Fenske_4e_ch07_Physical Assessment Techniques and Equipment.pptxafafssf

Health & Physical Assessment in
Nursing
Fourth Edition
Chapter 7
Physical Assessment
Techniques and
Equipment
Copyright © 2020, 2016, 2012 Pearson Education, Inc. All Rights Reserved

Learning Outcomes (1 of 2)
7.1 Differentiate between the four basic techniques
used by a professional nurse when performing physical
assessment.
7.2 Compare and contrast the purpose of equipment
required to perform a complete physical assessment.

Learning Outcomes (2 of 2)
7.3 Discuss professional responsibilities related to
critical thinking, patient safety and comfort, and
principles of standard precautions in nursing practice.

Introduction
• Physical assessment requires hands-on examination
of the patient and is an integral part of health
assessment process in order to provide safe, effective,
high-quality care (Douglas et al., 2016; Douglas,
Windsor, and Lewis, 2015).
• Together, the subjective and objective data provide
essential information for the nurse to use when
making decisions and caring for the patient.

Basic Techniques of Physical
Assessment (1 of 33)
• The nurse will use the four basic or cardinal
techniques to obtain objective and measurable data
during a physical assessment.
• It is important to note that these techniques are
performed in a particular order; inspection, palpation,
percussion, and auscultation, with the exception of
the abdominal assessment.
• Because percussion and palpation could alter the
natural sounds of the abdomen, it is important to
auscultate before performing palpation and
percussion.

Inspection
• The skill of observing the patient in a deliberate,
systematic manner begins when the nurse meets the
patient and continues until the end of the patient–
nurse interaction.
• It is important to complete inspection of the patient
before using any of the other techniques unless the
patient is a child, the nurse may need to vary the
approach to secure the child’s attention and
cooperation.

Inspection
• Inspection begins with a survey of the patient’s
appearance and a comparison of the right and left
sides of the patient’s body, which should be nearly
symmetric.

Inspection
• Assessment of each body system includes inspection
for:
– Color
– Shape
– Contour
– Symmetry
– Movement
– Drainage

Inspection
• When inspecting a large body region, the nurse
should proceed from general overview to specific
detail.
• Throughout inspection, the nurse applies the skills of
critical thinking to analyze the observations and
determine the significance of the findings to the
general health of the patient.
• Most of the inspection can be done without the help
of special instruments.

Palpation
• Palpation is the skill of assessing the patient through
the sense of touch to determine specific
characteristics of the body.

Palpation
• Characteristics obtained through palpation include:
– Size
– Shape
– Location
– Mobility of a part
– Position
– Vibrations

Palpation
• Characteristics obtained through palpation include:
– Temperature
– Texture
– Moisture
– Tenderness
– Edema

Palpation
• The nurses hand must be gentle, move slowly and
intentionally, and apply the correct amount of
pressure to use with the examining hand during
palpation.
• The hand has several sensitive areas; therefore, it is
important to use the part of the hand most
responsive to body structures and functions.

Palpation
• Parts of the hands used in palpation include:
– Finger tips
– Finger pads
– Base of the fingers
– Palmar surfaces of the fingers
– Dorsal and ulnar surfaces of the hands

Figure 7.2 Sensitive Areas of the
Hand

Palpation
• The finger pads are used for discrimination of
underlying structures and functions such as pulses,
superficial lymph nodes, or crepitus.
• Vibrations are best perceived by the examiner when
using the base of the fingers (metacarpophalangeal
joints).
• The ulnar surface of the hand, including the finger, is
most sensitive to vibrations such as fremitus.

Palpation
• The palmar aspect of the fingers is used to determine
position, consistency, texture, size of structures, pain,
and tenderness.
• The dorsal surface of the fingers is most sensitive to
temperature.
• The dominant hand is always more sensitive than the
nondominant hand.

Light Palpation
• The safest, least uncomfortable method and allows
the patient to become accustomed to the nurse’s
touch.
• Light palpation is used to assess surface
characteristics, such as skin texture, pulse, or a tender,
inflamed area near the surface of the skin.

Light Palpation
• For light palpation, the finger pads of the dominant
hand are placed on the surface of the area to be
examined. The hand is moved slowly, and the finger
pads, at a depth of 1 cm (0.39 in.), form circles on the
skin during assessment.

Figure 7.3 Light Palpation

Deep Palpation
• Deep palpation is used to palpate the abdomen and
organs that lie deep within a body cavity or or when
overlying musculature is thick, tense, or rigid, such as
in obesity or with abdominal guarding.
• Deep palpation is performed at a depth of 2 cm to 4
cm (approximately 0.75 in. to 1.5 in).

Deep Palpation
• When performing deep palpation, more than
moderate pressure is used by placing the palmar
surface of the fingers of the dominant hand on the
skin surface.
• Two-handed deep palpation may also be performed.
Performing palpation with the two-handed approach
provides extra support and pressure and allows the
nurse to palpate at a deeper level.

Figure 7.4 Deep Palpation

Deep Palpation
• Deep palpation is contraindicated if one suspects that
the rigidity is caused by inflammation or alterations in
underlying organs and structures due to conditions
such as dissecting aneurysms, peritonitis, or ectopic
pregnancy.

• Additional considerations when performing palpation
include:
– Explain the procedure.
– Help the patient relax and promote comfort by
keeping the patient warm, fingernails short, avoiding
wearing jewelry.
– Nonsterile gloves should be used if open skin areas
or drainage were noted during inspection.

• Additional considerations when performing palpation
include:
– Proceed slowly, using smooth, deliberate movements
and avoiding abrupt changes.
– Talk to the patient during the examination, explaining
each movement in advance.

Percussion
• Percussion is the third technique used by the nurse to
obtain data when performing physical assessment.
• Therefore, the nurse strikes through a body part with
an object, fingers, or reflex hammer, ultimately
producing a measurable sound.
• Three methods of percussion can be used: direct
percussion, blunt percussion, and indirect percussion.

Direct Percussion
• Direct percussion is the technique of tapping the body
with the fingertips of the dominant hand.
• Direct percussion is used to examine the thorax of an
infant and to assess the sinuses of an adult.

Figure 7.5 Direct Percussion

Blunt Percussion
• Blunt percussion involves placing the palm of the
nondominant hand flat against the body surface and
striking the nondominant hand with the dominant
hand with a closed fist to deliver a blow.
• This method is used for assessing pain and
tenderness in the gallbladder, liver, and kidneys.

Figure 7.6 Blunt Percussion

Indirect Percussion
• Indirect percussion is the technique most commonly
used because it produces sounds that are clearer and
more easily interpreted.
• A hammer or tapping finger used to strike an object is
called a plexor and a pleximeter refers to the device
that accepts the tap or blow from a hammer.

Figure 7.7 Indirect Percussion

Indirect Percussion
Helpful tips include:
• Ensure that motion is from the wrist, not the forearm
or plexor finger.
• Release the plexor finger immediately after the
delivery of two sharp strikes, as this action will allow
for the clearest, most accurate sound to be produced.
• Ensure that only the pleximeter makes contact with
the body.

Indirect Percussion
Helpful tips include :
• Use the tip of the plexor finger, (not the finger pad) to
deliver the blow as this will help produce the clearest
sound.
• Use two strikes and then reposition the pleximeter.
Delivery of more than two rapid consecutive strikes
creates the “woodpecker syndrome” and sounds are
muffled.

Sounds of Percussion
• Tympany is a loud, high-pitched, drumlike tone of
medium duration characteristic of an organ that is
filled with air that is heard commonly over the gastric
bubble in the stomach or over air-filled intestines.
• Resonance is a loud, low-pitched, hollow tone of long
duration. It is the normal finding over the lungs.

• Hyperresonance is an abnormally loud, low-pitched
tone of longer duration than resonance. It is heard
when air becomes trapped and overinflates the lungs.
• Dullness is a high-pitched tone that is soft and of
short duration. It is usually heard over solid body
organs such as the liver or a stool-filled colon.

• Flatness is a high-pitched tone, very soft, and of very
short duration. It occurs over solid tissue such as
muscle or bone.

• Characteristic features of the sounds elicited from
percussion include:
– Intensity or amplitude of a sound refers to the
softness or loudness of the sound. This is
influenced by the amount of air in the structure
and the ability of the structure to vibrate.
– Pitch or frequency of the sound refers to the
number of vibrations of sound per second. Slow
vibrations produce a low-pitched sound, whereas a
high-pitched sound comes from more rapid
vibrations.

• Characteristic features of the sounds elicited from
percussion include :
– Duration refers to the length of time of the
produced sound. This time frame ranges from very
short to very long, with variation in between.
– Quality refers to the recognizable overtones
produced by the vibration. This will be described
as clear, hollow, muffled, or dull.

Auscultation
• When auscultating, one uses both the unassisted
sense of hearing and special instruments such as a
stethoscope.
• Body sounds that can be heard with the ears alone
include speech, coughing, respirations, and
percussion tones.
• Stethoscopes work by blocking out other noises in the
environment.

Auscultation
• Auscultating body sounds requires a quiet
environment in which the nurse can listen not just for
the presence or absence of sounds but also for the
characteristics of each sound.
• Avoid auscultating over clothing, gowns, and sheets;
rubbing against patients’ clothes or drapes; or
touching the stethoscope tubing.

Auscultation
• Movement of the stethoscope over thick or coarse
hair on the chest or back may alter or obscure
sounds.
• Because many sounds may be heard at the same
time, it is important to focus on one sound at a time.

Equipment (1 of 9)
• Special equipment will help visualize, hear, and
measure data during an assessment
• Before beginning the physical assessment, the nurse
should gather all the equipment, organize it, and
place it within easy reach.

Equipment (2 of 9)
• Special equipment that may be used during a physical
assessment include:
– Goniometer: Measures the degree of joint and
flexion and extension.
– Skinfold calipers: Measure the thickness of
subcutaneous tissue.
– Transilluminator: Detects blood, fluid, or masses in
body cavities.

Equipment (3 of 9)
• Special equipment that may be used during a physical
assessment includes :
– Woods lamp: Detects fungal infections of the skin.
– Monofilament: Assesses peripheral nerve
sensation in the feet of a patient with diabetes, or
other neuropathic or circulatory disorders.

Equipment (4 of 9)
Stethoscope
• The stethoscope is used to auscultate body sounds
such as blood pressure, heart sounds, respirations,
and bowel sounds.
• The stethoscope has three parts: the binaurals
(earpieces), the flexible tubing, and the end piece. The
end piece contains the diaphragm and the bell.

Equipment (5 of 9)
Stethoscope
• The diaphragm, screens out low-pitched sounds and,
therefore, is best for transmitting high-pitched
sounds such as lung sounds and normal heart
sounds.
• The bell detects low-frequency sounds such as heart
murmurs. It is placed lightly against the patient’s skin
so that it forms a seal but does not flatten to a
diaphragm.

Figure 7.8a. Stethoscope with a Bell and
Diaphragm

Figure 7.8b. Close-Up of Diaphragm (Flat
Disc on Bottom) and a Bell (Top)

Equipment (6 of 9)
Doppler
• A Doppler uses ultrasonic waves to detect sounds that
are difficult to hear with a regular stethoscope, such
as fetal heart sounds and peripheral pulses that
cannot be easily palpated.
• When using the Doppler to assess the pulse, turn it
on, apply a small amount of gel to the end of the
probe, or transducer and place the probe gently
against the patient’s skin over the artery to be
auscultated.

Figure 7.11 Using a Doppler Ultrasound

Equipment (7 of 9)
Ophthalmoscope
• An ophthalmoscope is used to inspect internal eye
structures. The light source shines light through the
viewing aperture, which is adjusted to select one of
five apertures.
• The apertures include:
– The large aperture that is used most often. It emits
a large, full spot for viewing dilated pupils.
– The small aperture is used for undilated pupils.

Figure 7.12 Ophthalmoscope
Demonstrating Aperture

Equipment (8 of 9)
Ophthalmoscope
• Apertures of the ophthalmoscope :
– The red-free filter shines a green beam used to
examine the optic disc for pallor or hemorrhaging,
which appears black with this filter.
– The grid allows the examiner to assess the size,
location, and pattern of any lesions.
– The slit allows for examination of the anterior eye
and aids in assessing the elevation or depression
of lesions.

Figure 7.13 Apertures of Ophthalmoscope

Equipment (9 of 9)
Otoscope
• The otoscope is used to inspect the external ear
structures. The main components of the otoscope are
the handle, the light, the lens, and specula of various
sizes.
• The specula are used to narrow the beam of light.
• The nurse should select the largest specula that will fit
into the patient’s ear canal.

Figure 7.14 Otoscope

Professional Responsibilities (1 of 14)
Cues
• Cues are bits of information that hint at the possibility
of a health problem.
• To become skilled at cue recognition, nurses should
cultivate their senses until they readily perceive even
slight cues.
• Grimacing, guarding (protective posture), or wincing
when a patient moves or when a body part is moved
during assessment are cues to examine the
underlying joint and muscles for problems or masses.

Cues
• Cues that suggest hearing loss include not following
directions, looking at the examiner’s lips during
conversation, or speaking in a loud voice.
• Asymmetry of facial expression is a cue to assess
function of the cranial nerves.
• Odors are cues to suggest a problem with hygiene or
drainage from an orifice or wound.

Critical Thinking
• The interpretation of cues and other collected data
uses the process of critical thinking.
• Once cues are recognized and data are collected, the
findings must be interpreted.
• The data are compared to normative values and
ranges.
• Data are clustered, and patterns are identified.

Critical Thinking
• Missing information is identified and, after the
database is completed, valid conclusions are drawn.
At this time, the nurse establishes priorities of care.
• In collaboration with the patient, the nurse identifies
desired patient outcomes and develops the patient’s
nursing care plan.
• Evaluation follows implementation of each nursing
intervention.

Providing a Safe and Comfortable Environment
• Provide a space that is appropriate for the setting,
ensures maintenance of dignity and privacy for the
patient, noting special considerations for each
patient.
• The examination room should be warm, private, and
free from distractions and interruptions.
• Overhead lighting must ensure good visibility and be
free of distortion.

• Before beginning the assessment, the nurse should
thoroughly explain to the patient what is to follow and
encourage the patient to ask questions.
• Provide an interpreter as needed.

• It is the nurse’s responsibility to ensure that the
patient understands the procedures to be performed
and that all necessary consent forms are signed.
• In most cases, patients should empty their bladder
before the examination.

• Ensure the room is warm prior to having the patient
change into a gown.
• Before reentering the examination room knock to
alert the patient.
• Use drapes to preserve the patient’s privacy and to
provide warmth. Use the drape to expose only the
part of the body being examined and cover the
surrounding area.

• To begin the assessment, the patient should be
positioned on a sturdy examination table with a firm
surface that is covered with a clean sheet or paper
cover.
• The table’s height should allow the examination to be
performed without stooping. The nurse should also
have a stool to sit on during certain parts of the
examination and a small table or stand to hold the
examination equipment.

• During the assessment, the nurse should explain each
step in advance so that the patient can anticipate the
nurse’s movements.
• Alleviate the patient’s anxiety by approaching the
examination gradually, first by communicating with
the patient, then by performing simple
measurements such as height, weight, temperature,
and pulse, which most patients find familiar and
nonthreatening.

• The examination should be individualized according
to the patient’s personal values and beliefs.
• Consider the patient’s age, health status, level of
functioning, and severity of illness at all times and
adapt the examination accordingly.

Techniques and Equipment for the Assessment of
the Obese Patient
• To ensure both comfort and safety, chairs in the
waiting and examination areas and wheelchairs used
for transport must be wide and sturdy.
• Extra-large examination gowns should be available.
• Scales with a capacity of greater than 350 pounds are
required.

the Obese Patient
• Examination tables should be wide and sturdy with
hand bars or footstools to help the patient move onto
the table.
• Examination tables should be bolted to the floor to
avoid tipping.
• If the patient needs helps stepping up or sitting on
the exam table, use a gait belt or other assistive
device to provide stability and support.

the Obese Patient
• A large adult-size cuff, a thigh cuff, or special cuffs
designed for an obese patient must be considered for
accurate measurement of the blood pressure
(Dambaugh and Ecklund, 2016).
• Keep the head of the examination table elevated as
much as possible during the examination. If the
patient’s head must be lowered, the nurse should
continually monitor the patient’s respiratory status.

Standard Precautions (1 of 6)
• Throughout the physical assessment, the professional
nurse is required to apply the principles of asepsis.
• Before beginning the physical assessment, the nurse
should wash her hands in the presence of the patient.

• According to the World Health Organization (WHO,
2009) recommendations, nurses should scrub and
rinse hands with soap for 40 to 60 seconds when the
hands are visibly soiled, after using the restroom,
after removing gloves, and before and after contact
with medical equipment.
• Alcohol-based antiseptic hand rubs in the form of
rinses, gels, or foams should be used before and after
direct patient contact.

• Nonsterile examination gloves should be available
and used appropriately during the assessment.
• The bell and diaphragm of the stethoscope should be
cleaned after the assessment of each patient to
prevent the spread of infection.
• Healthcare-associated infections (HAIs) are of
concern. Hand washing and the use of antiseptic hand
rubs are the most effective ways to prevent transfer of
infection from one patient to another in both clinical
and hospital settings.

• To decrease the risk of infection transfer between
patients, medical staff should ensure the proper
cleaning, use, and disposal of medical equipment
used during the physical assessment.
• A light disinfectant should be used to cleanse the
surface between use on different patients.
• Equipment that touches nonintact skin or mucous
membranes should be cleaned with a high-level
disinfectant between all patients.

• Equipment that enters normally sterile areas or the
bloodstream should be cleaned and sterilized
between every use.
• When using medical equipment during a physical
examination, the nurse should prepare all the needed
instruments and tools in a clean area. The clean area
should be draped with a sterile cloth or paper liner,
and clean or sterile instruments should be placed on
the clean surface.

• Dirty equipment should be separated from clean
equipment to prevent potential cross-contamination
of infectious agents between different areas of the
body.

Patient Hazards
• Throughout the procedure, it is necessary to
anticipate potential hazards and modify the
assessment to prevent them.
• Some assessment techniques may injure the patient if
used indiscriminately.

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