Class 2-Assessment Techniques and Safety in the Clinical Setting

Question 1

-Gathering objective data through physical assessment
-developing your sense of vision, hearing, smell, and touch
-requires practice and repetition

Question 2

Cultivating your senses

Answer 2

-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

Question 3

Inspection

Answer 3

*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

Question 4

Palpation

Answer 4

**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

Question 5

What parts of hand for palpation?

Answer 5

-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)

Question 6

How to palpate?

Answer 6

-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

Question 7

Flow of palpation

Answer 7

-top to bottom
-left to right
-simultaneously
-compare symmetrically
-may need to implement relaxation techniques for deep palpation

Question 8

Common areas of palpation

Answer 8

-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

Question 9

Characteristics assessed by palpation

Answer 9

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

Question 10

Percussion

Answer 10

-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

Question 11

2 percussion methods

Answer 11

1. the stationary hand
2. the striking hand

Question 12

The stationary hand

Answer 12

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

Question 13

The striking hand

Answer 13

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

Question 14

Percussion

Answer 14

-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)

Question 15

Characteristics of sounds

Answer 15

-amplitude (intensity): loud or soft sound
-pitch (frequency): number of vibrations per second
-quality (timbre): subjective difference
-duration: length of time sound lingers

Question 16

More characteristics

Answer 16

-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

Question 17

Auscultation

Answer 17

-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)

Question 18

Auscultation: Basic principles

Answer 18

-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

Question 19

Conducting effective auscultation

Answer 19

-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

Question 20

Preparing for the physical exam

Answer 20

-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

Question 21

Conducting the physical exam

Answer 21

-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

Question 22

Examination of the aging adult: making accommodations for older patients

Answer 22

-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

Question 23

A safer environment

Answer 23

-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

Question 24

Standard precautions for use with all patients

Answer 24

-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)