Copyright 2002, Delmar, A division of Thomson Learning Chapter 8 Physical Assessment Techniques

Copyright 2002, Delmar, A division of Thomson Learning

Chapter 8

Physical Assessment Techniques


Competencies Describe how to maintain standard

precautions during physical assessment.

Describe how to perform inspection, palpation, percussion, auscultation, and which areas of the body are assessed with each technique.

(continues)


Competencies Establish an environment suitable

for conducting a physical assessment.

Demonstrate inspection, palpation, percussion, and auscultation in the clinical setting.


Aspects of Physical Assessment Purposes of physical assessment

Screening of general well-being Validation of complaints that

caused the patient to seek health care

Monitoring of current health problems

Formulation of diagnoses and treatments


Role of the Nurse Comprehensive physical assessment

vs. Focused physical assessment Utilize standard precautions during

assessment Legal issues

Accurate, complete documentation Ensure patient is properly informed of

assessment procedures


Assessment Techniques Inspection (I) Palpation (P) Percussion (P) Auscultation (A) Usually follow order IPPA, except

for the abdomen (IAPP)


Inspection Use of one’s senses of vision and

smell to consciously observe the patient

Careful observation


(continues)

Palpation Act of touching the patient in a

therapeutic manner Light palpation

Superficial, delicate, gentle Uses finger pads Depress 1 cm below surface Provides information on skin texture,

moisture, masses, fluid, muscle guarding, and tenderness


Palpation Deep palpation Provide information about the position of

organs, masses, their size, shape, mobility and consistency

Uses hands Depress 4 to 5 cm below skin surface Most commonly used for assessing

abdominal and reproductive structures(continues)


Palpation Tips

Warm hands Short nails Inform patient of when, where, and

how the touch will occur


Percussion Striking one object against another to

cause vibrations that produce sound Analyze sounds by intensity,

duration, pitch Any part of the body can be

percussed Most commonly used for abdomen

and thorax


Quality of Sounds Flatness Dullness Resonance Hyperresonance Tympany


Percussion Techniques

Immediate Mediate or indirect Direct fist Indirect fist


Auscultation Act of active listening to body organs Listening to voluntary and

involuntary sounds Quiet environment is needed to

perform Analyze sounds in relation to

intensity, pitch, duration, quality, and location


Types of Auscultation Direct or immediate

Listening with the unaided ear Indirect or mediate

Listening with an amplication device Examples: stethoscope, doppler


Commonly Used Equipment Pen and paper Tape measure Clean gloves Penlight Scale Thermometer Sphygmomanometer

(continues)


Commonly Used Equipment Stethoscope Otoscope Opthalmoscope Visual acuity charts Tuning fork Reflex hammer Lubricant


Preparing for a Physical Assessment Clean, professional dress Proper identification Introduce self Well-lit, warm, private, quiet room Short fingernails Warm hands and equipment Prevent hair or jewelry from interfering with

the exam Explain exam

(continues)


Preparing for a Physical Assessment Dress patient in gown, drape, and

underpants Have patient void prior to

assessment Wash hands Adhere to standard precautions

(continues)


Preparing for a Physical Assessment Position patient as needed Avoid negative or crude remarks Be cognizant of facial expressions Perform exam in head-to-toe or

other systematic manner Thank the patient when exam is

concluded Thoroughly document findings


(continues)

Positioning for Physical Exam Fowler’s

Used to assess skin, head, neck, eyes, ears, nose, mouth, throat, thorax, lungs, heart, peripheral vasculature, neurological system

Horizontal recumbent Used to assess breasts, heart,

peripheral vasculature, abdomen, musculoskeletal system


Positioning for Physical Exam Dorsal recumbent

Used to assess female genitalia

Lithotomy Used to assess female genitalia

Knee-chest Used to assess rectum and prostate

Sims Used to assess rectum and female genitalia


Golden Rules for Physical Assessment Stand on the right side of the

patient to establish a dominant side for assessment

Use a head-to-toe approach Compare right to left sides of the

body for symmetry Least invasive to most invasive Systematic approach

Documents

Copyright 2002, Delmar, A division of Thomson Learning Chapter 8 Physical Assessment Techniques