Inspection, Palpation, Percussion and Auscultation

ASSESSMENT – is collecting validating, organizing and recording data about the client’s health status.

OrNursing Assessment – is the systematic

collection and ordering of information that allows a nurse to make a nursing diagnostic.

The patient assessment is an important tool in working with the patient . it serves multiple functions.

Functions or Purpose of the Assessment It is the basis for corretly assessing the current

health status of the patient as well as identifying the illness that is present and its cause.

It is an aid to recognition of latest health problems

It enables you to create a plan for appropriate patient care.

It recognizes the center role of the patient in the team.

It enables the nurse to anticipate patient problems.

Assessing a client’s health status is a major component of nursing care and has 2 aspects:

The Nursing health historyThe Physical health Examination (Physical

Health Assessment)

A – Nursing Health History – Gathered through interview

Components of Nursing Health HistoryBiographic data – Name, Address, age, sex,

race, marital status, occupation, religion.Chief complaint or reason for visit – The

primary reason given by the client as to why he sought consolations or hospitalization.

History of present illness (HPI) includes the ff:

1. Usual health status 2. Elaboration of the chief complaints 3. Relevant family & disability assessment

Past health History – includes childhood illness, childhood immunizations:

Allergies, accidents and injuries, hospitalizations, medications.

5. Family history illness – includes ages of siblings, parents & grandparents and their current state of health or the cause of death.

6. Review of systems – review of al health problems by body system. It is through which the functioning of the major organ system can be assessed.

7. Life-style/usual patterns of daily life-Includes personal habits, diet, sleep/rest patterns, activities of daily living and recreations/hobbies. These data provide basis for planning health promotion, maintenance and restoration.

8. Social data- includes family history, ethic affiliation, educational history, occupational history, economic status and home.

9. Psychological data- includes general survey of appearance and behavior, major stressors, usual coping pattern, communication style, self concept and mood.

II. Assessing a client’s health status is a major component of nursing case and has two aspects:

General survey The nursing Health HistoryPhysical Examination

The Physical Examination can be of 3 types;

Complete assessment (e.g when a client is admitted) to a health care agency.

Examination of a body system (e.g cardiovascular system)

Examination of a body area (e’g the lungs, when difficulty of breathing is observed)

Physical Health Examination- may be conducted

Conducted from the head to the toes (Chepalo-caudal, Skin, Hair, nails, Head, face, ears, eyes, nose, sinuses, mouth, throat, neck, breasts and oxillae. Thorax/back. Heart and peripheral vessels, upper extremities, abdomen, anus and rectum/genitalia, lower extremities.

Determine mental status or state of awareness at the beginning of physical examination.

Protect the client’s privacy during the entire procedure.

Prepare the needed articles and equipment.

Mode of Examination or Methods of Examination

Inspection.- assessing by the use of sense of sight.It should be deliberate, purposeful and

systematic. The nurse inspects with the naked eye and which lighted instrument such as otoscope. Nurse frequently use visual inspection to asses moisture, color and texture of body surfaces, as well as shape, position, size and color and symmetry of the body. Lighting must be sufficient for the nurse to see clearly, either natural or artificial light can be used.

Ex. When using the auditory senses it is important to have a quiet environment, it is important to have a quiet environment for accurate hearing.

Percussion- it is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt.

2 Types of Percussion:1. Direct

2. Indirect

Direct percussion- the nurse strikes the area to be percussed directly with the pads of two, three or four fingers or with the pad of the middle finger. The strikes are rapid, and the movement is from the wrist. This technique is not generally used to percuss the thortex but is useful in percussing adults’’ sinuses.

Indirect Percussion- is the striking of an object e.g a finger held against the body area to be examined. The middle finger of the non-dominant hand, referred to as the pleximeter, is placed firmly on the clients skin. On the distal phalanx and joint of this finger should be in contact with the skin. The motion comes from the wrist: the forearm remains stationary. The angle between the plexor and the pleximeter, should be 90 degrees and the blows must be firm, rapid and short to obtain a clear sound.

Percussion is used to determine the size and shape of the internal organ. It indicates whether tissue is fluid filled, air filled or solid.

Percussion elicits 5 types of sound;1. Flatness 2. Resonance 3.

Dulness4. Hyper resonance 5. Tympanny

Flatness- is an extremely dull sound produced by very dense tissue.

Dullness-is a thud like sound produced by dense tissue such as the liver, spleen or heart

Resonance-is a hollow sound such as that produced by lungs filled with air

Tympanny-is a musical or drum like sound produced from an air-filled stomach.

A percussion sound is described according to intensity, pitch, duration and quality.

Auscultation-is the process of listening to sounds produced within the body. This may be direct or indirect.

Direct auscultation-is the use of the remained ear, for example, to listen to a respiration wheeze or the grating of a miving joint.

Indirect Auscultation-is the use of a stethoscope which transmits the sounds to nurses’ ears.

A stethoscope is used primarily to listen to sounds from within the body, such as bowel sounds or value sounds of the heart within the body and blood pressure. The stethoscope should be 30-35 cm (12-14 in) long, with an interval diameter of about 0.3 cm (1/8 in). it should have both a flat-disc and a bell-shaped diaphragm.

The flat-disc diaphragm best transmits high pitched sound. (e.g. bronchial sounds) and the bell shaped best transmits low-pitched sounds, such as some heart sounds. The earpieces of the stethoscope should fit comfortably into the nurse, ears with earpieces facing toward. The diaphragm of the stethoscope is placed firmly but lightly against the client’s skin.

If a client is very hairy, it may be necessary to damper the hairs with a moist cloth so that they will lie flat against the skin and not a cause scratching sounds.

Auscultated sounds are described according to their pitch, intensity, duration and quality. The pitch is the frequency if the vibration, (the number of vibrations per sound.)

The intensity (amplitude) refers to the loudness or softness of a sound. Example: bronchial sounds heard from the trachea, others are soft, for example normal breath sounds heard in the lungs.

Position: The different positions which were studied already prior to this present segment.

Special Considerations:

The sequence of methods fro physical examination of the abdomen is as follows: Inspection, Auscultation, Percussion, Palpation (IAPP). No abdominal palpation among clients with tumor of the liver or kidney.

During physical examination of the abdomen, it is important to flex the knees to relax the abdominal muscles, thereby facilitating the examination of abdominal organs.

The sequence of examining the abdomen is as follows: right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant.

The best position when examining the chest is sitting/upright position. This permits examination of both anterior and posterior chest.

The best position when examining the back is standing position. This enables the examiner to assess the posture and gait of the client.

To palpate the neck for lymphadenopathy or enlargement of the thyroid gland, the nurse stands behind the client.

If opthalmoscopy is done, darken the room for better illumination.

If a female client is examined by a male doctor, a female nurse must be in attendance.

If instrument vaginal examination is done, pour warm water over the vaginal speculum before use.

General SurveyTo assess the general appearance and behavior of an

individual.Age, sex, raceBody build, ht., wt. in relation to the client’s age, life-

style and health.Posture and gaitHygiene and grooming Body and breath odorSigns of distressObvious signs Attitude Affect and moodSpeech Thought process

Preparing the client

Most people need an explanation of the physical examination. The nurse should explain when and where it will take place, why it is important, and what will happen during the examination. Health examinations are usually painless; however, it is important to determine in advance any positions that are contraindicated for particular client. The nurse assists the clients as needed to undress and put on a gown.

Clients should empty their bladders before the examination. Doing so helps them feel more relaxed and facilitates palpitation of the abdomen and pubic area. If a urinalysis is required, the urine should be collected in a container for that purpose.

When assessing adults it is important to recognize that people of the same age differ markedly. Box 28-3 provides special considerations for assessing adults, especially elders.

If clients are elderly and or frail it is wise to plan several assessment times in order to not overtire them. Often clients ate anxious about what the nurse will find. They can be reassured during the examination by explanations at each step.

The sequence of the assessment differs with children and adults. With children, always proceed from the least invasive or uncomfortable to then more invasive. Examination of the head and neck, heart and lungs, and range of motion can be done early in the process, while the ears, mouth and abdomen, and genitals should be left for the end of the exam.

Preparing the Environment

It is important to prepare the environment before starting the assessment. The time for physical assessment should be convenient to both the client and the nurse. The environment needs to be well lighted and the equipment should be organized for use.

Providing privacy is important. Most people are embarrassed if their bodies are exposed or if others can overhear or view them during the assessment. Family and friends should not be present unless the client asks for someone.

 

Positioning Several positions are frequently required

during the physical assessment. It is important to consider the client’s ability to assume a position. The client’s physical condition, energy level, and age should also be taken into consideration.

Some positions are embarrassing and uncomfortable and therefore should not be maintained for long. The assessment is organized so that several body areas can be assessed in one position, thus minimizing of position changes needed.

Draping Drapes should be arranged so that the area

to be assessed is exposed and other body areas are covered. Exposure of the body is frequently embarrassing to clients. Drapes provide not only a degree of privacy but also warmth. Drapes are made of paper, cloth or be linen.

Instrumentation All equipment required for the health

assessment should be clean, in good working order, and readily accessible. Equipment is frequently set up on trays, ready for use.

Health Assessment of the AdultBe aware of normal physiologic changes that occur with

age.Be aware of stiffness of muscles and joints from aging

changes or history of orthopedic surgery. The client may need modification of the usual positioning necessary for the examination and assessment.

Expose only the areas of the body to be examined in order to avoid chilling.

Permit ample time for the client to answer questions and assume the required positions.

Be aware of cultural differences. The client may want a family member present during disrobing.

Arrange for an interpreter if the client’s language differs from that of the nurse.

Ask clients how they wish to be addressed, such as mrs. Or miss.

Adapt assessment techniques to any sensory impairment; for example, make sure eyeglasses or hearing aids are nearby.