HA Ch. 8 Assessment Techniques

As appropriate, contact with blood fluids, blood, mucous membranes, etc.

When to wear gloves?

Protect body fluids/transmitting bacteria

What is the purpose of wearing gloves?

Wash with soap and water or foam in and out

How to preform hand hygiene?

Prevent transmission of pathogens, wash visibly soiled, and before/after contact with c. diff patient

Purpose of hand hygiene?

Sterilizing equipment, wiping

How to preform equipment cleaning?

Prevent transmission of pathogens

Purpose of equipment cleaning?

Inspection, palpation, percussion, auscultation (IPPA)

Assessment order

Inspection

Concentrated watching, preformed first, symmetry

• Purposeful observations

• Often done during collection of subjective data

• Preformed first, requires good lighting, adequate exposure of body part

• Inspection equipment

How to preform inspection?

• Provides first impression

• Symmetry: compare left and right sides of body

• Otoscope (ears), Ophthalmoscope (eyes), pen light, speculums to expose body part

What is the purpose/expected finding of inspection?

Palpation

Applies sense of touch to assess

1. Temperature

2. Fine tactile discrimination

3. Light palpation

4. Deep palpation

5. Bimanual palpation

What are types of palpations?

Use DORSA (back of hand)

How to palpate temperature?

BEST for determining temperature bc skin there is thinner

Why use DORSA of hand to palpate temperature?

Using FINGERTIPS, feelings for texture, swelling, pulsation, detecting lumps

How to palpate Fine tactile discrimination?

Light Palpation

Pressing into skin 1cm deep to check for tenderness and pain, used to identify surface characteristics

Deep Palpation

Pressing into skin 5-8cm to feel for organs, used to identify abdominal contents

Bimanual Palpation

Using both hands to envelope/capture certain body parts; like kidneys, uterus, etc. for precise delimitation (finding bounds)

Stationary hand, striking hand; looking for characteristics of percussion notes (air-filed and tympany)

How do preform percussion technique?

Resonant, hyper resonant (lungs)

What are air-filled percussion notes looking at?

Abdomen

What are tympany percussion notes looking at?

Assesses and determines density of underlying organs

Purpose of percussion?

Resonant

Medium loud, low pitch, clear/hollow

Tympany

Loud, high pitch, musical, drum-like

Dull

Soft, high pitch, muffled thud

Over lung tissue

Where are resonant notes typically found?

Over air-filled viscus: stomach or intestine

Where are tympany notes typically found?

Relatively dense organ: liver or spleen

Where are dull notes typically found?

Muscle and bone

Where are flat notes typically found?

Auscultation

Listening to sounds that body produces

Stethoscope

What do you use to preform auscultation?

No

Does the stethoscope magnify sound?

Nose

Slope of earpiece of stethoscope points towards…

14-18in long

How long is the tubing of stethoscope?

Diaphragm (stethoscope)

Used for HIGH pitched sounds heard from BREATH, BOWEL, AND NORMAL HEART SOUNDS

Bell (stethoscope)

Used for LOW patched sounds heard from HEART SOUNDS OR MURMURS

one

How many end pieces does a tunable diaphragm have?

Do not wake up sleeping baby/toddler, listen to heart, lungs, and abdomen FIRST, caregiver present/holding

How to assess infants and toddlers?

Caregiver present; offer good explanations, allow play with equipment, reduce fears; caregiver can hold them

How to assess preschoolers?

Sit/lay of exam table, what and why, offer explanations, likes to cooperate

How to assess school age children?

Shows genuine interest, confidentiality and friendship is important, normalize

How to assess adolescents?

Minimize position change to lessen fatigue

How to assess older adults?

Observe

Inspect means to

Even tone, consistent with genetic background

What should the general overall pigmentation be in a patient?

Observe skin tone

Should you observe OR palpate skin tone?

Skin warm to touch, equal bilaterally

What should the temperature be in a patient?

Palpate

Should you observe OR palate the skin temperature?

Translucent nail plate, even, pink

What should the expected nail look be in a patient?