Jarvis: Physical Examination & Health Assessment, 6th Edition

Chapter 8: Assessment Techniques and the Clinical Setting Key Points Print This section discusses key points about assessment techniques. Physical examination requires the sequential use of four assessment techniques: inspection, palpation, percussion, and auscultation. Inspection is close, careful observation of the patient as a whole and then of each body system. When conducting an inspection, use the patients body as the control and compare the right and left sides of the body to determine symmetry. Inspection requires good lighting, adequate exposure, and at times, the use of special instruments, such as an otoscope or penlight. Palpation is the use of touch to assess texture, temperature, moisture, and organ location and size. This technique also helps identify swelling, vibrations, pulsations, rigidity or spasticity, crepitation, lumps or masses, and tenderness or pain. o Different parts of the hands are best for assessing different factors. The fingertips are best for fine tactile discrimination. Grasping with the fingers and thumb is ideal for detecting position, shape, and consistency of an organ or mass. The backs of the hands and fingers are good for determining temperature. The base of the fingers or ulnar surface of the hand is best for assessing vibration. o Palpation may be light, deep, or bimanual. Light palpation evaluates surface characteristics and identifies areas of tenderness. Deep palpation assesses an organ or mass deeper in a body cavity. Bimanual palpation is the use of both hands to envelop or capture certain body parts or organs, such as the kidneys. Percussion is tapping the patients skin with short, sharp strokes to create percussion sounds. This technique is used to assess the location, size, and density of an organ, detect an abnormal mass, or elicit a deep tendon reflex. o To perform percussion, place your interphalangeal joint firmly on the patients skin with the rest of your hand lifted off the skin. Then use the middle finger of your dominant hand to strike the stationary finger at a right angle. Deliver two short, sharp taps, using a quick wrist action. o Each percussion sound has four components. Amplitude is the sounds intensity, which may be loud or soft. Pitch describes the number of vibrations per second and may be high-pitched or low-pitched. Quality (or timbre) is the subjective difference due to a sounds distinctive overtones. Duration is the length of time the note lingers. Auscultation is listening to sounds made by the body, usually using a stethoscope. The heart, blood vessels, lungs, and abdomen are commonly auscultated areas. o Use the stethoscopes diaphragm for high-pitched sounds, such as breath, bowel, and normal heart sounds. Use the stethoscopes bell for soft, low-pitched sounds,
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such as extra heart sounds or murmurs. o To ensure accurate auscultation, eliminate confusing artifacts, for example, by making sure the room is quiet and warm and not listening through clothing. This section presents critical points about the clinical setting. The examination room should be warm, comfortable, quiet, private, and well lit. Before beginning the examination, ensure that all your equipment is within easy reach and laid out in an organized fashion. Observe infection control measures to prevent the spread of infection. o Maintain a clean field. For example, clean your stethoscope endpiece with an alcohol wipe before and after every patient contact. Also designate clean versus used areas for equipment. o The single most important step to decrease microorganism transmission is thorough handwashing or using an alcohol-based hand rub. Perform hand hygiene before and after physical contact with each patient, after contact with body fluids or contaminated equipment, and after removing gloves. o Use Standard Precautions for all patients. Use transmission-based precautions for patients with documented or suspected transmissible infections. To reduce patient anxiety, maintain a confident, considerate, and unhurried manner. Begin with familiar, nonthreatening actions, such as measuring height, weight, and vital signs. After the person puts on a patient gown, return to the room and clean your hands in his or her presence. During the examination, explain each step and how the patient can cooperate. Proceed systematically and offer brief teaching, as appropriate. Adjust the examination based on the patients developmental needs. o Pay special attention to a childs position and preparation. Consider the childs developmental stage when determining the examination sequence. Use a less threatening approach, and encourage a parent to be present for an infant, toddler, or preschooler. For an older child, be sure to maintain privacy. o For an aging adult, adjust the position and preparation as needed. And pace the examination to match the older adults pace, which may be slowed. o When examining a patient in distress, you may need to collect a mini-database and then complete the assessment after the initial distress is resolved.