(155) Physical Assessment Techniques

Inspection: _________ examination

VISUAL examination

You are percussing a patient. You hear a tympany sound when performing your assessment on the patient's abdominal area, specifically when over the stomach. Is this a normal finding?

YES! Perscussion sounds: Tympany-- [loud/high pitch] Musical or drumlike, sustained longest, Heard over air-filled viscus like stomach or intestine (Jarvis pg17)

The nurse performs an inspection of the patient to find __________. The inspection is _______, _______, & ________.

ABNORMALITIES The inspection is DELIBERATE, FOCUSED, & SYSTEMATIC

The nurse percusses over the patient's scapulae. The sound is dull. The nurse records this as "no data". Is this an accurate recording? If not, what should be recorded?

This is accurate. "Avoid the ribs and scapulae. Percussing over a bone always yields no data because it always sounds "dull"." (Jarvis pg16)

Inspection requires comparing: a) the patient with other patients b) the left and right sides of the body c) the patient's words with their chart d) what you feel & what you see

B) the left and right sides of the body "...learn to use the person as his or her own control and compare the right and left sides of the body" (Jarvis pg15)

Percussion: Amplitude: soft Pitch: high Quality: muffled thud Duration: short Location: Over relatively dense organs (spleen, liver) What percussion sound is being described?

Dull (Jarvis pg17)

Palpation should be performed with the pressure & hand position the nurse feels most comfortable. The nurse should use the same part of the hand for all palpation techniques to reassure the patient of his/her technique. True or False?!

FALSE! "Different parts of the hands are best suited for assessing different factors" (Jarvis pg15)

The nurse should always begin with deep palpation and move to light palpation. True or False?

FALSE! "Start with light palpation to detect surface characteristics and accustom the person to being touched." (Jarvis pg15)

Listening to sounds produced by the body with a stethoscope is called percussion. True or False?

FALSE! This is called auscultation. (Jarvis pg17)

4 skills used for physical assessment

Inspection Palpation Percussion Auscultation (the order of performance will vary based on body system)

What physical assessment technique uses the sense of touch as part of the assessment?

Palpation

Percussion: Amplitude: Medium loud Pitch: low Quality: clear, hollow Duration: Moderate Location: Normal lung tissue What percussion sound is being described?

Resonant (Jarvis pg17)

A normal lung should sound resonant, while a lung with an abnormal amount of air within would sound hyperresonant. Hyperresonance might be heard in patients with emphysema. True or False

TRUE! Hyperresonance might be heard over an over-filled lung or over a normal child's lung Think-- with more air, the lung is like a bigger drum and makes louder, longer, booming sounds = hyperresonant (Jarvis pg17)

Ask the patient about tender areas. Palpate those areas last. True or False?

TRUE! "Identify any tender areas and palpate them last." (Jarvis pg15)

Palpation uses your sense of touch to assess these factors: (SATA) a) temperature & texture b) vibration or pulsation c) size & weight d) presence of cancers & tumors

a & b Wrong: c) size & weight-- Size of masses might be approximated with palpation but weight should be measured with a scale, not estimated. d) presence of cancers & tumors-- Masses or lumps might be felt with palpation, but cancers and tumors require diagnosis and further tests to confirm.

Which of the following is incorrect regarding percussion of a patient. a) Pressing hard with the full stationary hand will give a good platform for the striking hand, resulting in clear vibrations. b) Use the middle finger of your dominant hand to strike, with just the fingertip making contact. c) Percuss two times in a location using even staccato blows, lifting the striking finger quickly. d) The pleximeter is on the patient's skin, while the plexor is the striking finger.

a) Pressing hard with the FULL stationary hand will give a good platform for the striking hand, resulting in clear vibrations IS INCORRECT "Hyperextend the middle finger of your nondominant hand (the pleximeter) and place its distal portion firmly against the person's skin...Lift the rest of the stationary hand up off the person's skin; otherwise the resting hand will dampen off the produced vibrations..." (Jarvis pg16)

A patient needs deep palpation of the abdomen. The nurse knows to use _______ pressure. a) intermittent b) slow, continuous c) light d) varying

a) intermittent "When deep palpation is needed, intermittent pressure is better than one long, continuous palpation." (Jarvis pg15)

A good inspection requires: (SATA) a) the occasional use of instruments b) exposure to the patient c) adequate lighting d) gloves

a, b, c (lighting is most important!) Wrong: d) Inspection is LOOKING at the patient. Gloves will not likely be needed to inspect the patient.

What factors are typically problematic for auscultation? a) a hairy chest b) many layers of clothing c) overly dry or oily skin d) a cold patient

a, b, d a) hair = crackling noises b) auscultation cannot be done through clothing d) a cold patient will likely shiver & give inaccurate sounds.

The _______ has a flat edge and is best for high-pitched sounds like bowel sounds or normal heart sounds. a) bell b) diaphragm c) plexor d) pleximeter

b) diaphargm Wrong: a) bell-- best for low pitched sounds, like extra heart sounds or murmurs c) plexor-- the striking finger of percussion d) pleximeter-- the hyperextended middle finger of on the skin when percussing

Tapping the person's skin with short, sharp strokes to assess underlying structures, describes: a) palpation b) percussion c) manual assessment d) auscultation

b) percussion (Jarvis pg16)

Percussion strokes yield characteristic sounds that depict 3 characteristics of the underlying organs. What 3 characteristics? a) size, weight, & turgor b) size, location, & density c) functionality, density, & sensitivity d) pain, pressure, & skin breakdown

b) size, weight & density "The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ." (Jarvis p16)

Palpation technique should be: a) quick and smooth b) slow and systematic c) symmetrical and rhythmic d) deep and targeted

b) slow and systematic Wrong: a) Palpation should not be quick. c) Palpation might not always be symmetrical depending on the internal organs & focus of the physical assessment. It may not be rhythmic either. d) Palpation may be deep, but it can also be light. It may not always be targeted.

The primary reason for keeping the patient & room warm during auscultation is: a) to promote comfort & a positive nurse-patient relationship b) to eliminate shivering c) to keep your stethoscope warm d) for better circulation & clearer heart sounds

b) to eliminate shivering Shivering may cause inaccurate sounds due to the vibration of the patient's body against the stethoscope.

Bimanual palpation requires: a) one hand b) two hands c) special instruments d) two people

b) two hands "...requires the use of both hands to envelope or capture certain body parts or organs...for more precise delimitation." (Jarvis pg16)

It is important to use _____ terms in the patient's chart when describing physical assessment findings. a) understandable b) slang c) medical d) professional

c) medical

The grasping action of the fingers and thumb is best for feeling:

the position, shape, and consistency of an organ or mass (Jarvis pg15)

Normal lung tissue should sound ______ when percussion is performed. a) dull or flat b) hyperresonant c) resonant d) tympany

c) resonant Resonant-- [Medium loud/low pitch] Clear/Hollow quality; Moderate duration, Heard over normal lung tissue (Jarvis pg17)

The nurse would not auscultate the ______ to listen for abnormal sounds. a) heart, lungs, or abdomen b) the blood vessels c) the skeletal muscles d) the smooth muscles

c) skeletal muscles All the other options CAN be auscultated.

When percussing a patient to listen for vibration sounds-- the action of the striking hand is in the _______. a) plexor b) forearm c) wrist d) bicep

c) wrist "Hold your forearm close to the skin surface with your upper arm and shoulder steady but not rigid. The action is all in the wrist, and it must be relaxed." (Jarvis pg16)

The nurse is palpating for temperature. What part of the hand would give the best biofeedback? a) fingertips b) ball of the hand c) metacarpophalangeal joints d) dorsa of hand

d) The dorsa of the hand (back) would give the best feedback. The skin is thinner here. Wrong: a) fingertips-- best for texture, swelling, pulsatility, lumps b) ball of hand-- vibration c) metacarpophalangeal joints (base of fingers)-- vibration (Jarvis pg15)

You are percussing a patient's thigh muscle. What sound should you hear? a) resonant b) tympany c) hyperresonant d) flat

d) flat (Jarvis pg17)

The fingertips are best for feeling:

fine tactile discrimination (skin texture, swelling, pulsatility, and presence of lumps) (Jarvis pg15)

Percussion: Amplitude: very soft Pitch: high Quality: dead stop; absolute dullness Duration: very short Location: thigh muscles, bone, tumor What percussion sound is being described?

flat (Jarvis pg 17)

The diaphragm of the stethoscope is best for _______-pitched sounds, like ________ or _______.

high-pitched sounds lung or bowel sounds

Percussion: Amplitude: louder Pitch: lower Quality: booming Duration: longer Location: normal child's lung, overfilled adult lung What percussion sound is being described?

hyperresonance (Jarvis pg17)

Percussion: Amplitude: Medium loud Pitch: low Quality: clear, hollow Duration: moderate Location: normal lung tissue What percussion sound is being described?

resonant (Jarvis pg17)

The bell of the stethoscope is best for ______, _______-pitched sounds. Like a _________ or _________. (Jarvis pg17)

soft, low-pitched sounds extra heart sound or murmur

The dorsa of the hands and fingers is best for feeling:

temperature (due to thinner skin) (Jarvis pg15)

The base of the the fingers or ulnar surface is best for feeling:

vibration (Jarvis pg15)