Class 2-Assessment Techniques and Safety in the Clinical Setting Flashcards
-Gathering objective data through physical assessment
-developing your sense of vision, hearing, smell, and touch
-requires practice and repetition
Cultivating your senses
-physical examination requires use of technical skills through senses (sight, smell, touch, or hearing) to obtain data
-requisite skills performed one at a time typically in this order:
-inspection
-palpation
-percussion
-auscultation
Inspection
*remove clothing
-careful, thorough observation
-is the very first step in the assessment process
-do not rush, begins the moment you meet the individual
-compare patient’s right side with left side, look for similarities, differences, symmetry
-use good lighting
-obtain adequate exposure (of the patient)
-may require position changes
-will use tools such as penlight, oto, and ophthalmoscope
-look for tumors, hernias, scars/surgeries
Palpation
**do not palpate abdomen; when touched stimulates bowel sounds so auscultate
-using your sense of touch
-assess texture, temperature, moisture, organ location, and size
-cannot determine disease state of an organ
-detect swelling, vibration, pulsation, rigidity, crepitation
-detect a lump, mass, tenderness, or pain
-light palpation: use to detect surface characteristics
-deep palpation: use intermittent pressure to examine abdominal contents
-ask any pain or tenderness; do that part LAST & gentle
What parts of hand for palpation?
-can use various parts of the hand
-fingertips for fine discrimination such as texture, swelling, pulsation, presence of lumps
-grasping action of finger and thumb can be used to detect shape, size, position, and consistency of an organ
-base of fingers or ulnar surface (small finger side of the hand) to detect vibration
-dorsum (back of hand) of hand to detect temperature changes
-bimanual palpation (both hands)
How to palpate?
-palpate slowly and systematically using calm and gentle approach
-ask the patient if there are any tender areas and palpate these areas LAST
-always begin with light palpation and move to deep palpation
Flow of palpation
-top to bottom
-left to right
-simultaneously
-compare symmetrically
-may need to implement relaxation techniques for deep palpation
Common areas of palpation
-lymph nodes (neck) simultaneous
-sinuses (simultaneous)
-abdomen (clockwise pattern); quadrants
-spine (top to bottom)
-pulses (simultaneous right and left or individually)
-uterus (bimanual)
-heart (fingertips over precordium); region of thorax immediately in front of heart
Characteristics assessed by palpation
cluster cues
-texture
-temperature
-moisture
-organ location and size
-swelling
-vibration or pulsation
-rigidity or spasticity
-crepitation (crack, air trapped in tissues; Rice Krispies-pneumothorax)
-presence of lumps or masses
-presence of tenderness or pain
Percussion
-tapping the skin with short, sharp strokes that produce a vibration (with a characteristic sound) to assess underlying structures
-emits a sound that depicts size, location, density of an organ
-mapping location and size: sound will change as you move off/away from the organ
-density: sound will change as you percuss over air, fluid, or solid structures
-abnormal mass: can be detected up to 5 cm deep
-pain: can detect underlying inflammation
-tendon: can elicit a deep tendon reflex
2 percussion methods
- the stationary hand
- the striking hand
The stationary hand
see slide 11 for visual
-hyperextend the middle finger (the pleximeter)
-place distal joint and tip firmly against the person’s skin
-only distal joint and tip of middle finger should be touching the person’s skin
The striking hand
see slide 12 for visual
-use the middle finger of your dominant hand (the plexor)
-hold forearm to skin surface making muscles steady but not rigid
-flex striking finger so tip makes contact
Percussion
-What sounds will I hear?
-Remember percussion produces a vibration within the structures below and will elicit a characteristic sound
-structures with more air will produce a louder, longer, deeper sound because it can vibrate freely (lungs)
-denser, more solid structures produce a softer, higher, shorter sound because they can’t vibrate as easily (liver)
Characteristics of sounds
-amplitude (intensity): loud or soft sound
-pitch (frequency): number of vibrations per second
-quality (timbre): subjective difference
-duration: length of time sound lingers
More characteristics
-resonant, over lung fields, sound clear, hollow
-hyper resonant, over child lungs or COPD
-tympany, over abdomen (air filled areas), sounds drum like
-dull, over organs (liver) sounds like a muffled thud
-flat, over bone, muscle, tumor, sound comes to a dead stop
-amplitude can be loud or soft
Auscultation
-using a stethoscope to block out room sounds so that you can hear sounds produced by the body
-diaphragm used to detect high pitched sound (lungs, abdomen, heart) (bigger side)
-bell used to detect low pitched sounds (vascular sounds, extra heart sounds) bruit; turbulent blood flow (smaller side)
Auscultation: Basic principles
-eliminate extra noise
-keep environment warm and warm your stethoscope
-avoid listening over hairy body areas
-never listen through a patient’s gown or clothing
-avoid your own artifact
Conducting effective auscultation
-turn stethoscope for bell or diaphragm if required
-clean with alcohol before placing on patient, warm it
-earpieces should point toward your nose
-for diaphragm: place firmly
-for bell: place lightly
- never listen through clothing
-avoid breathing, moving or bumping tubing
-listen to 1 sound at a time
-practice, practice, practice
Preparing for the physical exam
-height of bed or exam table, avoid stooping
-establish a clean field and layout equipment ahead of time
-place equipment within easy reach
-wash hands, have gloves readily available
-provide privacy
-proper lighting and room temperature
-perform exam from the right side of the patient; assess heart
-introduce yourself, identify patient, tell them what you will do, and that you will give them a summary of your findings at the end of the exam
-remind patient to let you know if there is anything that is making them uncomfortable
Conducting the physical exam
-develop a sequence and stick to it
-jog notes along the way if needed
-should have a logical flow, avoid having the patient change position multiple times
-if you do forget something, go back to it when it is easiest for the patient
-speak to the patient during the exam (periodically) to maintain a rapport
-encourage patient to ask questions, treat patient with dignity and respect
-allow privacy for patient to change, return to room, thank patient
Examination of the aging adult: making accommodations for older patients
-slower pace
-consider visual and/or hearing deficits
-arrange your sequence to allow for as few position changes as possible, be flexible
-may need rest periods between areas of exam
-get name, date of birth, check name band
A safer environment
-clean the equipment
-clean vs. used area for handling equipment
-nosocomial infections
-handwashing or alcohol-based hand rub
-wear gloves
-standard precautions
-transmission-based precautions
-lock wheels
Standard precautions for use with all patients
-hand hygiene
-use of gloves, mask, eye protection, or face shield
-respiratory hygiene/cough etiquette
-personal protective equipment (PPE)
-precautions in the clinical setting:
-standard
-transmission-based –>contact (c. diff, MRSA), droplet (influenza), airborne (TB, covid)
