Copyright 2002, Delmar, A division of Thomson Learning Chapter 8 Physical Assessment Techniques

Copyright 2002, Delmar, A division of Thomson Learning Competencies Describe how to maintain standard precautions during physical assessment. Describe how to perform inspection, palpation, percussion, auscultation, and which areas of the body are assessed with each technique. (continues)

Copyright 2002, Delmar, A division of Thomson Learning Competencies Establish an environment suitable for conducting a physical assessment. Demonstrate inspection, palpation, percussion, and auscultation in the clinical setting.

Copyright 2002, Delmar, A division of Thomson Learning Aspects of Physical Assessment Purposes of physical assessment  Screening of general well-being  Validation of complaints that caused the patient to seek health care  Monitoring of current health problems  Formulation of diagnoses and treatments

Copyright 2002, Delmar, A division of Thomson Learning Role of the Nurse Comprehensive physical assessment vs. Focused physical assessment Utilize standard precautions during assessment Legal issues  Accurate, complete documentation  Ensure patient is properly informed of assessment procedures

Copyright 2002, Delmar, A division of Thomson Learning Assessment Techniques Inspection (I) Palpation (P) Percussion (P) Auscultation (A) Usually follow order IPPA, except for the abdomen (IAPP)

Copyright 2002, Delmar, A division of Thomson Learning Inspection Use of one’s senses of vision and smell to consciously observe the patient Careful observation

Copyright 2002, Delmar, A division of Thomson Learning (continues) Palpation Act of touching the patient in a therapeutic manner Light palpation  Superficial, delicate, gentle  Uses finger pads  Depress 1 cm below surface  Provides information on skin texture, moisture, masses, fluid, muscle guarding, and tenderness

Copyright 2002, Delmar, A division of Thomson Learning Palpation Deep palpation Provide information about the position of organs, masses, their size, shape, mobility and consistency Uses hands Depress 4 to 5 cm below skin surface Most commonly used for assessing abdominal and reproductive structures (continues)

Copyright 2002, Delmar, A division of Thomson Learning Palpation Tips  Warm hands  Short nails  Inform patient of when, where, and how the touch will occur

Copyright 2002, Delmar, A division of Thomson Learning Percussion Striking one object against another to cause vibrations that produce sound Analyze sounds by intensity, duration, pitch Any part of the body can be percussed Most commonly used for abdomen and thorax

Copyright 2002, Delmar, A division of Thomson Learning Quality of Sounds Flatness Dullness Resonance Hyperresonance Tympany

Copyright 2002, Delmar, A division of Thomson Learning Percussion Techniques  Immediate  Mediate or indirect  Direct fist  Indirect fist

Copyright 2002, Delmar, A division of Thomson Learning Auscultation Act of active listening to body organs Listening to voluntary and involuntary sounds Quiet environment is needed to perform Analyze sounds in relation to intensity, pitch, duration, quality, and location

Copyright 2002, Delmar, A division of Thomson Learning Types of Auscultation Direct or immediate  Listening with the unaided ear Indirect or mediate  Listening with an amplication device  Examples: stethoscope, doppler

Copyright 2002, Delmar, A division of Thomson Learning Commonly Used Equipment Pen and paper Tape measure Clean gloves Penlight Scale Thermometer Sphygmomanometer (continues)

Copyright 2002, Delmar, A division of Thomson Learning Commonly Used Equipment Stethoscope Otoscope Opthalmoscope Visual acuity charts Tuning fork Reflex hammer Lubricant

Copyright 2002, Delmar, A division of Thomson Learning Preparing for a Physical Assessment Clean, professional dress Proper identification Introduce self Well-lit, warm, private, quiet room Short fingernails Warm hands and equipment Prevent hair or jewelry from interfering with the exam Explain exam (continues)

Copyright 2002, Delmar, A division of Thomson Learning Preparing for a Physical Assessment Dress patient in gown, drape, and underpants Have patient void prior to assessment Wash hands Adhere to standard precautions (continues)

Copyright 2002, Delmar, A division of Thomson Learning Preparing for a Physical Assessment Position patient as needed Avoid negative or crude remarks Be cognizant of facial expressions Perform exam in head-to-toe or other systematic manner Thank the patient when exam is concluded Thoroughly document findings

Copyright 2002, Delmar, A division of Thomson Learning (continues) Positioning for Physical Exam Fowler’s  Used to assess skin, head, neck, eyes, ears, nose, mouth, throat, thorax, lungs, heart, peripheral vasculature, neurological system Horizontal recumbent  Used to assess breasts, heart, peripheral vasculature, abdomen, musculoskeletal system

Copyright 2002, Delmar, A division of Thomson Learning Positioning for Physical Exam Dorsal recumbent  Used to assess female genitalia Lithotomy  Used to assess female genitalia Knee-chest  Used to assess rectum and prostate Sims  Used to assess rectum and female genitalia

Copyright 2002, Delmar, A division of Thomson Learning Golden Rules for Physical Assessment Stand on the right side of the patient to establish a dominant side for assessment Use a head-to-toe approach Compare right to left sides of the body for symmetry Least invasive to most invasive Systematic approach