Chapter 3 Technique and Equipment for Physical Assessment

infection control practices

measures to reduce the risk of transmitting infection from bodily fluids and non-intact skin

the potential for infection transmission always exists

hand hygiene

the single most important component to reduce infection transmission

soap and water

40 to 60 seconds

when visibly dirty, or contaminated, before eating, and after restroom

alcohol hand rub that's at least 60% alcohol

before and after contact with patients/objects

personal protective equipment

gloves, masks, eye protection, face shields, and gowns

environmental control

clean countertop and keyboard

be mindful of latex allergies

Healthcare professionals are at risk for developing latex allergies because of frequent exposure

ALWAYS ASK PATIENTS IF THEY HAVE A LATEX ALLERGY

patient placement

mindful of those with infections and those at risk

cough etiquette or respiratory hygiene

Cover your nose/mouth with a tissue when you cough, and promptly dispose of the contaminated tissue.

"Chicken wing"

Place a surgical mask on a patient if it does not compromise respiratory function or is applicable; this may not be feasible in pediatric populations.

Perform hand hygiene after contact with contaminated respiratory secretions

Maintain spatial separation greater than 3 feet from persons with respiratory infection

latex allergy risks

frequent exposure increases the chance of developing

8-17% of health care professionals (vs 1% general population)

Patients with spina bifida have a higher risk

Patients who have had multiple medical procedures or surgeries, especially genitourinary surgery

preventing latex allergy

use nonlatex gloves if not working with infectious materials

use powder-free, low-allergen

do not use oil-based hand lotions

Wash hands immediately after removing latex gloves

principles of assessment

patient preparation

cephalocaudal (head to toe)

Periphery inward

Less personal to more personal

Gradually move into the client's territory

proceed by systems/regions

pain producing/intimate/invasive last

occur on examination table

if child is less than 6 months old the exam should:

decrease fear and distress

if the child is older than 6 months the child may need to remain on the caregiver's lap to:

inspection, palpation, percussion, and auscultation

Techniques of physical assessment:

inspection

visual exam including body movement, posture, and smell

observe the rate, depth, and effort of breathing (respiratory)

color of skin, lips, nail beds (integumentary)

Equipment to facilitate: penlight, otoscope, ophthalmoscope, vaginal speculum, and wood lamps

palpation

requires touch to determine texture, size, shape, consistency, pulsations, and location

palmar surfaces of finger pads

determine, position, texture, size, consistency, masses, fluid and crepitus

ulnar surface of hand

most sensitive to vibration

dorsal surface of hand

most sensitive to temperature

light palpation

1 cm

deep skin

assess pulsations and tenderness

deep palpation

4 cm

determines organ size and contour

bimanual

two hand technique used to trap mass or organ (uterus, kidney, or breasts)

percussion

evaluates size, borders, and consistency of internal organs

detect tenderness and determines extent of fluid in body cavity

direct percussion

strike finger or hand directly against patient body

indirect percussion

requires both hands

the distal aspect of the middle finger of the non-dominant hand against the skin

strike the distal interphalangeal joint with the tip of the middle finger of the dominant hand. other fingers must be elevated to prevent the dampening of vibrations. Tapping motion, do not leave fingertip on finger

listen for vibrations

tympany

abdomen (stomach, gas bubbles)

resonance

lungs (hollow)

hyperresonance

over-inflated lungs (booming)

flatness

bones and muscles (extremely dull)

dullness

liver (thud like)

auscultation

listening to sounds in the body using stethoscope

diaphragm of stethoscope

flat surface

used for high pitched sounds: breath bowel and normal heart sounds

bell of stethoscope

cup-shaped, concave in shape

used to hear soft, low-pitched sounds: extra heart or vascular sounds

press very lightly, with just enough pressure to ensure contact with the skin and a complete seal around the edge

the head should span one intercostal space on the client's thorax

To approximate the size of the head of the stethoscope for an infant or a child:

fetoscope

is used to hear the heartbeats of the fetus

Best heard after 18-22 weeks

The heart starts beating around 5 weeks

Doppler can be used around 12 weeks

supine

lying on back

provides easy access to pulse sites

dorsal recumbent

a position where the patient is lying supine with the knees flexed

this position is used for abdominal assessment because it promotes relaxation of abdominal muscles

sims

body position in which a person is lying on his left side with the upper knee flexed and raised toward the chest

flexion of hip and knee improves exposure of rectal area

prone

lying face down on stomach

this position is used only to assess the extension of the hip joint

lateral recumbent

lying on either the left or right side

this position assists in detecting murmurs

sitting

provides full expansion of lungs and better visualization of symmetry of upper body parts

lithotomy

supine position, with the waist rat at the edge of the bed and legs raised and kept on a foot stand attached on either side of the edge of the bed.

this position provides maximal exposure of genitalia and facilitates insertion of vaginal septum

knee-chest

patient resting on knees and chest with head turned to the side, arms extended on the bed, elbows flexed and resting on the bed. Thighs are in upright position, with hips raised above body level.

this position provides maximal exposure of rectal area

tripod position

An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.

a position that may be assumed during respiratory distress to facilitate the use of respiratory accessory muscles.

fetal position

Relationship of the landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis.

intensity, pitch, duration, and quality

characteristics of sounds heard by auscultation:

intensity of sound

Amount of energy in a wave; determined by the amplitude, relates to perceived loudness

pitch of sound

the frequency of the wave

duration of sound

Its length (long or short) during auscultation

quality of sound

how well a sound can be heard; determined by the amount of energy producing the sound and the distance the sound is from the observer