Key Points Ch. 8, 340

Stethoscope's Bell

Use for soft, low-pitched sounds, such as extra heart sounds or murmurs

Adjust the examination position, preparation, and sequence based on the patient's developmental needs

1. Consider the child'd developmental stage when determining exam sequence 2. Aging adult, adjust the position and preparation as needed. Pace the exam to match the older adult's pace,which may be slowed 3. When examining a patient in distress you may need to alter the position during the exam. First collect a mini-database, and then complete the assessment after the initial distress is resolved.

Observe infection control measures to prevent the spread of infection

1. Maintain clean equipment and a clean field 2. The most important step to decrease microorganism transmission is through handwashing or using an alcohol-based rub. Perform hand hygiene before and after physical contact with each patient, after contact with body fluids or contaminated equipment, and after removing gloves.

Physical examination requires the sequential use of four assessment techniques:

inspection, palpation, percussion, and auscultation.

Components of percussion

Aplitude - Sound's intensity, which may be loud or soft Pitch - or frequency describes the nuber of vibrations per second Quality- (or timbre) is the subjective difference resulting from a sound's distinctive overtone Duration - length of time the note lingers

Which of the following is considered when preparing to examine an older adult?

Base the pace of the examination on the patient's needs and abilities.

Accurate Ausculation

Eliminate confusing artifacts, for example, by making sure the room is quiet and warm and not listening through clothing

Examination room

Should be warm, comfortable, quiet, private and well lit. Before beginning the exam, ensure that all of your equipment is withing easy reach and laid out in an organized fashion.

Percussion

Tapping the patient's skin with a short, sharp strokes to assess underlying structures. This technique is used to assess the location, size, and density of an organ; detect a fairly superficial abnormal mass; or elicit a deep tendon reflex

Stethoscope's Diaphragm

Use for high-pitched sounds, such as breath, bowel, and normal heart sounds.

To examine a toddler, the nurse should:

allow the child to sit on the parent's lap.

Fingertips - palpation

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

Reduce patient anxiety

by beginning with familiar, non-threatening actions, such as measuring height, weight, and vital signs. After the patient puts on the gown, return to the room and clean hands in his/her presence.

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.

During exam

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

Fine tactile discrimination is best achieved with the:

fingertips The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration.

How to perform percussion on patient

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, using a quick wrist action. stationary finger at a right angle. Deliver two even, staccato blows, using a quick wrist action.

Deep palpation is used to:

identify abdominal contents. Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note.

The examiner should use handwashing instead of an alcohol-based hand rub:

if the patient has an infection with Clostridium difficile.

A funduscopic examination is an examination of the:

internal structures of the eye. An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares.

Inspection

is 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

Auscultation

listening to sounds produced by the body, usually using a stethoscope. The heart, blood vessels, lungs, and abdomen are commonly auscultated areas

At the end of the examination, the examiner should:

review the findings with the patient

When performing percussion, the examiner:

strikes the stationary finger at the distal interphalangeal joint. To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed).

The dorsa of the hands are used to determine:

temperature. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for vibration. A grasping action of the fingers and thumb is the best way to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination.

Amplitude is:

the intensity (soft or loud) of sound. Amplitude is the intensity of sound. Duration is the length of time the note lingers. Pitch is the number of vibrations per second (high or low). Quality is the subjective difference owing to a sound's distinctive overtones.

Palpatation

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