Faculty of Nursing-IUG Chapter (4) Physical Assessment Techniques

2 Indications for the Physical Exam Routine screening Routine screening Eligibility prerequisite for health insurance, military service, job, sports, school Eligibility prerequisite for health insurance, military service, job, sports, school Admission to a hospital or long term care facility Admission to a hospital or long term care facility

3 STEPS OF ASSESSMENT Think Think Organize Organize Don’t forget…Nutrition / Height & Weight Don’t forget…Nutrition / Height & Weight Environment: Environment: Accommodate special needs (cultural sensitivity) Accommodate special needs (cultural sensitivity) Equipment - clean surface & clean equipment Room - quiet, warm & well lit Equipment - clean surface & clean equipment Room - quiet, warm & well lit Maintain privacy Maintain privacy Observe & Listen Observe & Listen

4 DON’T FORGET REVIEWING GENERAL INFORMATION REVIEWING GENERAL INFORMATION INTRODUCTION TO CLIENT INTRODUCTION TO CLIENT OBTAINING THE HEALTH HISTORY OBTAINING THE HEALTH HISTORY PAIN ASSESSMENT PAIN ASSESSMENT THIS IS KEY TO HOLISTIC APPROACH THIS IS KEY TO HOLISTIC APPROACH

Physical Assessment There are four techniques to use in performing physical assessment: 1.Inspection 2. Palpation 3. Percussion 4. Auscultation Note: there are five addition skill known as olfaction 5

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1. Inspection: Inspection is defined as “the use of the senses of vision, smell and hearing to observe the normal condition or any deviations from normal of various body parts.” The nurse inspects or looks body parts to detect normal characteristics or significant physical sings. Inspection helps to know normal characteristics before trying to distinguish abnormal findings in different ages. The quality of an inspection depends on the nurse's willingness to spend time doing a thorough job. 7

8 Inspection Use vision, hearing & smell Use vision, hearing & smell Always first Always first Look for symmetry Look for symmetry Use good lighting Use good lighting Use good exposure Use good exposure

9 Principles of Accurate Inspection Good lightening either day light or artificial light is suitable. Good lightening either day light or artificial light is suitable. Expose body parts being observed only. Expose body parts being observed only. look before touching. look before touching. warm room for examination of the client “not cold not hot". warm room for examination of the client “not cold not hot". Observe for color, size, location, texture, symmetry, odors, and sounds. Observe for color, size, location, texture, symmetry, odors, and sounds. Compare each area inspected with the opposite side of body if possible. Compare each area inspected with the opposite side of body if possible. Use pen light to inspect body cavities. Use pen light to inspect body cavities.

Palpation Touch & feel with hands to determine: Touch & feel with hands to determine:  Texture – use fingertips  Texture – use fingertips (roughness, smoothness).  Temperature – use back of hand  Temperature – use back of hand (warm, hot, cold).  Moisture  Moisture (dry, wet, or moist).  Organ location and size  Consistency of structure  Consistency of structure (solid, fluid, filled ) Slow and systematic Slow and systematic Light to deep Light to deep Light palpation (tenderness) Light palpation (tenderness) Deep palpation (abdominal organs/masses) Deep palpation (abdominal organs/masses)

11 Principles for Accurate Palpation Examiner finger nails should be short. Examiner finger nails should be short. Use sensitive part of the hand. Use sensitive part of the hand. Light Palpation precedes deep palpation. Light Palpation precedes deep palpation. Start with light then deep palpation Start with light then deep palpation Tender area are palpated last Tender area are palpated last Tell client to take slow deep breath to enhance muscle relaxation. Tell client to take slow deep breath to enhance muscle relaxation. Examine condition of the abdominal organs Examine condition of the abdominal organs Depressed areas must be approximately “2cm” Depressed areas must be approximately “2cm” Assess turger of skin measured by lightly grasping the body part with finger tips. Assess turger of skin measured by lightly grasping the body part with finger tips.

12 Light palpation

13 Deep palpation

Percussion Tap a portion of the body to elicit tenderness that varies with the density of underlying structures. Percussion denotes location, size and density of underlying structures, percussion requires dexterity. Methods of percussion: Direct method: Direct method: involving striking the body surface directly with one or two fingers. Indirect method: Indirect method: performed by placing the middle finger of the examiner’s non dominant hand “pleximeter hand” firmly against the body surface with palm and fingers remaining off the skin, and the tip of the middle finger of the dominant hand “plexor” strikes the base of the distal joint of the pleximeter. Use a quick & sharp stroke

15 Percussion

Description of sounds Sound produced by the body is characterized by intensity, frequency, duration and quality. Intensity, or loudness, associated with physiologic sound is low; thus, the use of the stethoscope is needed. Frequency, or pitch, of physiologic sound is in reality “noise” in that most sounds consist of a frequency spectrum as opposed to the single-frequency sounds that we associate with music or the tuning fork. Duration relates to the time elapsed from the beginning of the sound till the end of the sound. Quality of sound relates to overtones that allow one to distinguish between different sounds. 16

17 SoundIntensityPitchDurationQualityExample TympanyLoudHighModerateDrum like Large pneumothorax Resonance Moderate to loud LowLonghollowNormal lung Hyper- resonance Very loud Very low Longer than resonance Booming Emphysematous lung Dullness Soft to moderate HighModerateThud likeLiver FlatnessSoftHighShortFlatMuscle Sounds produced by percussion

Five percussion sounds produced in different body regions 1. Resonant – normal lung 2. Hyper resonant: it’s a louder and lower pitched than resonant sounds. Normally heard in children and very thin adults, and abnormally in emphysema 3. Tympany : A hollow drum-like sound produced when a gas-containing cavity is tapped sharply. Tympany is heard if the chest contains free air (pneumothorax) air filled (stomach) 3. Tympany : A hollow drum-like sound produced when a gas-containing cavity is tapped sharply. Tympany is heard if the chest contains free air (pneumothorax) or the abdomen is distended with gas air filled (stomach) 4. Dull or thud like sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors 5. Flat: shown in no air areas such as thigh muscle, bone and tumor

Auscultation “To listen for various breath, heart, and bowel sounds” Direct or immediate Direct or immediate auscultation is accomplished by the unassisted ear that is without amplifying device. This form of auscultation often involves the application of the ear directly to a body surface where the sound is most prominent. Mediate auscultation: the use of sound augmentation device such as a stethoscope in the detection of body sounds.

20 Auscultation Listening to body sounds Listening to body sounds Movement of air (lungs) Movement of air (lungs) Blood flow (heart) Blood flow (heart) Fluid & gas movement (bowels) Fluid & gas movement (bowels) Remember the sound changes in the abdomen… Remember the sound changes in the abdomen…

21 HOW TO BEGIN… Positions for physical exam Positions for physical exam Using a stethoscope: Using a stethoscope: Longer the tube – more sound has to travel Longer the tube – more sound has to travel Hold diaphragm firmly against client’s skin (NOT THROUGH CLOTHING) Hold diaphragm firmly against client’s skin (NOT THROUGH CLOTHING) If using bell – less pressure If using bell – less pressure Warm in your hands first! Warm in your hands first! Listen / Concentrate on the sounds Listen / Concentrate on the sounds

22 Olfaction Another skill that used during assessment, certain alteration is body function create characteristic body odors, smelling can detect abnormalities that unrecognized by other means. Assessment of characteristic odors: Alcohol odor from oral cavity means ingestion of alcohol. Ammonia from urine means urinary tract infection. Body odor from skin, particularly in areas where body parts rub together means poor hygiene, excess perspiration (bromidrosis).

Feces odor from wound site means wound abscess, but if this odor from vomitus this means bowel obstruction, and if the odor from rectal area this means fecal incontinence. Foul–smelling stools in infant from stool means mal absorption syndrome. Halitosis from oral cavity means poor dental and oral hygiene, gum disease. Sweet, fruity ketones from oral cavity may be from diabetic acidosis. Musty odor from casted body part means infection inside cast. Fetid odor from tracheostomy or mucous secretions means infection of bronchial tree (pseudomonas bacteria).

Basic Guidelines for physical Assessment 1. Obtain a nursing history and survey 2. Maintain privacy. 3. Explain the procedure 4. Always inspect, palpate, percuss, and then auscultate except abdominal start with auscultate 5. Compare symmetrical sides 6. If abnormality (Symptom analysis ) 7. Client teaching 8. Allow time for client’s questions. Remember "Remember: the most important guideline for adequate physical assessment is conscious, continuous practice of physical assessment skills".

Variation in physical assessment of the pediatric client. Sequence of physical assessment is dependent upon the developmental level of the client. Allowing time for interaction with the child prior to beginning the examination helps to reduce fears. In certain age groups, portions of assessment will require physical restraint of the client with the help of another adult.

Distraction and play should be intermingled throughout the examination to assist in maintaining rapport with the pediatric client. Involving assistance from the child’s significant caregiver may facilitate a more meaningful examination of the younger client. The examiner should be prepared to alter the order of the assessment and approach to the child based on the child’s response. Protest or an uncooperative attitude toward the examiner is a normal finding in children from birth to early adolescence, throughout parts or even all the assessment process.

Variations for physical assessment of the geriatric client. Remember: normal variation related to aging may be observed in all parts of the physical examination. Dividing the physical assessment into parts in order to avoid fatigue in the older client. Provide room with comfortable temperature and no drafts. Allow sufficient time for client to respond to directions. If possible assess the elderly clients in a setting where they have an opportunity to perform normal activities of daily living in order to determine the client’s optimum potential.