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Chapter 8

Assessment Techniques and Safety in the Clinical Setting

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

Close, careful scrutiny, first of individual as a whole and then of each body system

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 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.

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

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 (split tongue valve), reflex hammer

Bivalve vaginal speculum, materials for cytology, 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?

Wash hands and don gloves, gown, and protective face shield.

Don gloves and wash hands after examination; no other protective equipment is necessary.

Wash hands and don two pairs of gloves and gown.

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.