Chapter 8 Assessment Techniques and Safety in the Clinical Setting

Percussion sound has four components

Amplitude: the sounds intensity (loud or soft) Pitch or frequency: number of vibrations per second Quality (or timbre): subjective difference resulting from a sound's distinctive overtones. Duration: length of time the note lingers.

During the examination

Explain each step and how the patient can cooperate. Proceed systematically and offer brief teaching, as appropriate.

Physical examination

Four assessment techniques: Inspection: close, careful observation of the individual as a whole and then of each body system. Use the patient's body as the control and compare the right and left sides of the body to determine symmetry. Inspection requires good lighting, adequate exposure, and sometimes the use of certain instruments, such as an otoscope or penlight. Palpation: the use of touch to assess texture, temperature, moisture, and organ location and size. This technique also helps identify swelling, vibration or pulsation, rigidity or spasticity, crepitation, lumps or masses, and tenderness or pain. 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 the best for assessing vibration. Light palpation detects surface characteristics and accustoms the person to being touched. Deep palpation assesses an organ or mass deeper in a body cavity. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs. Percussion: is tapping the patient's skin with short, sharp strokes to assess underlying structures. This technique is best used to assess location, size, and density of an organ; detect a fairly superficial abnormal mass; or elicit a deep tendon reflex. To do this, hyperextend the middle finger of your nondominant hand and place its distal joint and tip firmly against the person's skin. Then use the middle finger of your dominant hand to strike the stationary finger at a right angle. Deliver two even staccato blows with a quick wrist action.

Auscultation

Listening to sounds produced by the body, usually using a stethoscope. The heart, blood vessels, lungs, and abdomen are commonly auscultated areas. Use the stethoscope's diaphragm for high-pitched sounds, such as breath, bowel, and normal heart sounds. Use the stethoscope's bell for soft-low pitched sounds, such as heart sounds or murmurs. To ensure accurate auscultation, eliminate confusing artifacts, for example, by making sure the room is quiet and warm and not listening through clothing.

Infection control measures

Maintain clean equipment and a clean field. The most important step to decreased microorganism transmission is through handwashing or using 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. Use standard precautions for all patients. Use transmission-based precautions for patients with documented or suspected transmissible infections.

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.

Reduce patient anxiety

by beginning with familiar, non-threatening 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.

Make exam adjustments

depending on the patient's developmental needs such as position, preparation. Pace the exam to match older adults pace which may be slowed. When examining a patient in distress, you may need to alter the position during the examination. First, collect a mini-database, and then complete the assessment after the initial distress is resolved.