4 basic assessment techniques
- *** this is done the most. it is the 1st & ongoing part of the exam
Physical exams begin w/inspection
- a visual exam of the body, including body movement & posture (data by obtained by smell is also part of inspection)
- examination of every body system includes technique of inspection
creating shadows by directing light at right angles to the area being inspected
- involves using hands to feel texture, size, shape, consistency, pulsations and location of certain parts of the clients body
• Gentle touch, warm hands,and short nails to prevent discomfort or injury to client
- Touch has cultural symbolism and significance.
- State purpose, manner, and location of touching.
- Wear gloves when palpating mucous membranes or
other areas where contact with body fluids is possible.
- is performed to evaluate the size, borders, and consistency of internal organs, to detect tenderness and determine the extent of fluid in a body cavity
Ex. bladder after surgery & kidney tenderness
- involves striking a finger or hand directly against the client's body
- for tenderness
- both hands and is done by different methods depending on the body system
- for sound
- percuss 2 or 3 times in one location before moving on to another
- stronger percussion is needed for obese or muscular
a loud (relatively), high-pitched sound heard over the abdomen. air in abdomen
is heard over normal lung tissue (larger amount of air)
is heard in overinflated lungs (ex. emphysema)
is heard over the liver & heart
is heard over bones and muscle
• Listen for sound and characteristics
- intensity - pitch - duration - quality
• Concentrate; sounds may be transitory or subtle.
- Closing eyes may improve listening.
- Selective listening is isolating specific sounds,
such as air during inspiration, or a single heart
• Optimize quality of auscultation findings.
- quiet room
- Stethoscope must be placed directly on skin
- If client is cold and shivers, involuntary muscle
contractions may interfere with normal sounds.
• Auscultates sounds within body not easily audible by ear
• Acoustic most common
• Sound transmitted through tubes to ear
- Does not magnify sound but blocks extraneous sound making difficult sounds easier to hear
- Four components: earpieces, binaurals, tubing, and head with diaphragm and bell
• Earpieces may be hard or soft.
- Should fit snugly and completely fill ear canal
• Binaurals are tubes of metal that connect stethoscope tubing to ear pieces.
- Allow ear pieces to be angled toward nose to project sound toward tympanic membrane.
• Tubing usually firm polyvinyl no longer than 12 to 18 inches (30 to 46 cm)
used to hear higher pitched sounds, such as breath sounds, bowel sounds & normal heart sounds
used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruits)
• Tuning fork has two purposes: auditory screening and assessment of vibratory sensation.
• Sharply strike tuning fork on heel of hand.
- neuropathy & diabetic patients don't have feeling of vibrations
eye: snellen chart = distance
• Snellen chart is wall chart 20 feet from client.
- 11 lines of letters decreasing in size
- Letter size indicates visual acuity from 20 feet
- Tests one eye at a time
- Provides visual acuity number
- Top number = distance from chart
- Bottom number = distance person with normal
vision should be able to read line
• Colors of horizontal lines, red and green color perception
- Top line green, bottom line red
- Ask client which line is longer as screening for
field perception measurement.
• E chart used for young children and
non-English‐speaking clients - Scored same as Snellen
• Jaeger and the Rosenbaum charts are commonly used to evaluate near vision.
- Rosenbaum consists of numbers, Es, Xs, and Os in graduated sizes.
- Held 14 inches away, one eye at a time
- Visual acuity is measured same as Snellen.
- Jaeger equivalent is shown on same chart.
- consists of magnification lens, light source, and speculum inserted into auditory canal to inspect external auditory canal and tympanic membrane
- is an instrument consisting of series of lenses, mirrors, and light apertures to inspect internal eye structures.
calipers for skin fold thickness
• Measure thickness of subcutaneous tissue to estimate amount of body fat.
• Different models may be used for different points on body.
• Most frequent location is posterior aspect of triceps.
• Determines degree of flexion or extension of joint
• Two‐piece ruler jointed in middle with a protractor‐type measuring device
• Placed over joint; as individual extends or flexes joint, degrees of flexion and extension are measured on protractor
Ex. stroke victims --> limbs cannot contract
• Doppler uses ultrasonic waves to detect and amplify difficult‐to‐hear vascular sounds, such as fetal heart tones or peripheral pulses.
• Coupling gel applied to client's skin; then transducer is slid over skin surface until blood flow is heard in earpieces.
- As blood in vessels ebbs and flows, Doppler picks up and amplifies subtle changes in pitch; the resulting sound that nurse hears is a swishing, pulsating sound.
• Volume control may further amplify sound.
• Spreads opening of nares to inspect internal surfaces of nose
• Two instruments may be used as a nasal speculum.
- Simple nasal speculum is used in conjunction with penlight to inspect lower and middle turbinates of the nose.
- Gently squeezing handle of speculum causes blades of speculum to open and spread nares.
- Second type is broad‐tipped, cone‐shaped device that is placed on the end of an otoscope.
percussion or reflex hammer
• Used to test deep tendon reflexes
• Percussion (reflex) hammer consists of a
triangular rubber component on end of a metal handle.
- Flat surface commonly used when striking tendon directly.
- Pointed surface used to strike tendon directly or to strike a finger, which is placed on a small tendon such as client's biceps tendon.
- Neurologic hammer can also be used to test deep tendon reflexes; similar to percussion hammer, but the rubber striking end is rounded on both sides.
• Used to test lower extremity sensation
• Small, flexible wire‐like device attached to
handle and bends at 10 g of pressure
- Used to assess sensation on various parts of
foot, to touch intact skin only
- Inability to feel suggests reduced peripheral
- test for neuropathy, diabetes, chemotherapy patient
• Used to differentiate characteristics of tissue, fluid, and air in specific body cavity
• Strong light source with narrow beam at distal section of light
• Room darkened, light placed against skin over body cavity
- Light is transmitted differently through air, fluid, or tissue with different glowing red hues.
- Character of glowing light hues determines if area under surface is filled with air, fluid, or tissue.
• Latex allergy, a reaction to proteins in latex rubber, is increasing.
• Amount of exposure threshold unknown, but increased exposure leads to increased risk.
- Health care providers are at risk from frequent exposure and may use nonlatex gloves.
- Clients may have latex allergy, particularly children with spina bifida and clients with multiple medical procedures or surgeries, especially genitourinary surgery