Collecting Objective Data: Physical Exam Techniques Flashcards
Protect examiner in any part of the
examination when the examiner may have contact with blood, body fluids, secretions, excretions, and contaminated items, or when disease-causing agents could be transmitted to or from the client
gloves and gown
Measure diastolic and systolic blood pressure;
stethoscope to auscultate blood sounds
when measuring blood pressure
Sphygmomanometer and stethoscope
Measure body temperature
Thermometer
Take heart rate, pulse rate
Watch with second hand
Determine perceived pain level
Pain rating scale
Measure skinfold thickness of subcutaneous
tissue
Skinfold calipers
Test for fungus
Wood’s light
Enlarge visibility of lesion
Magnifying glass
Predict one’s risk to develop pressure sore
Braden Scale for predicting pressure sore risk
Determine the degree of healing of a pressure injury
pressure injury Scale for
Healing (PUSH)
Test for strabismus
Opaque card
Test pupillary constriction
Penlight
View the red reflex and examine the retina of the eye
Ophthalmoscope
Test for bone and air conduction of sound
tuning fork
View the ear canal and tympanic membrane
Otoscope
Provide light to view the mouth and the throat and to transilluminate the sinuses
Penlight
Depress tongue to view throat, check
looseness of teeth, view cheeks, and check strength of tongue
Tongue depressor
View the internal nose
Otoscope with wide-tip
attachment
Test for vibratory sensation
Tuning fork
Test for rise of uvula and gag reflex
Tongue depressor
It is important that the nurse strive to ensure that the
examination setting meets the following conditions (6)
- Comfortable, room temperature
- Private area free of interruptions from others
- Quiet area free of distractions
- Adequate lighting
- Firm examination table or bed at a height that prevents stooping
- A bedside table/tray to hold the equipment needed for the examination
means cleaning your hands by using handwashing (washing hands
with soap and water), antiseptic handwash, antiseptic hand rub (i.e., alcohol-based
hand sanitizer including foam or gel), or surgical hand antisepsis.
Hand hygiene
are the most effective products for reducing the number of germs on the hands of health care providers.
Alcohol-based hand sanitizers
are the preferred method for cleaning your hands in most clinical situations.
Alcohol-based hand sanitizers
Wash your hands with ??? whenever they are visibly dirty, before eating, and after using the restroom.
soap and water
Establish the ??? during the client interview before the physical
examination takes place.
nurse–client relationship
This position is good
for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs,
and upper extremities. This position is also useful because it permits full expansion
of the lungs and it allows the examiner to assess symmetry of upper body parts.
sitting
This position allows the abdominal muscles to relax and provides easy
access to peripheral pulse sites. Areas assessed with the client in this position may
include head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities.
supine
This position may be more
comfortable than the supine position for clients with pain in the back or the
abdomen. Areas that may be assessed with the client in this position include head,
neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses. The
abdomen should not be assessed because the abdominal muscles are contracted
in this position.
dorsal recumbent
This position is useful for assessing the rectal and vaginal areas. The
client may need some assistance getting into this position. Clients with joint
problems and elderly clients may have some difficulty assuming and maintaining
this position.
sims
This position allows
the examiner to assess posture, balance, and gait. This position is also used for
examining the male genitalia.
standing
used primarily to assess the hip joint. The back can also be assessed with the
client in this position. Clients with cardiac and respiratory problems cannot tolerate
this position.
prone
useful for
examining the rectum. This position may be embarrassing and uncomfortable for
the client; therefore, the client should be kept in the position for as limited a time as
possible.
knee-chest position
s used to examine the female
genitalia, reproductive tracts, and the rectum. The client may require assistance
getting into this position. It is an exposed position, and clients may feel
embarrassed. In addition, elderly clients may not be able to assume this position
for very long or at all. Therefore, it is best to keep the client well draped during the
examination and to perform the examination as quickly as possible.
lithotomy
Four basic techniques must be mastered before you can perform a thorough and
complete assessment of the client. These techniques are ?
inspection, palpation,
percussion, and auscultation.
involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings.
Inspection
consists of using parts of the hand to touch and feel for some characteristics
Palpation
Three different parts of the hand are used during palpation
the fingerpads,
ulnar/palmar surface,
and dorsal surface
hand part: Fine discriminations: pulses, texture, size, consistency, shape, crepitus
Fingerpads
hand part: Vibrations, thrills, fremitus
Ulnar or palmar surface
hand part: Temperature
Dorsal (back) surface
the four types of palpation
light
moderate
deep
bimanual
palpation: To perform ? palpation (Fig. 3-1), place your dominant hand
lightly on the surface of the structure. There should be very little or no depression (<1 cm). Feel the surface structure using a circular motion. Use this
technique to feel for pulses, tenderness, surface skin texture, temperature, and
moisture.
light
palpation: Depress the skin surface 1 to 2 cm (0.5–0.75 in.) with your
dominant hand, and use a circular motion to feel for easily palpable body organs and masses. Note the size, consistency, and mobility of structures you palpate.
moderate
palpation: Place your dominant hand on the skin surface and your
nondominant hand on top of your dominant hand to apply pressure (Fig. 3-2).
This should result in a surface depression between 2.5 and 5 cm (1 and 2 in.).
This allows you to feel very deep organs or structures that are covered by thick muscle.
deep
palpation: Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated (Fig. 3-3). Use one hand to apply pressure and the other hand to feel the structure. Note the size, shape, consistency, and mobility of the structures you palpate
Bimanual
involves tapping body parts to produce sound waves. These sound waves
or vibrations enable the examiner to assess underlying structures.
Percussion
The three types of percussion are
direct, blunt, and indirect
is the direct tapping of a body part with one or two fingertips to elicit possible tenderness (e.g., tenderness over the sinuses).
Direct percussion
is used to detect tenderness over organs (e.g., kidneys) by placing one hand flat on 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
is the most commonly
used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures.
Indirect or mediate percussion
As density increases, the sound of the tone becomes ???
quieter
??? produces a soft tone,
??? produces a louder tone, and
??? produces an even louder tone.
Solid tissue
fluid
air
is a type of assessment technique that requires the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system,
movement of the bowel, and movement of air through the respiratory tract.
Auscultation
Use the ??? of the stethoscope to listen for low-pitched sounds such as abnormal
heart sounds and bruits
bell
Use the ??? of the stethoscope to listen for high-pitched sounds, such as normal heart sounds, breath sounds, and bowel sounds, and press the diaphragm
firmly on the body part being auscultated.
diaphragm
