HA- Assessment Techniques

Name the Assessment Order

Inspection

Palpation

Percussion

Auscultation

What happens during the Inspection stage? What equipment is needed?

Inspection happens first, starts along with the general survey when you first enter the patient's room, and is often done during the collection of subjective data.

These are purposeful observations.

Compare symmetry- right and left sides of body.

Equipment needed-

otoscope, ophthalmoscope, pen light, speculums to expose body part.

Describe different types of Palpation techniques and assessments and how/where you would use them.

1. Temperature

Use the dorsa of hands and fingertips

2. Fine Tactile Discrimination

Use fingertips to assess skin texture, swelling, pulsation, and presence of lumps.

3. Light Palpation

Detect surface characteristics. Start with this. Can use this to detect pulses as well. Includes circular movements.

4. Deep Palpation

Assessment of organs - borders & tenderness - 5-8 cm.

More advanced technique.

5. Bimanual Palpation

Detects position, shape, consistency of organ or mass.

More advanced technique using both hands.

What are some things you might assess when using Palpation?

temperature

texture

moisture

organ location and size

swelling

vibration - use ulnar surface

pulsation

rigidity or spasticity

crepitation

presence of lumps or masses

presence of tenderness or pain

Crepitation

a grating or crackling sound or sensation - as in an arthritic knee

Describe Percussion technique and "Percussion Notes".

Used to map out location and size of an organ. Signals density, and can detect an abnormal mass.

The middle finger of the stationary hand is placed on the patient's skin. The middle finger of the striking hand taps the finger of the stationary hand just below the nail bed with a relaxed wrist.

Resonant: air-filled, clear and hollow - lungs

Hyperresonant: booming quality, normal over child's lungs, abnormal in adult's- increased amount of air.

Tympany: drumlike quality - abdomen

Dull: Soft and muffled - dense organ - liver/spleen

Flat: Very soft and a dead-stop - no air is present such as over thigh muscle, bone, or tumor

What is Auscultation and what is used?

Listening to sounds the body produces

A stethoscope is used.

Describe how to use the stethoscope correctly.

Clean!

Environment - stethoscope does not magnify sound.

Earpieces point towards nose.

Tubing between 14-18 inches long

Place directly on the skin.

Press firmly on the diaphragm - used for High pitched sounds heard from the breath, bowels, and heart.

Press lightly on the Bell - used for low pitched sounds heard from other heart sounds and murmurs.

What to consider when assessing infants and toddlers:

separation and stranger anxiety

sleeping - do non-invasive assessments first

they may be on the parent's lap

security blanket or toy

toddler negativism

What to consider when assessing a preschooler:

use cooperation through choices, play, and games.

Allow child to remain in the parent's lap.

animism

What to consider when assessing a school age child:

Incorporate "what and why". Included teaching.

Allow them to cooperate.

Perform assessment from head to toe

What to consider when assessing an Adolescent:

Head to Toe assessment

work around clothes as much as possible.

Examine alone without parent or sibling present.

Respect and communicate appropriately.

What to consider when assessing the Older Adult

Promote comfortable position changes.

Allow rest.

Use physical touch.

Head to toe approach.