Chapter 8: Assessment Techniques and Safety in Clinical Setting

Bimanual palpation

Bimanual palpation used to inspect organs such as the kidneys, uterus, or adnexa for more precise delimitation

Fingertips

Best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps

Fingers and thumb

Detection of position, shape, and consistency of an organ or mass

Dorsa (back) 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

Base of fingers or ulnar surface of hand:

Best for vibration

How to begin inspection?

With a general survey

Inspection always requires:

• Good lighting

• Adequate exposure

• Occasional use of instruments → otoscope, ophthalmoscope, penlight, nasal and vaginal specula

Palpation applies sense of touch to assess the following:

 Texture, temperature and moisture

 Organ location and size

 Swelling, vibration, pulsation or crepitation (crackling)

 Rigidity or spasticity

 Presence of lumps or masses

 Presence of tenderness or pain

Percussion

Tapping person’s skin with short, sharp strokes to assess

underlying structures

Use percussion for:

 Mapping location and size of organs

 Signaling density of a structure by a characteristic note

 Detecting a superficial abnormal mass

• Percussion vibrations penetrate about 5 cm deep.

• Deeper mass would give no change in percussion

 Eliciting pain if underlying structure is inflamed

 Eliciting deep tendon reflex using percussion hammer

Amplitude

Intensity; loud/soft

Pitch

Frequency; number of vibrations per second

Quality

Timbre; subjective difference

Duration

Length of time sound lingers

Stethoscope does not magnify sound, but it blocks out extraneous sounds. True or false?

True.

When using stethoscope, make sure to

• Eliminate extra noise.

• Keep environment warm and warm your stethoscope.

• Avoid listening over hairy body areas.

• Never listen through a patient’s gown or clothing.

• Avoid your own artifact

Measurement of vital signs requires

Platform scale (with height attachment), stethoscope, sphygmomanometer, and thermometer. Pulse oximetry reading can be included.

Other equipment

• Skinfold calipers, skin marking pen, and tuning fork

• 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

Contact Precautions

Wash hands, don gown, don gloves

Droplet Precautions

Wash hands, don gown, mask, gloves

Airborne Precuations

Wash hands, don gown, respirator, face shield/goggles, gloves

The nurse is preparing to do a physical assessment on a patient who is end-stage HIV positive. What should the nurse do for self-protection?

1. Wash hands and don gloves, gown, and protective face shield.

2. Don gloves and wash hands after examination; no other protective equipment is necessary.

3. Wash hands and don two pairs of gloves and gown.

4. Wash hands, don gloves, and wash hands after examination; no other protective equipment is necessary.

4

Examining a sick person

• You may need to alter position during examination.

• Adapt assessment to patient’s comfort level.

• May be necessary just to examine body areas appropriate to problem, collecting a mini database.

• You may return to finish a complete assessment after initial distress has been resolved.

Ball/ulnar surface of hands

Detect vibrations/shrills

Arrange in sequential order:

1. Percussion

2. Palpation

3. Auscultation

4. Inspection

Least intrusive to most intrusive; Inspection → Palpation → Percussion → Auscultation

Position patient with overwhelming fatigue in

Supine

Position patient with shortness of breath in

Sitting up