Chapter 8.pptxChapter_008_Assessment_Techniques.pptx

Chapter 8
Assessment Techniques and
Safety in the Clinical Setting
Copyright © 2020 by Elsevier Inc. All rights reserved.

 Physical examination requires use of technical
skills through senses (sight, smell, touch, or
hearing) to obtain data.
 Requisite skills performed one at a time typically
in this order
 Inspection
 Palpation
 Percussion
 Auscultation
Cultivating Your Senses

 Inspection is concentrated watching.
 Close, careful scrutiny, first of individual as a whole and then of each
body system.
 you may feel embarrassed
 Begins when you first meet person with a general survey
 As you proceed through examination, start assessment of each
body system with inspection.
 Inspection always comes first.
 Inspection requires
 good lighting.
 adequate exposure.
 occasional use of instruments, including otoscope, ophthalmoscope,
penlight, or nasal and vaginal specula, to enlarge your view.
Inspection

 Palpation applies sense of touch to assess the following:
 Texture, temperature and moisture
 Organ location and size
 Swelling, vibration, pulsation or crepitation
 Rigidity or spasticity
 Presence of lumps or masses
 Presence of tenderness or pain
 Should be performed slow and systematic
 Start with light and proceed to deep.
 Bimanual palpation is used for certain body parts or organs.
Palpation

 Different parts of hands are best suited for
assessing different factors:
 Fingertips: best for fine tactile discrimination of skin
texture, swelling, pulsation, determining presence of
lumps
 Fingers and thumb: detection of position, shape, and
consistency of an organ or mass
 Dorsa of hands and fingers: best for determining
temperature because skin here is thinner than on
palms
 Base of fingers or ulnar surface of hand: best for
vibration
Palpation Techniques

 Tapping person’s skin with short, sharp strokes to assess
underlying structures
 Percussion has following uses:
 Mapping location and size of organs
 Signaling density (air, fluid, or solid) of a structure by a
characteristic note
 Detecting a superficial abnormal mass
• Percussion vibrations penetrate about 5 cm deep.
• Deeper mass would give no change in percussion.
 Eliciting pain if underlying structure is inflamed
 Eliciting deep tendon reflex using percussion hammer
 Technique should be practiced to achieve competence.
 Stationary hand: Pleximeter—middle finger hyperextension
 Striking hand: Plexor—striking finger
Percussion

Percussion Methods (1 of 2)
 The Stationary Hand
 Hyperextend the
middle finger (the
pleximeter).
 Place distal joint and
tip firmly against the
person’s skin.
 Only distal joint and tip
of middle finger should
be touching the
person’s skin.

Percussion Methods (2 of 2)
 The striking hand
 Use the middle finger
of your dominant hand
(the plexor).
 Hold forearm to skin
surface making
muscles steady but not
rigid.
 Flex striking finger so
tip makes contact.

 Characteristics of sounds
 Amplitude (intensity)—loud or soft sound
 Pitch (frequency)—number of vibrations per second
 Quality (timbre)—subjective difference
 Duration—length of time sound lingers
 Basic principles
 Structure with more air produces louder, deeper
sound compared with denser structure.
 Variations occur in clinical practice based on
individual anatomical differences.
 Percuss 2 times in each location using even, staccato
blows
Production of Sounds

Auscultation
 Listening to sounds
produced by body
 Stethoscope does not
magnify sound, but it
blocks out extraneous
sounds.
 Fit and quality of the
stethoscope is important.
• Diaphragm—flat edge,
high pitched sounds
• Bell—deep, hollow cuplike
shape, soft pitched sounds
• Turnable diaphragms—
allows you to listen to both
high pitched and soft
pitched sounds
https://www.youtube.com/
watch?v=v1Z7I7guG08

 Eliminate extra noise.
 Keep environment warm and warm your
stethoscope.
 Avoid listening over hairy body areas.
 Never listen through a patient’s gown or clothing.
 Avoid your own artifact.
Auscultation: Basic Principles

 Standard equipment needed for a screening
physical examination
 Be prepared to have all necessary equipment in place
before starting examination.
 Perform hand hygiene.
 Protective equipment including but not limited to
gloves
 Measurement of vital signs requires platform scale
(with height attachment), stethoscope,
sphygmomanometer, and thermometer. Pulse
oximetry reading can be included.
Standard Equipment

 Other equipment needed for a screening
physical examination
 Otoscope, ophthalmoscope, penlight, and pocket
vision screener
 Skinfold calipers, skin marking pen, and tuning fork
 Nasal speculum, tongue depressor, and cotton balls
 Flexible tape measure and ruler, sharp object, reflex
hammer
 vaginal speculum, lubricant, and fecal occult blood
materials
Other Equipment

 Components based on preventing spread of
transmission from body sources
 Hand hygiene
• Key factor in decreasing spread of infection
• Before and after patient care
• Protocols for visibly or not visibly soiled
 Use of protective equipment
• Gloves, gown, mask, eye protection, or face shield
 Respiratory hygiene/cough etiquette
• Education, posted signs, and source control measures
Standard Precautions for Use with All
Patients

Question 1
The nurse is preparing to do a physical assessment
on a patient who is end-stage HIV positive. What
should the nurse do for self-protection?
1. Wash hands and don gloves, gown, and protective
face shield.
2. Don gloves and wash hands after examination; no
other protective equipment is necessary.
3. Wash hands and don two pairs of gloves and gown.
4. Wash hands, don gloves, and wash hands after
examination; no other protective equipment is
necessary.

Answer to Question 1
 The correct answer is 4. The nurse should
always wash hands prior to the examination. This
patient should be treated with “standard
precautions.” Gloves are necessary with all
patients, regardless of HIV status
 Option 1 is incorrect because a gown and face
shield are not necessary for use with patients
who have HIV.
 Option 2 is incorrect because hands should be
washed prior to physical examination.
 Option 3 is incorrect because double-gloving is
not necessary.

The Clinical Setting:
General Approach
 Consider your emotional state and that of the
person being examined.
 The patient is usually anxious due to the
anticipation of being examined by a stranger and
the unknown outcome of the examination.
 If anxiety can be reduced, the person will feel
more comfortable and data gathered will more
closely describe the person’s natural state.

The Clinical Setting: Hands On
 Measurement and vital signs
 Have patient change into examination gown.
 Maintain privacy and respect.
 Perform hand hygiene.
 Provide explanations.
 Begin with person’s hands as point of initial contact.
 Concentrate on one step at a time—avoid distractions.
 Examination sequence—offer health teaching
 Provide explanations.
 Summarize findings for person.

Developmental Competence
 Order of the developmental stage is more
meaningful than the chronologic age.
 Position, preparation, and sequence will vary
across the life cycle.
 Infants and toddlers
 Preschool, school-age child. and adolescent
 Aging adult
 Increase comfort with a positive memory of
health care providers.

Examination of the Person
Who Is Sick
 The ill person
 You may need to alter position during examination.
 Adapt assessment to patient’s comfort level.
 May be necessary just to examine body areas
appropriate to problem, collecting a mini database.
 You may return to finish a complete assessment
after initial distress has been resolved.

Chapter 8.pptxChapter_008_Assessment_Techniques.pptx

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