Assessment Techniques & Safety in the Clinical Setting

Jarvis Chapter 8

Physical Exam

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

• Performed one at a time and in this order (except for abdominal exams)

Inspection

• Concentrated wathcing

• Close, careful scruitny, first of the individual as a whole and then of each body system

• Begins the moment you first meet / see the person

• Compare right and left sides of the body

• Requires good lighting, adequate exposure and occasional instruments (otoscope, opthalmoscope, penlight, nasal and vaginal specula)

Palpation

• Follows and often comfirms findings from the inspection stage

• Applies your sense of touch to assess the following factors

  • Texture

  • Temp

  • moisure

  • organ location / size and any swelling

  • vibration / pulsation

  • crepitation

  • presence of lumps / masses

  • presence of tenderness / pain

• Palpation show be slow and systematic

• Warm your hands first

• Identify any tender areas and palpate them last

• Start with light palpation to detect surface characterisitcs and then deeper palpation

Palpation Techniques: Fingertips

Best for fine tactile discrimination of:

• skin texture

• swelling

• pulsation

• determining presence of lumps

Palpation Techniques: Fingers & Thumb

Perform a grasping motion with fingers and thumb to detect the position, shape, and consistency of an organ or mass

Palpation Techniques: Dorsa of Hands / Fingers

Best for determing temperature because the skin is thinner than on the palms

Palpation Techniques: Metacarpophalangeal Joints / Ulnar Surface of the Hand

Best for feeling vibrations

Bimanual Palpation

Requires the use of both of your hands to envelop or capture certain body parts or organs as the kidneys, uterus, or adnexa for more precise delimitation

Percussion

• Tapping on the person’s skin with short, sharp strokes to assess underlying structures

• Yields an audible vibration and a characteristic sound that depicts the location, size, and density of the underlying organ/body structure

• Percuss two times in each location using even blows by flicking your wrist

Production of Sound

• All sound results from vibrations which are differentiated by:

  • Amplitude: intensity, loud or soft

  • Pitch: frequency, number of vibrations per secon

  • Quality: timbre, a subjective difference caused by distinctive overtones of a sound

  • Duration: length of time the note lingers

Different Percussion Sounds in the Body

• Resonant: medium-loud, low pitch, clear, hollow, moderate duration — normal adult lung tissue

• Hyperresonant: louder, low pitch, booming, longer duration — normal in children’s lungs, abnormal in adults — over lungs with increased amount of air (emphysema)

• Tympany: loud, high-pitched, drum-like, longest duration — over air-filled viscus (stomach, intestines)

• Dull: soft, high pitch, muffled thud, short duration — relatively dense organs (liver, spleen)

Auscultation

• listening to sounds produced by the body

• some body sounds like a gurgling stomach you can hear without help but most body sounds are quiet

• Stethoscopes help block out extraneous room sounds in order to hear softer sounds

• Never listen through clothing, always on the skin

• Keep the exam room quiet

Stethoscope

• Stethoscopes help block out extraneous room sounds to hear softer sounds

• The slope of ear pieces need to point forward and match the size of the ear canal

• Tubing should be a thick material, with a diameter of 4mm (1/8 inch) and 36-46 cm long (14-18 inches)

• Diaphragm: flat edge is best for high-pitched sounds (breath, bowel, normal heart), hold firmly against skin to leave a slight ring afterward

• Bell: deep, hollow, cuplike shape best for soft, low-pitched sounds (extra heart sounds, murmurs), hold lightly against the skin just enough to form a seal

• Warm the stethoscope before placing on the patient’s skin and clean it between patients

Equipment Needed for a Physical Exam

• Platform scale with height attachment

• Sphygmomanometer

• Stethoscope

• Thermometer

• Pulse ox

• flashlight/penlight

• Otoscope

• Opthalmoscope

• Tuning fork

• nasal speculum

• tongue depressor

• Pocket Vision Screener

• skin-marking pen

• flexible tape measure and ruler

• reflex hammer

• sharp objects (split tongue blade)

• cotton balls

• bivalve vaginal speculum

• clean gloves

• alcohol wipes

• hand sanitizer

• lubricant

• fecal occult blood tests

• materials for cytologic study

Otoscope

Funnels light into the ear canal and onto the tympanic membrane for viewing

• Different specula are available in different sizes

Opthalmoscope

Illuminates the internal eye structures through a system of lenses and mirrors

Standard Precautions

The principle that all blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes may contain transmissible agents. Precautions apply to all patients and in any health care setting:

• Hand hygiene: before and after every physical patient encounter, contact with any body fluids, contact with equipment that touched body fluids, after removing gloves

• Use of gloves, gown, mask, eye protection, or face shield

• Respiratory hygiene/cough etiquette

Transmission-Based Precautions

• Additional precautions based on the specific infectious agent

  • Contact: contagious agents spread by direct contact,, wear a gown and gloves — c. diff

  • Droplet: infection spread by close respiratory contact, mask — flu, pertussis

  • Airborne: Smaller infectious respiratory particles that can stay in the air and travel further, gown, respirator, eye protection, gloves, HEPA filter, negative pressure — tuberculosis, COVID