Chapter 3—Physical Examination Techniques and Equipment

Chapter 3—Physical Examination Techniques and Equipment

Four Physical Assessment Techniques
Inspection: observing patient visually for general appearance or specific details Palpation: clinical touching of specific body areas to assess characteristics Percussion: tapping technique with hands to determine condition of solid or air-filled body areas Auscultation: using a stethoscope to assessment movement of air or fluid within specific body systems

Precautions to Prevent Infection
Diligent hand hygiene Most important transmission prevention strategy Five sequential steps for patient-to-patient pathogen transmission WHO recommended implementation Glove use When to wear gloves When to change gloves Glove removal

Precautions to Prevent Infection—(cont.)
Standard precautions Purpose: prevent disease transmission during contact with nonintact skin, mucous membranes, body substances, and bloodborne contacts Respiratory hygiene/cough etiquette strategies Latex allergy Prevention: avoid contact whenever possible Skin reactions Minimize hand eczema via alcohol-based hand rubs

Inspection Purpose: provides objective physical data leading to accurate diagnoses and treatment Consciously observing patients, gathering data Only technique used for every body part, system Overall observation = general survey Adequate exposure of each body part is necessary, maintaining modesty is very important. Devices may limit visibility: Adjust device to facilitate complete inspection. Accurate documentation of findings are important for communication; are legally binding Note if data is consistent; identify patterns or clusters.

Inspection—(cont.) Characteristics for inspection
Physical characteristics; odors Behaviors Age; gender Level of alertness Body size, shape Skin color Hygiene Posture Level of comfort/anxiety

Palpation Purpose: patient physical assessment using touch for various characteristics of skin, other organs Texture; temperature; moisture; size; shape Location; position; vibration; crepitus; tenderness Pain; edema Finger pads: fine discrimination Pulses, small lumps; skin texture, edema Finger palmar surfaces, finger joints Firmness, contour, position, size, pain, tenderness

Palpation Hand Palm: abdominal assessment
Dorsal surface of hand: temperature Light palpation (1 cm): begin with Appropriate for surface characteristics Moderate (1 to 2 cm) to deep palpation (2 to 4 cm) Assess abdominal organ characteristics. Use pressure from both hands, palmar surface of fingers.

Percussion Purpose: produce sound or elicit tenderness
Conducted sounds via Dense tissue: quiet tones Quietest over bones Air, fluid: louder tones Loudest over lungs, hollow stomach Direct percussion: Tap fingers directly on skin. Indirect percussion: Use nondominant hand as barrier on which to strongly tap.

Percussion—(cont.) Percussion tones Flat; dull Resonant; tympanic
Percussion sounds Intensity or loudness: volume of sound Pitch or frequency: vibration oscillation speed Duration: length of time sound lasts Quality: subjective description of sound

Auscultation Purpose: listening for body sounds, typically from organs and tissues, to assess function Common foci Blood pressure; lungs Heart; abdomen Descriptors Intensity; pitch Duration; quality Crackles

Auscultation—(cont.) Stethoscope Conducts (does not amplify) sound
Blocks environmental noise Parts Ear tips Differing sizes, firmness Earpiece: tilted slightly forward Flexible tubing: 21 to 27 in. Chest piece: diaphragm, bell (some varieties)

Advanced Techniques, Special Equipment
Ophthalmoscope Visualizes interior eye structures Visual acuity chart Otoscope Enables visualization of ear canal, tympanic membrane Tuning fork Conductive versus sensorineural hearing loss Neuromuscular vibration sense

Advanced Techniques, Special Equipment—(cont.)
Reflex hammer Neurological responses of deep tendons Vaginal speculum Goniometer Skinfold calipers

Equipment for a Complete Physical Assessment
Gather all equipment. Appropriate equipment depends on the type of examination. General assessment: hospital setting Vital signs equipment Thermometer; alcohol; blood pressure cuff or machine; watch with second hand; stethoscope Scale; flashlight Materials for recording findings

Documenting Findings Inspection Visualization of general appearance
Palpation Assessing condition via sense of touch Percussion Tapping to assess condition of hollow or fluid-filled spaces Auscultation Listening to assess organ and tissue condition

Question Palpation is the assessment of the patient through touch. What is light palpation appropriate for? A. Assessment of the size, shape, and consistency of abdominal organs B. Assessment of any guarding, grimacing, or tension C. Assessment of inflamed areas of skin D. Assessment of 2 to 4 cm below body surface

Answer Rationale: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site).

NCLEX-Style Review Questions
Which of the following interventions is most important to prevent nosocomial infections? Proper glove use Hand hygiene Appropriate draping Quiet environment

Rationale: Hand hygiene is the single most important intervention to prevent the spread of infection. Either handwashing or using hand gel between patients is acceptable.

Standard precautions are used on every patient because it is not always known whether a patient is infected. state that hand gel is used for infection with Clostridium difficile. include the use of gowns, gloves, and masks with all patients. recognize that transmission-based precautions are common.

Rationale: Standard precautions are used with every patient to prevent exposure to potential viruses, bacteria, or fungi. Hand gel is ineffective against Clostridium difficile. Gowns, gloves, and masks are used only when there is potential contact with body secretions. Transmission-based precautions, including droplet, airborne, or contact precautions, are used with select groups of patients who have identified infections.

Latex allergies always result in anaphylactic reactions and shock. can be reduced by moisturizing the hands after washing. cannot be caused by equipment such as a stethoscope. are more common in nurses and in frequently hospitalized patients.

Rationale: Latex allergies are more common in nurses and frequently hospitalized patients. They may result in anaphylactic or less severe reactions (e.g., difficulty breathing, itching, hives). The only way to avoid latex reactions is to avoid exposure to latex, which may be present in some stethoscopes, equipment, and stoppers of some medication vials.

Which of the following is an appropriate use of gloves? Gloves are worn during anticipated contact with intact skin. Gloves are removed when going from clean to contaminated areas. Gloves are worn during anticipated contact with body secretions. Gloves are removed when assessing the back of an incontinent patient.

Rationale: Health care providers should wear gloves to prevent exposure when they are at risk of coming into contact with body secretions of patients. They protect patients by preventing nurses from transmitting infections from contaminated to cleaner areas. Generally, the area around the bed or examination table is considered most contaminated, whereas supply cupboards and computers are considered clean. Gloves should never be worn from the room into the hall.

Which of the following is an example of inspection? Heart rate and rhythm regular Lungs clear Abdomen tympanic Skin pink

Rationale: Inspection involves visual information.

The patient is complaining of abdominal pain. What technique is used to form an overall impression? Auscultation Light palpation Direct percussion Deep palpation

Rationale: An overall impression of the abdomen is gained by lightly palpating for tenderness and firmness. Auscultation provides information about gastrointestinal motility. Percussion provides information about an air-filled versus a solid or fluid-filled cavity. Deep palpation is used to identify the location of organs, masses, or tumors.

Tympany is a percussion sound commonly located in the thorax. upper arm. abdomen. lower leg.

Rationale: Percussion sounds are hyperresonant (diseased lungs), resonant (normal lungs), tympanic (abdomen), dull (over organs), and flat (over bone).

Which organs or body areas does the nurse auscultate as part of the admitting assessment? Heart, lungs, and abdomen Kidneys, bladder, and ureters Abdomen, flank, and groin Neck, jaw, and clavicle

Rationale: The nurse auscultates heart, breath, and abdominal sounds as part of the complete assessment. All these involve movement, which generates sounds.

What technique facilitates accurate auscultation? Earpieces of the stethoscope are positioned to point toward the back. The tubing of the stethoscope is long and dark in color. The chestpiece of the stethoscope is sealed against the skin. The diaphragm of the stethoscope is used for low- frequency sounds.

Rationale: Earpieces always point toward the front, following the same position as the nose. Tubing should be short and thick to optimize sound transmission. The chestpiece should be completely on the patient's skin to diminish transmission of room noise and to optimize sounds from the patient. The diaphragm is used for high- frequency sounds (e.g., bowel sounds); the bell is used for low-frequency sounds.

When assessing the child, the nurse makes the following adaptation to the usual techniques: A pediatric stethoscope is used for better contact. The child is seated away from the parent. The room is full of toys for play. The child is undressed, including the diaper.

Rationale: A pediatric stethoscope is smaller than the adult size, allowing for the full diaphragm to be sealed on the patient's skin. The parent may wish to hold the child for security and comfort. If the room is full of toys, the child may prefer to play and be hesitant to be examined. The child is kept covered as much as possible to avoid chilling; when clothes are removed, the diaper usually partly covers the genitals to prevent the child from involuntarily urinating on the examiner.

Chapter 3—Physical Examination Techniques and Equipment

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Chapter 3—Physical Examination Techniques and Equipment

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