Chapter 8: Assessment techniques (palpation) Flashcards
Order of physical assessment
inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion).
Focused Inspection
inspection phase
takes time and yields a surprising amount of information.
focused assessment
is significantly more than a “quick glance
best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms
dorsa (backs) of the hands and fingers
best for fine, tactile discrimination
Fingertips
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient
palpation
what involves vision
inspection
assesses through the use of palpable vibrations and audible sounds
percussion
what uses the sense of hearing.
auscultation
initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.
Light palpation
use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa
Bimanual palpation
what yields a sound that depicts the location, size, and density of the underlying organ
Percussion
Turgor and texture are assessed with?
palpation
percussion,
the nurse should percuss two times over each location
percussion
The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm.
Percussion over relatively dense organs, such as the liver or spleen makes what sound
dull
requires good lighting, adequate exposure, and occasional use of certain instruments (otoscope, ophthalmoscope, penlight, nasal and vaginal specula) to enlarge your view
Inspection
what assess texture; temperature; moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity (muscle tightness), crepitation, presence of lumps or masses, and presence of tenderness or pain.
Palpation
what part of arm Best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps
fingertips
what detects the position, shape, and consistency of an organ or mass
grasping action of the fingers and thumb
whats best detecting vibration
Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand
deep palpation
(as for abdominal contents), intermittent pressure is better than one long, continuous palpation.
Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors
percussion
Signaling the density (air, fluid, or solid) of a structure by a characteristic note
percussiion
Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm (2 inches) deep
percussion
Eliciting a deep tendon reflex
using percussion hammer
Hyperextend the middle finger (the pleximeter) and place its distal joint and tip firmly against the person’s skin. Avoid placement over the ribs, scapulae, and other bony prominences.
-direct percussion- involves tapping lightly with pad of finger directly on clients skin
Stationary Hand (method of percussion)
the goal is to hit the portion of the finger that is pushing the hardest into the skin surface
Use the middle finger of your dominant hand as the striking finger (the plexor) (Fig. 8.3). Hold your forearm close to the skin surface, with your upper arm and shoulder steady.
-indirect percussion (use both hands) strike stationary finger like hammer to produce best sound
Flex the striking finger so that its tip, not the finger pad, makes contact. It hits directly at right angles to the stationary finger.
Striking Hand (method of percussion)
(1) amplitude (or intensity), a loud or soft sound;
(2) pitch (or frequency), the number of vibrations per second;
(3) quality (timbre), a subjective difference caused by the distinctive overtones of a sound;
(4) duration, the length of time the note lingers.
Percussion vibrations produce waves aka notes
(1) amplitude (or intensity)- medium-loud
(2) pitch (or frequency)- low
(3) quality (timbre)- clear,hollow
(4) duration- moderate
Normal lung tissue-Resonant
(1) amplitude (or intensity)-Louder
(2) pitch (or frequency)-Lower
(3) quality (timbre)- Booming
(4) duration- Longer
Hyperresonant
Normal over child’s lung
Abnormal in the adult, over lungs with increased amount of air as in emphysema
(1) amplitude (or intensity)-Loud
(2) pitch (or frequency)-High
(3) quality (timbre)- Musical and drumlike (like the kettledrum
(4) duration- Sustained longest
Tympany
Over air-filled viscus (e.g., the stomach, the intestine)
(1) amplitude (or intensity)-soft
(2) pitch (or frequency)-high
(3) quality (timbre)- muffled thud
(4) duration- short
Dull
Relatively dense organ as liver or spleen
(1) amplitude (or intensity)-very soft
(2) pitch (or frequency)-high
(3) quality (timbre)- A dead stop of sound, absolute dullness
(4) duration- very short
Flat
When no air is present, over thigh muscles or bone or over tumor
funnels light into the ear canal and onto the tympanic membrane
Otoscope
stethoscope
long tubing distort sound
best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be firmly held against the person’s skin, firmly enough to leave a ring.
Diaphragm of stethoscope
best for soft, low-pitched sounds such as extra heart sounds or murmurs.
Bell of Stethoscope
directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear
Otoscope
Short, broad speculum
Visualize nares
used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism
Opthalmoscope
used, most often the small spot for undilated pupils or the large full spot for dilated pupils.
aperture of opthalmoscope
Rotating the lens selector dial
brings the object into focus.
shows a number, or diopter, that indicates the value of the lens in position. The black numbers indicate a positive lens, from 0 to +40. The red numbers indicate a negative lens, from 0 to −20
lens indicator (Opthalmoscope)
measure joint range of motion
goniometer
to augment pulse or blood pressure measurement
Doppler sonometer
test sensation in the foot, and bladder scanner to assess urine retention.
monofilament
used to assess size and location of lesions on the fundus
Grid
is used to auscultate fetal heart tones.
fetoscope
The sequence of the steps of the assessment may differ, depending on the ?
age of the person and the examiner’s preference
elicited at the end of the examination because it may cause the infant to cry.
Moro or startle reflex
develops 32 wks gestation response to sudden lost support 3 components: 1.spreading out arms (abduction) 2.crying 3.pulls arm and leg back in
Moro or startle reflex
defines the major task of infancy as establishing trust. An infant is completely dependent on the caregiver for his or her basic needs. If these needs are met promptly and consistently, the infant feels secure and learns to trust others
Erikson (developmental competence)
need feedback and reassurance
exam of head should be last
willing to undress (not age 2)
Preschool
child has a sense of modesty. The child should undress him or herself, leaving underpants on and using a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from the child’s head to the toes.
6-year old
