Unit 2: General survey, body measurements and vital signs

Inspection

is concentrated watching. It is close, careful scrutiny, first of the individual patient as a whole and then of each body system. It begins the moment you first meet the patient and develop a “general survey. It is always performed first. Initially you may feel embarrassed “staring” at the patient without also “doing something.” However, do not be too eager to touch the patient. A focused ________ takes time and yields a surprising amount of data. Learn to use each patient as their own baseline by comparing the right and left sides of the body. The two sides are nearly symmetrical. It requires good lighting, adequate exposure, and occasional use of certain instruments (otoscope, ophthalmoscope, penlight, nasal and vaginal specula) to enlarge your view

Palpation

It follows and often confirms points you noted during inspection. In _____, you apply your sense of touch to assess texture, temperature, moisture, and organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain. Different parts of your hands are best suited for assessing different factors. Your technique should be slow and systematic. A patient stiffens when touched suddenly, which makes it difficult for you to feel very much. Use a calm, gentle approach. Warm your hands by kneading them together or holding them under warm water. Identify any tender areas, and palpate them last.

Bimanual palpation

requires the use of both of your hands to envelop or detect certain body parts or organs—such as the kidneys, uterus, or adnexa—for more precise delimitation

Fingertips

best for fine tactile discrimination such as skin texture, swelling, pulsation, and determining presence of lumps

back of hands

best for determining temperature because the skin is thinner on the dorsa than on the palms

Percussion

is tapping the person’s skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ. it has the following uses:

• Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbours

• Signalling the density (air, fluid, or solid) of a structure by a characteristic note

• Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm deep, and so a deeper mass would yield no change in percussion

• Eliciting pain if the underlying structure is inflamed, as with sinus areas or over the kidneys

• Eliciting a deep tendon reflex with the percussion hammer

direct percussion

the striking hand contacts the body wall directly. This produces a sound and is used in percussing an infant’s thorax or an adult’s sinus areas.

Indirect percussion

is used more often and involves both hands. The striking hand contacts the stationary hand, which is fixed on the person’s skin. This yields a sound and a subtle vibration.

The stationary hand

Hyperextend the middle finger (the pleximeter) of your nondominant hand and place its distal joint firmly against the patient’s skin. Avoid the patient’s ribs and scapulae; percussing over a bone yields no data because it always sounds “dull.” Lift the rest of the stationary hand off the person’s skin; otherwise, the stationary hand will dampen the produced vibrations, just as a drummer uses a hand to halt a drum roll.

The striking hand

Use the middle finger of your dominant hand as the striking finger. Hold your forearm close to the patient’s skin surface, with your upper arm and shoulder steady. Scan your muscles to make sure they are steady but not rigid. The action is all in the wrist, and it must be relaxed. Spread your fingers, flick your wrist, and bounce your middle finger off the stationary finger. Aim for just behind the nail bed or at the distal interphalangeal joint; the goal is to hit the portion of the finger that is pushing the hardest into the patient’s skin surface. Flex the striking finger so that its tip, not the finger pad, makes contact. It hits directly at right angles to the stationary finger.

amplitude

loudness or softness of a sound

pitch

the number of vibrations per second

quality

a subjective difference in a sound’s distinctive overtones

duration

the length of time the note lingers.

Auscultation

is listening to sounds produced by parts of the body, such as the heart and blood vessels, the lungs, and the abdomen. You have probably already heard certain body sounds with your ear alone; for example, the harsh gurgling of very congested breathing. However, most body sounds are very soft and must be channelled through a stethoscope for you to evaluate them. The stethoscope does not magnify sound but does block out extraneous room sounds.

diaphragm

You use this part of the stethoscope most often because its flat edge is best for hearing high-pitched sounds: breath, bowel, and normal heart sounds.

bell

endpiece has a deep, hollow, cuplike shape. It is best for soft, low-pitched sounds such as extra heart sounds or murmurs. Hold it lightly against the patient’s skin, just enough that it forms a perfect seal. Pressing any harder causes the patient’s skin to act as a diaphragm, obliterating the low-pitched sounds.

resonant

diagram of a wave in a medium with low pitch, moderate duration, and a clear quality

Hyper-resonant

Diagram of a wave in a medium with lower pitch, longer duration, and a booming quality

Tympany

Diagram of a wave in a medium with high pitch, sustained longest duration, and with musical and drum like quality

Dull

Diagram of a wave in a medium with high pitch. short duration, and muffled thud quality

Flat

Diagram of a wave in a medium with high pitch, very short duration, and instant stop of sound with absolute dullness quality

environmental scan

scan of the area you are about to enter is the first step toward patient and practitioner safety.

otoscope

funnels light into the ear canal and onto the tympanic membrane. The base serves both as the handle and the battery power source. To attach the head, press it down onto the adaptor end of the base and turn clockwise until you feel it stop. To turn the light on, press the red button rheostat down and clockwise. (Always turn it off after use to increase the life of the bulb and battery.) Five specula, each a different size, are available to attach to the head. (The short, broad speculum is for viewing the nares.) Choose the largest one that will fit comfortably into the patient’s ear canal.

ophthalmoscope

illuminates the internal eye structures. Its system of lenses and mirrors enables you to look through the pupil at the fundus (background) of the eye, much like looking through a keyhole at a room beyond.

Hypotension

is considered less than 90/60 mm Hg in a normotensive adult.

Orthostatic Hypotension

is a specific type of hypotension that involves a drop in blood pressure associated with postural changes. Specifically, there is a drop in blood pressure when the client moves from lying to standing position (and sometimes from sitting to standing).