32 terms

1145 Techniques & equipment for physical assessement

4 basic assessment techniques
1. inspection
2. paplation
3. percussion
4. auscultation
- *** 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
tangential lighting
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
percussion: direct
- involves striking a finger or hand directly against the client's body
- for tenderness
percussion: indirect
- 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
percussion: tympany
a loud (relatively), high-pitched sound heard over the abdomen. air in abdomen
percussion: resonance
is heard over normal lung tissue (larger amount of air)
percussion: hyperresonance
is heard in overinflated lungs (ex. emphysema)
percussion: dullness
is heard over the liver & heart
percussion: flatness
is heard over bones and muscle
• Listening
• Stethoscope
• Listen for sound and characteristics
- intensity - pitch - duration - quality
Auscultation: tips
• 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)
stethoscope: diaphragm
used to hear higher pitched sounds, such as breath sounds, bowel sounds & normal heart sounds
stethoscope: bell
used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruits)
tuning fork
• 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
visual perception
• 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.
visual: kids
• E chart used for young children and
non-English‐speaking clients - Scored same as Snellen
visual: near
• 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.
nasal speculum
• 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