Chapter 9 - Assessment Techniques and the Clinical Setting Flashcards
In inspection..
- Do not rush
- Compare patient’s right side with left side
- Use good lighting
- Obtain adequate exposure (of the patient)
- Will include instruments in many body systems
Otoscope/ophthalmoscope
Specula: vaginal, nasal
Penlight
Used as part of a physical examination in which an object is felt (usually with the hands of a healthcare practitioner) to determine its size, shape, firmness, or location.
Palpation
Use different parts of the hands forPalpation:
Fingertips Thumb and forefinger grasp Dorsa Base of fingers Ulnar surface
Depress the skin 1 cm
Light palpation
Depress the skin 5 to 8 cm
Deep palpation
Palpation Specifics - Characteristics Assessed by Palpation
Texture Temperature Moisture Organ location and size Swelling Vibration or pulsation Rigidity or spasticity Crepitation Presence of lumps or masses Presence of tenderness or pain
Best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps
Fingertips
To detect the position, shape, and consistency of an organ or mass
A grasping action of the fingers and thumb
Best for determining temperature because the skin here is thinner than on the palms
The dorsa (backs) of hands and fingers
Best for vibration
Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand
- Tapping the client’s skin with short sharp strokes to assess underlying structured.
- Determine the border of an organ
- Signaling the density (i.e., air, fluid or solid) of a structure by a characteristic note
Percussion (Indirect, Blunt and Direct)
Characteristics of Percussion Notes
- Resonant
- Hyperresonant
- Tympany
- Dull
- Flat
Hollow (i.e., normal lung tissue) percussion
Resonant
Booming (i.e., inflated lung - emphysema) percussion
Hyperresonant
Drumlike (i.e., stomach) percussion
Tympany
Muffled thud (i.e., dense organ - liver, spleen) percussion
Dul
A dead stop of sound, absolute dullness (i.e., no air is present - thigh muscle, bone or tumour) percussion
Flat
Requires both hand because contact is made on the stationary hand against the skin
- Indirect Percussion
- Used to detect tenderness over organs (i.e., kidneys)
- Place one hand flat in the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.
- Blunt Percussion
Requires one hand
The striking hand (plexor) contacts the body wall
Example: Facial sinuses (Semester 3)
- Direct Percussion
- Fit and quality of stethoscope
- Diaphragm and bell endpieces
- Eliminate confusing artifacts
- Ask yourself, “What am I actually hearing? What should I be hearing at this spot?”
- Diaphragm = High Pitches
Example: Breath, bowel and normal heart (S1/S2) sounds - Bell = Low Pitches
Example: Murmurs and extra heart sounds (S3/S4)
Auscultation
Warm and comfortable
Quiet, private and proper lighting
Examination Room
Should be positioned so it is accessible from both sides
Bedside stand is essential for equipment
Examination Table
Other Places of Examination
Hospital Room
Long Term Care (LTC) Room
Developmental Considerations for Infants
The major task of infancy as establishing trust. If basic needs are met promptly and consistently, the infant feels secure and learns to trust others.
Perform the examination 1 to 2 hours after the baby is fed, when the baby is not too drowsy or too hungry.
Maintain a warm environment.
Use a soft, crooning voice during the examination; babies respond more to the feeling in the tone of the voice than to what is actually said.
Offer the baby a pacifier for crying or during invasive steps.
When a baby is sleeping, seize the opportunity to listen to heart, lung, and abdomen sounds first.
Perform least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last.
Elicit the Moro, or “startle,” reflex at the end of the examination because it may cause the baby to cry.
Developmental Considerations for Toddlers
Toddlers are beginning to develop autonomy.
Toddlers may be difficult to examine; do not take this personally. Because they are acutely aware of being in a new environment, toddlers may be frightened and cling to the parents. Also, toddlers fear invasive procedures and dislike being restrained.
A toddler should be sitting up on the parent’s lap for all of the examination. When the toddler must be supine.
Children 1 or 2 years of age can understand symbols, and so a security object, such as a special blanket or teddy bear, is helpful.
Child 1 to 6 years old, focus more on the parent. Then turn your attention gradually to the child, at first to a toy or object the child is holding, or perhaps to compliment a dress or their hair.
Children 1 or 2 years of age like to say, “No.” Do not offer a choice when there really is none. Use clear firm instructions, in a tone that expects cooperation: “Now it is time for you to lie down so I can check your tummy.”
Demonstrate the procedures on the parent.
Praise the child when he or she is cooperative.
Developmental Considerations for Preschool-age children
Preschool-age children display developing initiative. The preschooler takes on tasks independently, plans the tasks, and follows them through. A child of this age is often cooperative, helpful, and easy to involve.
With a 3-year-old child, the parent should be present and may hold the child on his or her lap.
A 4- or 5-year-old child usually feels comfortable on the “Big Girl” or “Big Boy” (examining) table, with the parent present.
A preschooler can talk. Verbal communication becomes helpful now, but remember that the child’s understanding is still limited. Use short, simple explanations.
The preschooler is usually willing to undress. Leave underpants on until the genital examination.
Talk to the child and explain the steps in the examination exactly.
Preschoolers like to help; have the child hold the stethoscope for you.
Compliment the child on his or her cooperation
Developmental Considerations for School-age children
During the school-age period, the major task of children is developing industry. When successful, they have a feeling of accomplishment.
Break the ice with small talk about family, school, friends, music, or sports.
The child should undress himself or herself, leave underpants on, and don a gown and drape.
Comment on the body and how it works. An 8- or 9-year-old child has some understanding of the body and is interested to learn more.
As with adults, progress from head to toes.
Developmental Considerations for Adolescents
The major task in adolescence is developing a self-identity. This takes shape from various sets of values and different social roles (son or daughter, sibling, and student).
Peer group values and peer acceptance are important.
Examine the adolescent alone, without a parent or sibling present.
The adolescent’s body is changing rapidly. During the examination, the adolescent needs feedback that his or her own body is healthy and developing normally.
The adolescent has a keen awareness of body image, often comparing himself or herself with peers.
Communicate with some care. Do not treat the teenager like a child, but do not overestimate and treat him or her like an adult, either.
Focus your teaching on ways in which adolescents can achieve their own wellness.
As with the adult, a head-to-toe approach is appropriate. Examine genitalia last, and do so quickly.
Developmental Considerations for Older Adults
During later years, the tasks are developing the meaning of life and one’s own existence and adjusting to changes in physical strength and health.
Arrange the sequence to allow as few position changes as possible.
Allow rest periods when needed.
The pace of the examination may need to be slowed.
Use physical touch (unless there is a cultural contraindication). This is especially important with older adults because other senses, such as vision and hearing, may be diminished.
Note: Do not automatically mistake diminished vision or hearing for confusion.
Use the head-to-toe approach as in younger adults.
Developmental Considerations for Ill Patients
For a patient in some distress, alter the position during the examination.
Example: A patient with shortness of breath or ear pain may want to sit up, whereas a person with faintness or overwhelming fatigue may want to be supine.
Initially, it may be necessary just to examine the body areas appropriate to the problem, collecting a mini-database.
You may resume a complete assessment after the initial distress is alleviated.
