Topic 3 Lecture Video: Comprehensive notes on Physical Assessment: Inspection, Palpation, Percussion, Auscultation, and Pain Assessment
Four components of physical assessment
The four components used across body systems: inspection, palpation, percussion, auscultation.
Inspection is always the first step for every body system; it involves observing appearance, behavior, and overall presentation.
Often the phrase in nursing is “it depends,” but inspection is universally the initial element.
Inspection
Purpose: assess visual cues and behaviors to form an initial impression of the patient’s condition.
Examples of what you might inspect:
Integumentary system (skin, nails, hair) and general appearance.
Respirations and breathing pattern.
Overall vital signs appearance and signs of distress.
Note: assessment order may vary by body system (e.g., abdomen often prompts a different sequence).
Palpation
Sequence: typically inspection → palpation → percussion → auscultation, but order can vary by area (e.g., abdomen: inspection, auscultation, then palpation to avoid increasing peristalsis).
Scope and safety:
RN scope: light palpation only; deep palpation (~8 cm) is not within typical RN scope.
Light palpation depth: about .
Rules and technique:
Use different parts of the hand for different tasks:
Tips of fingers: best for detecting pulses and surface pulsations.
Fingertips and thumbs: borders and positioning of structures.
Dorsum of hand (back of hands): best for assessing temperature.
Base of fingers / ulnar surface: vibration (tactile fremitus) assessment.
Palpation tasks include evaluating temperature, borders of organs, vibrations, pulsations, lymph nodes, sinuses, and breast tissue inspection.
When palpating, use gentle, depressive pressure (usually 1–2 cm) in a circular motion; sometimes involves bimanual palpation.
Communication and patient comfort:
Always explain what you’re doing and why; touching patients requires consent and communication.
Be mindful that touching can be uncomfortable; adjust hand placement and pressure accordingly, and involve patient when possible (e.g., lifting breast tissue with back of the hand or with gloves).
Special considerations:
For assessment of apical pulse: located at the left side of the patient, midclavicular line, 5th intercostal space; in many females, this area is under breast tissue, so patients may need to lift tissue to allow palpation.
Abdomen-specific palpation note
If abdominal palpation is being performed, often auscultation is done first to avoid increasing peristalsis; palpation is usually light and then deeper as indicated.
Some patients cannot be safely palpated in certain areas; assessment order and technique may change for safety.
Percussion
Definition: tapping the skin with short, sharp strokes to assess underlying structures; can be direct or indirect percussion.
Direct vs indirect percussion:
Direct percussion: tapping directly with a finger on the body.
Indirect percussion: tapping with one hand placed on the body (e.g., on the patient) and striking with the other hand.
Common RN exposure: percussion is rarely practiced by registered nurses in head-to-toe assessments; more commonly performed by advanced practice providers.
Percussion concepts:
Sound differences help distinguish underlying structures: tympany vs dullness.
Tympany is like hollow structures (air-filled; more echo), dullness indicates solid or fluid-filled areas.
Practical takeaway:
You should have a basic understanding of percussion and its purpose, but it is not a primary RN skill in routine head-to-toe assessments.
Some clinical scenarios (e.g., certain advanced examinations) may require percussion; consult scope of practice and supervision.
Auscultation
Core tool: use of the stethoscope to listen to internal sounds.
Stethoscope usage tips:
Place directly on the skin when possible for best sound transmission.
Do not place your thumb over the bell or diaphragm; your thumb has a strong pulse that can distort sounds.
Clean your stethoscope before and after each patient interaction; use disposable stethoscopes in isolation or special precautions if needed.
Keep stethoscope clean and disinfected to prevent infection transmission.
Stethoscope components:
Diaphragm: larger, flat surface; hears high-pitched sounds (e.g., normal breath sounds, heart sounds).
Bell: smaller, concave surface; hears low-pitched sounds (e.g., some heart sounds, bruits).
Sound quality and pitch:
Diaphragm → high-pitched sounds.
Bell → low-pitched sounds.
Practical considerations:
In many settings, machines are used for vital signs, but manual auscultation remains essential for accurate assessment when readings are abnormal or need confirmation.
Expect variability in patient presentations and be prepared to move between diaphragm and bell as needed for different body systems.
Clinical practice realities:
Patients, including children or anxious individuals, may be uncomfortable with having the stethoscope placed directly on the skin; communicate and obtain consent.
In isolation or infectious-type precautions, disposable equipment may be used.
Night shift considerations and lighting for assessment
Adequate lighting is essential for true inspection, especially during night shifts.
q fifteens (15-minute patient rounds) require careful observation and documentation, including clear lighting to ensure accuracy of inspections and palpations.
If patient is in distress or urgent care is needed (e.g., breathing difficulties, medication administration), turn on lights to ensure visibility and safety.
Pain assessment: concepts, types, sources, and ethics
Pain is a complex, highly subjective experience arising from the central nervous system; it acts as a protective mechanism but can persist beyond tissue healing.
Four major sources of pain:
Visceral pain: pain from internal organs.
Cutaneous (superficial) pain: skin and subcutaneous tissue.
Deep somatic pain: pain from muscles, tendons, joints, bones, vessels.
Referred pain: pain felt in a location different from its origin (e.g., chest pain perceived in jaw or neck in some women).
Types of pain:
Acute pain: sharp and sudden; typically lasts < 6\ \mathrm{months}; usually protective and self-limiting with a typical trajectory.
Chronic pain: persists beyond the healing of the injury; often not accompanied by obvious physical signs; may be nonmalignant or malignant (cancer-related).
Neuropathic pain: pain originating from nervous system damage or altered pain signaling; may be described as electric shock, burning, tingling, numbness, or phantom limb pain.
Acute pain examples and trajectory:
Common injuries (e.g., collarbone fracture) have a known healing trajectory; pain reduces as healing progresses.
Postoperative pain often tapered over time with medication adjustments.
Nonmalignant chronic pain specifics:
Pain intensity may not correlate with visible physical findings; pain arises from abnormal pain processing and nerve signaling.
Malignant pain (cancer-related):
Pain behaviors may differ (e.g., patients might sleep through pain); pain management requires different considerations.
Neuropathic pain examples and consequences:
Diabetes-related peripheral neuropathy causing numbness or burning; phantom limb pain after amputation.
Neuropathy increases risk of injury due to reduced sensation, ulcers, and delayed detection of tissue damage.
Implications for older adults:
Pain is not a normal part of aging; age alone does not justify under-treatment.
Older adults may underreport pain due to beliefs, biases, or cognitive changes; assessment should be thorough and compassionate.
Functional status (ADLs, IADLs, AADLs) can be affected by pain; assess how pain impacts dressing, ambulation, toileting, fatigue, and activity tolerance.
Pain disparities and ethical considerations:
Biases exist in pain assessment and treatment (gender, race, and ethnicity).
Data show disparities in analgesic administration; e.g., some minorities may receive less analgesia than Caucasians for similar conditions.
“Pain is what the patient says it is” – validate patient reports, even if there are concerns about drug-seeking behavior; protect patient dignity while ensuring safety and appropriate analgesia.
Advocacy is essential: challenge biases, ensure appropriate analgesia, and involve the patient in decisions.
Pain assessment tools and approaches:
Numerical pain scale: 0–10.
Faces/emoji scale: useful for children or developmentally delayed patients.
FLAC scale (and other nonverbal scales) for patients who cannot communicate verbally (e.g., intubated or sedated).
Flat scale (less preferred, used when patient cannot communicate): rely on observed behaviors and clinical judgment.
PQRS-TU framework for pain assessment (provocation, palliation, quality, region, severity, timing, understanding):
Provocation/Palliation: what makes pain worse or better?
Quality: is the pain sharp, dull, burning, radiating, intermittent?
Region: where is the pain located? Does it radiate?
Severity: how severe is the pain (0–10 or other scale)?
Timing: when did it start? Is it constant or intermittent? Does it vary with time of day or activity?
Understanding: what is the patient’s understanding of the cause and what is their expectation for management?
Nonverbal pain cues:
Generally unreliable as a sole indicator; use in combination with patient report when possible.
Acute pain behaviors: guarding, grimacing, vocalization/moaning, agitation, restlessness, diaphoresis.
Chronic pain behaviors: bracing, rubbing, diminished activity, sighing, changes in appetite; may be less dramatic due to adaptation.
Pain in non-communicative patients:
Use alternative scales and clinical judgment; treat pain proactively if a reasonable person would expect pain in that situation.
Practical and ethical guidance for pain care:
Avoid demeaning language (e.g., “calm down”); communicate with empathy and respect.
Consider social and cultural factors in pain perception and expression.
Remain vigilant for potential biases and advocate for safe, effective analgesia.
Practical and integration notes
Pain assessment is a vital part of the physical assessment and informs treatment decisions; always document the patient’s own report and shape care around their needs.
Foundational knowledge connects anatomy and physiology (A&P) with clinical assessment and pathophysiology; expect these concepts to recur in medical-surgical topics.
Real-world relevance:
In practice, many challenges involve balancing compassionate care with safety and effective pain management.
Clear communication, patient advocacy, and ethical practice are essential in all patient interactions.
Quick reference: common location and technique reminders
Apical pulse location: left side, midclavicular line, 5th intercostal space; in many women, under breast tissue; may require patient assistance to lift tissue.
Abdomen assessment sequence typically follows inspection → auscultation → palpation → percussion (with safety considerations).
Stethoscope tips:
Skin contact preferred for accurate auscultation.
Do not rest thumb on the bell/diaphragm to avoid distorting sounds.
Clean before and after every patient interaction; use disposable equipment when needed.
Understand which sounds are best heard with the diaphragm (high-pitched) vs the bell (low-pitched).
Connections to foundational principles
Patient-centered care: explain procedures, obtain consent, involve patients in decisions, respect autonomy.
Evidence-based practice: use best practices for auscultation, palpation techniques, stethoscope use, and pain assessment tools.
Safety and infection control: proper stethoscope hygiene, isolation precautions, and use of disposable equipment when indicated.
Ethical practice: awareness of biases in pain assessment and treatment; strive for equitable care across gender, race, and age groups.