Chapter 9 - Assessment Techniques and the Clinical Setting

Question 1

In inspection..

Answer 1

• 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

Question 2

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.

Answer 2

Palpation

Question 3

Use different parts of the hands forPalpation:

Answer 3

Fingertips
Thumb and forefinger grasp
Dorsa
Base of fingers
Ulnar surface

Question 4

Depress the skin 1 cm

Answer 4

Light palpation

Question 5

Depress the skin 5 to 8 cm

Answer 5

Deep palpation

Question 6

Palpation Specifics - Characteristics Assessed by Palpation

Answer 6

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

Question 7

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

Answer 7

Fingertips

Question 8

To detect the position, shape, and consistency of an organ or mass

Answer 8

A grasping action of the fingers and thumb

Question 9

Best for determining temperature because the skin here is thinner than on the palms

Answer 9

The dorsa (backs) of hands and fingers

Question 10

Best for vibration

Answer 10

Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand

Question 11

• 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

Answer 11

Percussion (Indirect, Blunt and Direct)

Question 12

Characteristics of Percussion Notes

Answer 12

1. Resonant
2. Hyperresonant
3. Tympany
4. Dull
5. Flat

Question 13

Hollow (i.e., normal lung tissue) percussion

Answer 13

Resonant

Question 14

Booming (i.e., inflated lung - emphysema) percussion

Answer 14

Hyperresonant

Question 15

Drumlike (i.e., stomach) percussion

Answer 15

Tympany

Question 16

Muffled thud (i.e., dense organ - liver, spleen) percussion

Answer 16

Dul

Question 17

A dead stop of sound, absolute dullness (i.e., no air is present - thigh muscle, bone or tumour) percussion

Answer 17

Flat

Question 18

Requires both hand because contact is made on the stationary hand against the skin

Answer 18

1. Indirect Percussion

Question 19

• 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.

Answer 19

2. Blunt Percussion

Question 20

Requires one hand
The striking hand (plexor) contacts the body wall
Example: Facial sinuses (Semester 3)

Answer 20

3. Direct Percussion

Question 21

• 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)

Answer 21

Auscultation

Question 22

Warm and comfortable

Quiet, private and proper lighting

Answer 22

Examination Room

Question 23

Should be positioned so it is accessible from both sides

Bedside stand is essential for equipment

Answer 23

Examination Table

Question 24

Other Places of Examination

Answer 24

Hospital Room

Long Term Care (LTC) Room

Question 25

Developmental Considerations for Infants

Answer 25

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.

Question 26

Developmental Considerations for Toddlers

Answer 26

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.

Question 27

Developmental Considerations for Preschool-age children

Answer 27

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

Question 28

Developmental Considerations for School-age children

Answer 28

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.

Question 29

Developmental Considerations for Adolescents

Answer 29

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.

Question 30

Developmental Considerations for Older Adults

Answer 30

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.

Question 31

Developmental Considerations for Ill Patients

Answer 31

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.