copyright © 2013 by mosby, an imprint of elsevier inc. techniques and equipment for physical...

CHAPTER 3

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Techniques and Equipment for Physical Assessment

DSN Kevin Dobi, MS, APRN

Infection Control Practices

Standard Precautions apply in all health care settings: Hand hygiene is the single-most important

component to reduce infection transmission. Utilize personal protective equipment as

necessary. Proper management of patient care

equipment is essential. Be mindful of latex allergies:

Health care professionals are at risk for developing latex allergies because of frequent exposure.

Patients may also have a latex allergy – Ask!Copyright © 2013 by Mosby, an imprint

of Elsevier Inc. 2

IPPA

Inspection

Palpation

Percussion

Auscultation


Inspection

Physical exams begin with inspection: Visual exam of body, including movement and

posture. Data obtained by smell are also a part of

inspection. Examination of every body system includes

technique of inspection. Patient is draped appropriately to maintain

modesty while allowing sufficient exposure for exam; adequate lighting is essential.


Inspection (contd.)

Patient should be thoroughly observed with a critical eye.

Concentration without distraction avoids overlooking potentially important data.

Inspection may seem easy to master, but practice is necessary to develop skill.

Use of equipment may facilitate inspection of certain body systems: Penlight, otoscope, ophthalmoscope, and

vaginal speculum.


Palpation

Use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas.

Requires nurse to move into personal space. Gentle touch, warm hands, and short nails to

prevent discomfort or injury to patient: 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.


Palpation (contd.)

Palmar surface of fingers and finger pads are more sensitive than fingertips. Better to determine position, texture, size,

consistency, masses, fluid, crepitus. Ulnar surface of hand to fifth finger is most

sensitive to vibration. Dorsal surface is better for assessing

temperature.


Palpation (contd.)

Using palmar surfaces of fingers may be light or deep and controlled by amount of pressure.

Light palpation accomplished by pressing to a depth of approximately 1 cm, used to assess skin, pulsations, and tenderness.

Deep palpation accomplished by pressing to a depth of 4 cm with one or two hands: used to determine organ size and contour.


Palpation (contd.)

Bimanual technique of palpation uses both hands, one anterior and one posterior, to entrap an organ or mass between fingertips to assess size and shape.

Light palpation should always precede deep palpation because deep palpation may cause tenderness or disrupt fluids, which may interfere with collecting data by light palpation.


Percussion

Percussion performed to: Evaluate size, borders, and consistency of

internal organs. Detect tenderness. Determine extent of fluid in a body cavity.


Percussion (contd.)

Direct percussion Strike finger or hand directly against patient’s

body Evaluate adult sinus by directly tapping finger

on sinus Elicit tenderness over kidney by striking

costovertebral angle (CVA) directly with fist


Percussion (contd.)

Indirect percussion requires both hands; methods can vary by system being assessed.

Place the distal aspect of the middle finger of the nondominant hand against the skin over the organ being percussed and strike the distal interphalangeal joint with the tip of the middle finger of the dominant hand.

Force of the downward snap of the striking finger comes form rapid flexion of the wrist.

Rebound quickly to avoid muffling of the vibration.


Percussion (contd.)

Tapping produces a vibration deep in body tissue, with subsequent sound waves.

Percuss two or three times in one location before moving to another.

Stronger percussion is needed for obese or very muscular patients because thickness of tissue can impede vibrations.


Percussion (contd.)

Five percussion tones: Tympany is loud, high-pitched sound heard

over abdomen. Resonance is heard over normal lung tissue. Hyperresonance is heard in overinflated lungs,

as in emphysema. Dullness is heard over liver. Flatness is heard over bones and muscle.


Auscultation

Auscultation is listening to sounds within body; nurse commonly uses stethoscope to facilitate auscultation.

Stethoscope is used for auscultation to block out extraneous sounds when evaluating condition of heart, blood vessels, lungs, and intestines.

Listen for sound and characteristics: Intensity, pitch, duration, and quality.


Auscultation (contd.)

Concentrate; sounds may be transitory or subtle: Selective listening is isolating specific sounds,

such as air during inspiration, or a single heart sound.

Optimize quality of auscultation findings: Best to auscultate in quiet room where noises

cannot interfere. Stethoscope must be placed directly on skin

because clothes obscure or alter sounds. If patient is cold and shivers, involuntary muscle

contractions may interfere with normal sounds. Friction of body hair rubbing against diaphragm

could be mistaken for abnormal lung sounds (crackles).


Patient Positioning

Position depends on type of exam and condition of patient: Sitting and supine positions are most

common. Appropriate draping in positions with adequate

exposure is needed for exam. Inability of patient to assume position may be a

significant finding about physical condition and may require accommodation.


Equipment Used During the Examination Process

Equipment is used to facilitate collection of data. Equipment used varies depending on type of

exam and problem being assessed and provides: Measurements: Temperature, weight, visual

acuity. Facilitation of examination technique:

Inspection, auscultation, percussion, or palpation.


Thermometers

Measure body temperature; three types: Electronic: Calculates and displays

temperature on digital screen within 15 to 30 seconds.

Tympanic: Temperatures are obtained by placing a probe into ear; studies have shown widely varying results.

Temporal artery: Utilizes infrared technology; studies demonstrate a high level of accuracy.


Stethoscope

Auscultates sounds within body not easily audible to human ear.

Four types of stethoscopes: Acoustic – most common Magnetic Electric Stereophonic

The acoustic stethoscope transmits sound waves from the source through the tube to the ears: 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.Copyright © 2013 by Mosby, an imprint

of Elsevier Inc. 25

Stethoscope (contd.)

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). Tubing longer than 18 inches may distort

sounds.


Stethoscope (contd.) Head includes two components:

Diaphragm is flat surface with rubber or plastic ring: Used to hear high-pitched sounds such as breath sounds,

bowel sounds, and normal heart sounds. Structure screens out low-pitched sounds

Bell constructed in concave shape: Used to hear soft, low-pitched sounds such as extra heart

sounds or vascular sounds (bruit). Should be pressed lightly on skin with just enough pressure

to ensure a complete seal around bell. A special type of acoustic stethoscope, a fetoscope, is

used to auscultate fetal heart: Fetoscope has a metal attachment that rests against the

head of nurse and aids in conduction of sound so that heart tones are heard more easily.


Equipment to MeasureBlood Pressure

Measures arterial blood pressure indirectly (noninvasively).

Sphygmomanometer consists of gauge to measure pressure, a cuff enclosing an inflatable bladder, and bulb with valve used to inflate and deflate bladder within cuff .

Cuff sizes vary. It is necessary to ensure the correct size is utilized for

accurate results. Stethoscope is used to auscultate blood

pressure.


Automated Blood Pressure Devices

A noninvasive blood pressure (NIBP) monitor is an electronic device attached to the cuff It senses blood flow vibrations and converts them

to electric impulses transmitted to digital readout. Readout indicates blood pressure, mean arterial

pressure, and pulse rate. It is not capable of determining quality of pulse,

such as rhythm or intensity. It may be programmed to repeat measurements

on a scheduled basis and to sound an alarm if measurements are outside of desired limits. It is an especially useful feature for patients

requiring frequent blood pressure monitoring.


Pulse Oximetry

Highly accurate noninvasive measurement estimates arterial oxygen saturation in blood.

Consists of LED probe emitting light waves that reflect off oxygenated and deoxygenated hemoglobin molecules circulating in blood.

Reflection used to estimate percentage of oxygen saturation in arterial blood and pulse rate. Sensor taped to ear, finger, or toe.


Scales

Measure body height and weight. Standing platform used for older children and

adults: Sensitive to 0.25 pound (0.1 kg) Attachment for height measurement. Electronic scales display digital readout.

Infant platform scale in ounces and grams.


Visual Acuity and Screening

Snellen chart is wall chart placed 20 feet from patient: 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. E chart used for young children and

non–English-speaking patients: Scored same as Snellen.


Visual Acuity and Screening (contd.)

Jaeger and 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 tested at a time.

Visual acuity is measured same as Snellen. Jaeger equivalent is shown on same chart.


Ophthalmoscope

Ophthalmoscope is an instrument consisting of series of lenses, mirrors, and light apertures to inspect internal eye structures: Head consists of lens selector dial and

aperture settings. Lens selector dial adjusts lenses that control

focus; unit of strength for each lens is diopter. Positive and negative lenses compensate for

myopia or hyperopia in both nurse’s and patient’s eyes and permit focusing at different places within patient’s eye.


Ophthalmoscope (contd.)

Aperture permits light variations during exam: If patient’s pupils have been dilated, the large

light may be used for internal eye examination.

Small light may be used if patient’s pupils are very small or if pupils have not been dilated.

Red-free filter shines green beam and facilitates identification of pallor of disc; hemorrhages appear black.

Slit light permits exam of anterior of eye and elevation or depression of a lesion.

Grid light facilitates an estimate of size, location, and pattern of fundal lesion.


Otoscope

Otoscope consists of magnification lens, light source, and speculum inserted into auditory canal to inspect external auditory canal and tympanic membrane.

Choose largest size speculum that fits into patient’s ear canal.

Pneumatic attachment produces small puffs of air against tympanic membrane to evaluate fluctuation of tympanic membrane in children.


Penlight

Provides focused light source for inspection. Penlight has many uses during a physical

assessment. Used to illuminate inside of mouth or nose,

highlight a lesion, or evaluate pupillary constriction.

Light transmitted from otoscope may be substituted as a focused light source.


Ruler and Tape Measure

Provide accurate measurement for various findings.

Small metric ruler with millimeter and centimeter markings is useful for measuring lesions or other marks on the skin.

Use transparent ruler. Tape measure, with inches on one side and

centimeters on reverse, is useful in various situations, such as when measuring length of an infant or circumference of extremity.


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.


Tuning Fork

Tuning fork has two purposes: Auditory screening and assessment of vibratory sensation.

High-pitched tuning fork with frequency of 500 to 1000 hertz (Hz) should be used to estimate hearing loss in range of normal speech (300 to 3000 Hz).

For neurologic vibratory evaluation, a pitch between 100 and 400 Hz should be used.

Sharply strike tuning fork on heel of hand.


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 patient’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.


Doppler

Doppler uses ultrasonic waves to detect and amplify difficult-to-hear vascular sounds such as fetal heart tones or peripheral pulses.

Coupling gel is applied to patient’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 the nurse hears is a swishing, pulsating sound. Volume control may further amplify sound.


Goniometer

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.


Calipers for Skinfold 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.


Vaginal Speculum

Spreads walls of vaginal canal to inspect vaginal tissue and cervix.

Three types with two blades and handle: Graves’ has variety of sizes and blade lengths. Pedersen has blades as long as Graves’ but

narrower and flatter to aid inspection. Pediatric, or virginal, is smaller in all

dimensions. Patient should be forewarned about clicking and

snapping sounds of opening speculum.


Audioscope

Basic screening for hearing acuity. Fast, simple test to detect problems. Tones created at different frequencies (1000 to

5000 Hz). Patient responds to hearing of tone by raising

finger. Light indicates tone sound, and patient should

respond at the same time.


Monofilament

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

sensation.


Transilluminator 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.


Wood’s Lamp

Used to detect fungal infection of skin; used with fluorescent dye to detect corneal abrasions.

Black light effect: Fungal infections exhibit fluorescent yellow-

green or blue-green color. Darkened room enhances clinical interpretation

of lesion colors.


Magnification Device

Used to assist identification of skin lesions. Small handheld magnification device assists

with inspection; some come with battery-powered light source.

Magnification and lighting facilitate inspection of wounds, skin lesions, and parasites.


Question 1

The nurse is preparing the room for the dermatologist. The nurse knows that the patient may have a fungal infection on the left leg. Which tool is not part of the setup for this assessment?

A. Wood’s lampB.MagnifierC.MonofilamentD.Ruler


Question 2

Collection of objective data from a patient with a swollen left elbow includes which piece of equipment?

A. MagnifierB. Blood pressure cuffC. Snellen chartD. Goniometer


copyright © 2013 by mosby, an imprint of elsevier inc. techniques and equipment for physical...

Documents

imprint of elsevier

aprn slide

deep palpation

light palpation

technique of inspection

body fluids

organ size

use of hands