes (Subjective, Objective, Assessment, Plan): For organizing patient
information.
● Gordon’s Functional Health Patterns: A systematic approach to assess various
aspects of health.
● Pain Assessment Tools: Numeric rating scales, visual analog scales, or Wong-Baker
Faces Pain Scale.

4. Importance of Health Assessment

● Identifies health problems and risk factors.

● Provides a baseline for care planning and interventions.
● Guides clinical decision-making and prioritization of care.
● Promotes patient education and engagement in their health.
Head-to-Toe Assessment Guide: Procedure, Normal, and Abnormal
Findings

1. Preparation

● Procedure:
○ Gather supplies, perform hand hygiene, and ensure privacy.
○ Confirm patient identity and ensure comfort.
○ Begin by observing the general appearance.

2. General Appearance

● Normal Findings: Patient is alert, oriented (AOx4), and appears well-groomed.

● Abnormal Findings: Confusion, distress, or poor hygiene.

3. Head and Face

● Procedure:
○ Inspect the scalp, face, and hair for abnormalities.
○ Palpate the cranium for tenderness or masses.
● Normal Findings: Symmetrical head and face, no lesions, and healthy hair.
● Abnormal Findings: Facial drooping (stroke), lice, alopecia, or scalp masses.

4. Eyes

● Procedure:
○ Check pupil reaction (PERRLA), sclera, and conjunctiva.
○ Test eye movement through six cardinal fields of gaze.
● Normal Findings: Pupils equal, round, and reactive to light; sclera white;
conjunctiva pink.
● Abnormal Findings: Yellow sclera (jaundice), unequal pupils (neurological issue), or
nystagmus.

5. Ears

● Procedure:
○ Inspect for redness or discharge and palpate for tenderness.
 ● Normal Findings: No redness, swelling, or discharge.
● Abnormal Findings: Ear pain, drainage, or hearing loss.

6. Nose

● Procedure:
○ Inspect for symmetry, discharge, and patency.
○ Palpate sinuses for tenderness.
● Normal Findings: Nose midline, no discharge, sinuses non-tender.
● Abnormal Findings: Nasal congestion, septal deviation, or drainage.

7. Mouth and Throat

● Procedure:
○ Inspect lips, gums, teeth, and throat.
○ Check tongue movement and gag reflex.
● Normal Findings: Lips pink, teeth intact, no swelling, and midline uvula.
● Abnormal Findings: Blue lips (cyanosis), broken teeth, thrush, or difficulty
swallowing.

8. Neck

● Procedure:
○ Inspect for symmetry and palpate lymph nodes and trachea.
○ Check range of motion and auscultate carotid arteries for bruits.
● Normal Findings: Trachea midline, no lymph enlargement, full range of motion.
● Abnormal Findings: Swollen lymph nodes, jugular vein distention (fluid overload).

9. Chest (Respiratory and Cardiovascular)

● Procedure:
○ Inspect breathing and chest shape.
○ Auscultate heart and lung sounds.
● Normal Findings: Breathing even, clear lung sounds, regular heart rate (S1 and S2).
● Abnormal Findings: Wheezing (asthma), crackles (fluid), or murmurs.

10. Abdomen
 ● Procedure:
○ Inspect, auscultate, and palpate.
○ Ask about bowel habits.
● Normal Findings: Soft, non-tender, active bowel sounds.
● Abnormal Findings: Absent bowel sounds, distention, or tenderness.

11. Upper Extremities

● Procedure:
○ Inspect for deformities, check pulses, and assess capillary refill.
○ Test strength and range of motion.
● Normal Findings: Symmetrical movements, strong pulses, cap refill < 2 seconds.
● Abnormal Findings: Weak pulses, swelling, or arm drift (stroke).

12. Lower Extremities

● Procedure:
○ Inspect for color, swelling, and ulcers.
○ Palpate pulses and check range of motion.
● Normal Findings: No swelling, strong pulses, normal range of motion.
● Abnormal Findings: Edema, weak pulses, or leg pain.

13. Skin

● Procedure:
○ Inspect for lesions, rashes, or pressure ulcers.
○ Palpate for temperature and moisture.
● Normal Findings: Skin intact, warm, and dry.
● Abnormal Findings: Redness, wounds, or cool skin (poor circulation).

14. Back and Spine

● Procedure:
○ Inspect for alignment and check skin over bony areas.
● Normal Findings: Spine straight, no skin breakdown.
● Abnormal Findings: Kyphosis, scoliosis, or pressure ulcers.
15. Documentation

● Always record findings accurately, noting any abnormalities for follow-up.

The IPPA assessment is a systematic approach used by healthcare providers to evaluate a

patient's condition. It stands for Inspection, Palpation, Percussion, and Auscultation and
is commonly used in physical exams. Here's a breakdown:

1. Inspection

● Procedure:
○ Use your eyes to observe the patient for any visible abnormalities.
○ Examine for skin color, symmetry, shape, movement, and overall appearance.
○ Begin as soon as you enter the room and continue throughout the
assessment.
● Normal Findings:
○ Symmetrical body structure, normal skin color for ethnicity, no visible
swelling or deformities.
● Abnormal Findings:
○ Cyanosis (blue skin), jaundice (yellow skin), asymmetry, swelling, or visible
deformities.

2. Palpation

● Procedure:
○ Use hands to feel the body, checking for texture, temperature, moisture,
tenderness, swelling, or masses.
○ Palpate lightly first, then proceed to deeper palpation as needed.
○ Be gentle and explain each step to the patient.
● Normal Findings:
○ Skin warm and dry, no tenderness or lumps, smooth texture.
● Abnormal Findings:
○ Cool or clammy skin, pain upon palpation, hard masses, or swelling.

3. Percussion

● Procedure:
 ○ Tap on the body using fingers or a percussion hammer to assess underlying
structures.
○ Listen for the sounds produced, which can indicate the type of tissue or fluid
beneath the surface.
○ Commonly used on the chest and abdomen.
● Normal Findings:
○ Resonance over lungs (normal air-filled spaces).
○ Tympany over the abdomen (air in intestines).
○ Dullness over solid organs like the liver.
● Abnormal Findings:
○ Hyperresonance (excess air, as in emphysema).
○ Flatness or dullness (fluid accumulation or masses).

4. Auscultation

● Procedure:
○ Use a stethoscope to listen to sounds made by internal organs, such as the
heart, lungs, and bowel.
○ Ensure the environment is quiet, and place the stethoscope firmly but gently
on the skin.
○ Use the diaphragm for high-pitched sounds (breath, bowel, and normal heart
sounds) and the bell for low-pitched sounds (murmurs, bruits).
● Normal Findings:
○ Clear breath sounds, regular heart rate and rhythm, active bowel sounds.
● Abnormal Findings:
○ Wheezing, crackles, or diminished breath sounds.
○ Irregular heart rhythm, murmurs, or bruits.
○ Absent or hyperactive bowel sounds.

Applications of IPPA in Specific Areas

● Respiratory: Inspect breathing, palpate for chest expansion, percuss for resonance,
auscultate for breath sounds.
● Cardiovascular: Inspect for jugular vein distention, palpate pulses, percuss for
heart borders (rare), auscultate heart sounds.
● Abdomen: Inspect for distention, auscultate bowel sounds (done before palpation
and percussion here to avoid altering sounds), percuss for tympany or dullness,
palpate for tenderness or masses.

Findings for Heart, Lungs, and Abdomen During Auscultation and

Percussion
1. Heart

Auscultation

● Normal Findings:
○ Heart Sounds: Clear S1 (lub) and S2 (dub) at the appropriate locations
(aortic, pulmonic, tricuspid, and mitral areas).
○ Rate and Rhythm: Regular rate, typically 60-100 beats per minute in adults.
○ No Extra Sounds: No murmurs, rubs, or gallops (S3 or S4).
● Abnormal Findings:
○ Murmurs: Caused by turbulent blood flow; graded from 1 (barely audible) to
6 (loud with a thrill).
■ Systolic murmur: Heard between S1 and S2 (e.g., aortic stenosis).
■ Diastolic murmur: Heard after S2 (e.g., mitral stenosis).
○ Gallops:
■ S3 (ventricular gallop): May indicate heart failure.
■ S4 (atrial gallop): Often associated with stiff ventricles, as in
hypertension.
○ Pericardial Rub: Scratchy sound, often linked to pericarditis.
○ Bruits: Low-pitched sound heard over carotid arteries, indicating arterial
narrowing.

Percussion

● Normal Findings:
○ Cardiac dullness: Dull sound over the left side of the chest where the heart
lies.
○ Lungs and heart borders are distinguishable.
● Abnormal Findings:
○ Enlarged dullness: May suggest cardiomegaly (enlarged heart).
○ No dullness where expected: Possible pneumothorax or displaced heart
borders.

2. Lungs

Auscultation

● Normal Findings:
○ Breath Sounds:
■ Vesicular: Soft and low-pitched, heard over most of the lung fields.
■ Bronchial: Louder and higher-pitched, heard over the trachea.
■ Bronchovesicular: Medium pitch, heard over main bronchi.
○ Symmetry: Breath sounds equal on both sides.
○ No adventitious sounds.
● Abnormal Findings:
 ○ Crackles (Rales): Popping sound, often associated with fluid in the alveoli
(e.g., pneumonia, pulmonary edema).
○ Wheezes: High-pitched whistling sound, indicating narrowed airways (e.g.,
asthma, COPD).
○ Rhonchi: Low-pitched, snore-like sound, associated with airway obstruction
(e.g., bronchitis).
○ Stridor: High-pitched sound over the upper airway, a sign of airway
obstruction.
○ Diminished/Absent Sounds: May indicate collapsed lung (atelectasis), fluid
accumulation (pleural effusion), or pneumothorax.

Percussion

● Normal Findings:
○ Resonance: Over air-filled lung tissue.
○ Flat/Dull: Over areas like the scapula or heart.
● Abnormal Findings:
○ Hyperresonance: Excess air (e.g., pneumothorax or emphysema).
○ Dullness: Fluid or solid tissue replacing air (e.g., pneumonia, pleural effusion,
tumor).

3. Abdomen

Auscultation

● Normal Findings:
○ Bowel Sounds: High-pitched, irregular gurgling every 5-30 seconds.
○ Vascular Sounds: Normally, no bruits are heard over major arteries (aortic,
renal, iliac, femoral).
● Abnormal Findings:
○ Absent Bowel Sounds: May indicate paralytic ileus or bowel obstruction
(listen for 5 minutes before confirming).
○ Hyperactive Bowel Sounds: High-pitched tinkling sounds, associated with
bowel obstruction or diarrhea.
○ Bruits: Swishing sound over arteries, indicating stenosis or aneurysm.

Percussion

● Normal Findings:
○ Tympany: Over gas-filled structures (e.g., stomach, intestines).
○ Dullness: Over solid organs (e.g., liver, spleen) or fluid-filled structures.
○ Liver Span: 6-12 cm of dullness in the mid-clavicular line.
○ Splenic Area: Tympany unless spleen is enlarged.
● Abnormal Findings:
○ Excess Tympany: Indicates excess gas (e.g., bowel obstruction).
○ Dullness Where Tympany Is Expected: Could indicate mass, fluid (ascites),
or organ enlargement (hepatomegaly, splenomegaly).
○ Shifting Dullness: Fluid in the abdomen (ascites).