Chapter 8 - Assessment Techniques and Safety in the Clinical Setting

Cultivating Your Senses

Physical examination requires the use of technical skills through the senses (sight, smell, touch, and hearing) to obtain data. The skills requisite for physical examination are inspection, palpation, percussion, and auscultation.

Inspection

Close, careful scrutiny, first of the individual as a whole and then of each body system, beginning when you first meet a person with a general survey. Inspection always comes first.

Palpation

Applies the sense of touch to assess the following in slow and systematic order: texture, temperature, moisture; organ location and size; swelling, vibration, pulsation, or crepitation; rigidity or spasticity; presence of lumps/masses; presence of tenderness/pain.

Palpation Techniques

• Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, and determining the 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

Percussion

Tapping a person's skin with short, sharp strokes to assess underlying structures.

Uses of Percussion

• Mapping the location and size of organs

• Signaling the density of a structure by a characteristic note

• Detecting a superficial abnormal mass

•Eliciting pain if the underlying structure is inflamed

• Eliciting a deep tendon reflex after using a percussion hammer

Stationary Hand (Percussion)

Pleximeter (middle finger hyperextension)

Striking Hand (Percussion)

Plexor (striking finger)

Percussion Method 1

The Stationary Hand: hyperextend the middle finger (pleximeter), place the distal joint and tip firmly against the person's skin; only the distal joint and tip of the middle finger should be touching the person's skin.

Percussion Method 2

The Striking Hand: Use the middle finger of your dominant hand (the plexor), hold the forearm to the skin surface, making muscles steady but not rigid, and flex the striking finger so the tip makes contact.

Production of Sounds

Percussing all over a body structure causes vibrations that produce characteristic waves that are heard as "notes," and are differentiated by amplitude, pitch, frequency, and duration.

Amplitude (Intensity)

Loud/soft sound

Pitch (Frequency)

Number of vibrations per second

Quality (timbre)

Subjective difference caused by the distinctive overtones of a sound.

Duration

Length of time the sound lingers.

Basic Principles of Sounds

• Structures with more air produce louder, deeper sounds compared with denser structures.

• Variations occur in clinical practice based on individual anatomical differences.

Resonant Sound

Medium-loud amplitude, low pitch, clear and hollow quality, moderate duration (ex., over normal lung tissue)

Hyperresonant Sound

Louder amplitude, lower pitch, booming quality, and moderate duration. (ex., normal over a child's lung, abnormal in an adult)

Tympany Sound

Loud amplitude, high pitch, musical/drumline quality, sustained longest duration. (ex., over air-filled viscus such as the stomach and intestines)

Dull Sound

Soft amplitude, high pitch, muffled thud quality, and short duration. (ex., relatively dense organs such as the liver or spleen)

Auscultation

Listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen, Most body sounds are very soft and must be channeled through a stethoscope to be evaluated.

Stethoscope

Does not magnify sound, but blocks out extraneous sounds. Fit and quality of the instrument are important. Used by listening through the diaphragm and/or bell.

Diaphragm

Most often used because its flat edge is the best for high-pitched sounds such as breath, bowel, and normal heart sounds.

Bell

The endpiece has a deep, hollow, cuplike shape that is best for soft, low-pitched sounds such as extra heart sounds/murmurs.

Basic Principles of Auscultation

• Eliminate extra noise

• Keep the environment warm and warm your stethoscope

• Avoid listening over hairy body areas

• Never listen through a patient's gown/clothing

• Avoid your own artifacts.

Setting for Examination

• Warm and comfortable

• Well-lit (artificial or daylight)

• Private

• Both sides of the exam table should be easily accessible

• Appropriate height so the examiner doesn't have to stoop

• Bedside table

Standard Equipment

Necessary tools needed for screening during physical examination are prepared and in place before starting: Perform hand hygiene; protective equipment including, but not limited to, gloves; measurement of vital signs (platform scale w/ height attachment, stethoscope, sphygmomanometer, and thermometer; pulse oximeter can be included)

Other Equipment

Other equipment needed for a screening physical exam: otoscope, ophthalmoscope, penlight, and pocket vision screener; skinfold calipers, skin marking pen, and tuning form; 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.

Otoscope

Funnels light into the ear canal and onto the tympanic membrane, with the base serving as the power source

Ophthalamoscope

Illuminates the internal eye structures, with the head attaching to the base adaptor.

Clean Field

• Clean your stethoscope with an alcohol wipe before/after easch use

•"Clean" and "Used" areas for equipment

• Take all steps to avoid transmission of infection.

• Avoid nosocomial (hospital-based) infections, which have led to the development of resistant infections (MRSA, VRE, and multidrug-resistant TB)

Handwashing

The single most important step to decrease the spread of microorganism transmission is performed:

1. Before/after every patient encounter

2. After contact with blood, bloody fluids, secretions, and excretions

3. After contact with contaminated equipment

4. After removing gloves

Transmission-Based Precautions

Additional precautions that are used with certain infectious agents.

Standard Precautions

Precautions taken with every patient encounter ,such as handwashing and wearing gloves are appropriate.

Contact Precautions

Used for infectious agents spread by direct contact, such as C. diff, requiring a gown and gloves to be worn for patient encounters.

Droplet Precautions

Used for infectious agents spread by close respiratory contact, such as influenza or pertussis, requiring the use of a basic surgical mask in addition to standard precautions.

Airborne Precautions

Used for protection against airborne agents like TB, requiring the use of a gown, respirator (e.x, N95), eye protection (if indicated), and gloves.

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. If anxiety can be reduced, the person will feel more comfortable, and the data gathered will more closely describe the person's natural state.

The Clinical Setting: Hands-On

• Begin with measurement and vital signs

• Have the patient change into an examination gown, maintaining privacy and respect

• Perform hand hygiene

• Provide explanations

• Begin with the person's hands as the point of initial contact

• Concentrate on one step at a time, avoiding distractions

• Examination sequence; offer health teaching

• Summarize findings for the person

Developmental Competence

• The order of the developmental stage is more meaningful than the chronological age

• Position, preparation, and sequence will vary across the life cycle: infants and toddlers; preschool, school-age child, and adolescent; and aging adult

• Increase comfort with a positive memory of health care providers.

Examination of the Sick Person

The ill person may need to alter their position during the examination; adapt the assessment to the patient's comfort level; it may be necessary just to examine body areas appropriate to the problem by collecting a mini-database; you may need to return to finish a complete assessment after initial distress has been resolved.