Fundamentals of Physical Assessment, Safety & Infection Control

Grade-Release Practice

• Grades are NOT shown immediately after the exam

  • Raw computer score is usually lower than final score

  • Faculty review item analysis (high vs. low performers, distractor choices, validity of each question)

  • ~75\% of the time points are added back

• Tests from both course sections are reviewed before release

  • May be held if many students are absent, or until most finals are completed

• Pedagogical/affective reasons

  • Avoids public anxiety (no tears/celebrations in test room)

  • Prevents discouragement before remaining exams

• Do not “read into” a delayed grade; faculty could simply be at appointments

Four Steps of the Physical Examination

1. Inspection ❯ 2. Palpation ❯ 3. Percussion ❯ 4. Auscultation

   • ALWAYS in this order—"look before you touch"

   • EXCEPTION: Abdomen → Inspection, Auscultation before palpation/percussion (touching stimulates bowel sounds)

Inspection

• “Concentrated watching” begins the moment you or the patient enter the room

• Compare right ↔ left for symmetry

• Adequate lighting is essential; turn lights on, use tangential lighting if needed

• Use privacy, non-staring technique; avoid making patient self-conscious

• Examples of what you see:

  • Skin color, scars, gait, breathing effort, facial expression

Palpation

• Purposes: texture, temperature, moisture, organ size/location, swelling, vibration, crepitation, masses, tenderness

  • Crepitation = palpable/auscultatory “crunching” (e.g., TMJ)

• Hand surfaces

  • Fingertips → fine discrimination, lumps, pulses

  • Dorsum of hand/fingers → temperature (most sensitive)

  • Base of fingers/ulnar surface → vibration

• Technique

  • Start light, then progress to deep (rare in novice nursing practice)

  • Avoid deep palpation over injured abdomen—risk of rupturing spleen/liver, etc.

• Pulse rule: never use your thumb (you feel your own pulse)

Percussion

• Short, sharp taps to map underlying structures (size, density, borders)

• How to strike

  • Non-dominant middle finger firmly on skin (pleximeter)

  • Strike distal interphalangeal joint with tip of dominant middle finger (plexor)

  • Two quick taps, lift

• Expected notes

  • Resonant = normal lung (hollow)

  • Hyper-resonant = COPD/emphysema (extra air)

  • Tympany = stomach/intestine (drum-like)

  • Dull = liver, spleen (muffled thud)

  • Flat = bone, large muscle (absolute dullness)

Auscultation & Stethoscope Use

• Earpieces point toward the nose for seal

• Bell vs. diaphragm

  • “Baby Bell” (small) → low-pitched sounds: bruits, murmurs, extra heart sounds

  • “Daddy Diaphragm” (large) → high-pitched: normal heart, lung, bowel sounds

• Switch sides by turning the stem until click; look for open/closed indicator

• ALWAYS on skin, not over clothing; press firmly enough to create a light seal

• Keep scope clean & warm (stethoscope hygiene with hand hygiene)

• Hair, obesity, large breasts & clothing can obscure sounds—adapt (press firmer, ask patient to lift breast, wet chest hair to reduce artifact)

• Lab requirement: practice with double-headed teaching stethoscope before check-off

Infection Control & Safety

• Best protection for patient & nurse: hand hygiene + cleaning stethoscope

• Standard (Universal) Precautions = gloves for every patient contact w/ body fluids

• Change gloves when

  • Damaged, soiled, after touching contaminated site then clean site, between patients

• Alcohol rub acceptable except when hands visibly soiled, or for C.\;difficile & Norovirus → SOAP & WATER

• Florence Nightingale: pioneer; proved handwashing lowered mortality (“Notes on Nursing”)

Personal Protective Equipment (PPE)

• Transmission-based categories

  • Contact → gown & gloves (e.g., draining wounds, scabies)

  • Droplet → surgical mask + standard (e.g., influenza)

  • Airborne → N-95 respirator, negative-pressure room (e.g., TB, COVID-19)

• Donning order (dance-hand mnemonic):

  • Gown → Mask/Respirator → Goggles/Face shield → Gloves

• Doffing order (Betty-Boop mnemonic):

  • Gloves → Goggles/Face shield → Gown → Mask then hand hygiene

General Survey

A quick, objective “first impression” covering 4 domains:

1. Physical Appearance

• Skin color: normal, \text{cyanosis}, pallor, jaundice, erythema, lesions

• Level of Consciousness (LOC) (Table 5-1)

  • Alert & oriented (\times 3 or \times 4: person, place, time, situation)

  • Confused, lethargic, obtunded, stupor, coma—ABNORMAL

• Overall appearance: no acute distress vs. clutching chest, diaphoresis, grimacing

2. Body Structure

• Stature, nutrition, symmetry, posture

• Tripod position → respiratory distress

• Obvious deformities (e.g., amputations, scoliosis)

3. Mobility

• Gait: smooth, balanced vs. shuffling, limping (see abnormal gaits p. 678)

• Use of assistive devices (cane, walker)

4. Behavior

• Facial expression, mood/affect (pleasant & cooperative desired)

• Speech

  • Clear, articulate vs. dysarthria (motor), dysphasia/aphasia (comprehension)

  • Monotone, rapid flight of ideas – note

• Dress: climate- & culture-appropriate

• Personal hygiene: clean vs. disheveled (may signal depression/illness)

Measurement Techniques

• Weight

  • Remove shoes/heavy clothes; use same scale & time for serial weights

  • Daily weights: before breakfast & after voiding preferred

• Height

  • Shoes off, feet/shoulders/buttocks against wall or stadiometer, looking straight ahead

Body Mass Index (BMI)

• Formula: \text{BMI}=\dfrac{\text{Weight (kg)}}{[\text{Height (m)}]^2}

• Classification

  • <18.5 Underweight

  • 18.5–24.9 Normal

  • 25–29.9 Overweight

  • \ge 30 Obese

• Screening only; muscular persons may read falsely high

Waist Circumference

• Measure at iliac crest after exhalation

• High risk: >35\;\text{in} (women) or >40\;\text{in} (men)

  • Associated with cardiovascular disease & type 2 diabetes

Special Populations: Aging Adult

• Height ↓ due to vertebral disk thinning; postural kyphosis common

• Muscle mass ↓, adipose ↑ around abdomen & hips

• Weight may drop; gait may narrow, arms help balance

Patient-Centered Technique & Teaching

• Unhurried, calm manner reduces patient anxiety

• Provide privacy: gown, drape, expose only what is examined, close curtain/door

• Allow patient to participate (e.g., hold breast for auscultation)

• Continuous micro-teaching: location of call light, signs of infection, med schedules

Mnemonics & Memory Aids Recapped

• Order of exam: I → P → Perc → Ausc (“IPPA”)

• Bell = “Baby, Bruits, low Bass”; Diaphragm = “Daddy, Daily sounds, high”

• PPE Donning: Gown → Mask → Goggles → Gloves (jazz-hands)

• PPE Doffing: Gloves → Goggles → Gown → Mask (Betty Boop, "Oh!")

Miscellaneous Lab / Classroom Notes

• Use dorsal hand or wrist for best temperature detection

• Practice percussion over own clavicle (flat) vs. stomach (tympany)

• Double-headed teaching scopes will be used for skill check-off

• Bed ergonomics: raise bed to spare your back; lower & 2 side-rails ↑ when leaving

• Document special hair styles (e.g., braids) when measuring head circumference

• Expect to “wear” fluids—gloves on entry is a safe habit, but answer NCLEX per guidelines