Auscultation and Percussion Techniques

Auscultation Guidelines

• Eliminate distracting or competing noises from the environment (e.g., radio, television, machinery).
• Expose the body part to be auscultated.
• Avoid auscultating through the client's clothing or gown, as rubbing obscures body sounds.
• Use the diaphragm of the stethoscope for high-pitched sounds like normal heart, breath, and bowel sounds; press firmly.
• Use the bell of the stethoscope for low-pitched sounds like abnormal heart sounds and bruits; hold it lightly.

Auscultation sound classifications

• Intensity (loud or soft).
• Pitch (high or low).
• Duration (length).
• Quality (musical, crackling, raspy) of the sound.

Auscultation

• An assessment technique using a stethoscope to listen for heart sounds, blood flow, bowel movement, and air flow.
• Stethoscopes are used because these body sounds are inaudible to the human ear.

Sounds (Tones) Elicited by Percussion

• Resonance is heard over parts of the body that are part air and part solid, and resonates with a hollow sound.
• Hyper-resonance is heard over areas with mostly air, and resonates with a booming sound.
• Tympany is heard over air, and resonates with a drumlike sound.
• Dullness is heard over more solid tissue, and resonates with a thudlike sound.
• Flatness is heard over very dense tissue, and resonates with a flat sound.

Indirect Percussion Techniques

• Indirect or mediate percussion is the most commonly used method of percussion.
• The tapping in indirect percussion produces a sound or tone that varies with the density of underlying structures.
• Solid tissue gives a soft tone, fluid a louder tone, and air an even louder tone.
• Withdraw the finger immediately after tapping to avoid damping the tone.
• Deliver two quick taps and listen carefully.
• Use quick, sharp taps by flexing your wrist, not your forearm.
• Place the middle finger of your non-dominant hand on the body part to be percussed.
• Keep other fingers off the body part being percussed to avoid damping the tone.
• Use the pad of your middle finger of the other hand (with a short fingernail) to strike the middle finger of your nondominant hand.

Direct Percussion

• Uses direct tapping of a body part with one or two fingertips to elicit possible tenderness, such as over the sinuses.

Blunt Percussion

• Detects tenderness over organs like the kidneys.
• Places one hand flat on the body surface and using the fist of the other hand to strike the back of the flat hand.

Percussion: Assessment Uses

• Percussion involves tapping body parts to produce sound waves or vibrations, enabling assessment of underlying structures.
• Percussion helps determine if an underlying structure is filled with air, fluid, or is a solid structure, thus determining density.
• Percussion is useful in detecting superficial abnormal structures or masses.
• Percussion vibrations penetrate approximately 5 cm deep.
• Deep masses typically do not produce changes in normal percussion vibrations.
• Deep tendon reflexes are elicited using a percussion hammer.
• Inflamed underlying structures and changes between organ borders are determinable using percussion.

Four Types of Palpation

• Light palpation should:
  • consist of using the dominant hand lightly on the surface of the structure.
  • have very little or no depression (less than 1 cm).
  • Feel the surface.
  • Use circular motion to assess pulses, tenderness, surface skin texture, temperature, and moisture.
• Moderate palpation should:
  • Depress the skin surface 1 to 2 cm (0.5 to 0.75 inch) with dominant hand.
  • Use a circular motion to feel for organs and masses that are easily felt
  • Assess for size, consistency, and mobility.
• Deep palpation should:
  • Involve placing the dominant hand on the skin surface and the nondominant hand on top to apply pressure until a depression of 2.5 to 5 cm (1 and 2 inches) is produced.
  • Used to feel very deep organs or structures under thick muscle.
• Bimanual palpation should:
  • Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen).
  • Apply pressure with one hand and feel with the other
  • Note structures you palpate for size, shape, consistency, and mobility/

Palpation General

• Palpation is using parts of the hand to touch and feel texture, temperature, moisture, mobility, consistency, pulse strength, size, shape, and tenderness.
• Examiners fingernails should be short.
• The examiners hands should be a comfortable temperature.
• Standard precautions should be followed.
• Palpation should proceed from starting with light palpation, then moderate, then deep, if needed.
• The depth of the structure and thickness of the tissue determine what kind of palpation should be used.
• Fingertips are sensitive to: fine discriminations: pulses, texture, size, consistency, shape, crepitus.
• The ulnar or palmar surface is sensitive to: vibrations, thrills, and fremitus.
• Dorsal (back) surface is sensitive to: temperature.

Inspection Guidelines and Overview

• Note the following characteristics while inspecting the client: color patterns, size, location, consistency, symmetry, movement, behavior, odors, and sounds.
• Inspection involves using the senses of vision and smell to observe and detect normal or abnormal findings.
• Inspection is used from the moment of meeting through the whole examination.
• Inspection precedes palpation, percussion, and auscultation because later techniques can alter appearance.
• Some body systems need special equipment (e.g., ophthalmoscope, otoscope).
• Make sure room temperature is comfortable.
• Use good lighting - preferably adequate sunlight.
• Look and observe before touching.
• Fully expose the body part while appropriately draping the client.
• Compare the appearance of symmetric body parts or both sides

Preparation for a physical examination

• This should include: preparing setting, oneself, and the client
• The physical setting should be quiet, private, well ventilated and adequately lit with both sides of the patient accessible.
• Minimize noisy equipment like TV's or radios
• Examiners should prepare themselves by assessing their feeling and prevent the spread of infectious agents.
• General principles when performing the examination are:
  • wear gloves and other PPE needed to avoid contact with bodily fluids
  • Wash your hands before and after examination and after removing gloves
  • If using a sharp object like a pin, dispose after contact
• Client Preparation:
  • Use the right-hand side of the examination table or bed
  • Ensure that the client has peed
• Ask the client to change positions
• Explain the process
  • Helps to ease their anxieties
  • Remember to integrate health protocols like self breast examinations.
  • Begin with less intrusive procedures like:
    • temperature
    • measuring pulse
    • checking blood pressure
    • height and weight
• Respect the client's requests like:
  • Family member present
  • Refraining from certain body parts

General supplies needed for examination

• Gloves
• Gown
• Scale with height attachment
• Snollen E chart
• Opaque card
• Otoscope
• Thermometer
• Watch with Second hand
• Patient Questionnaire
• Goniometer
• Skinfold callipers
• Flexible tape measure
• Penlight
• Tuning foot

Different patient positions

• Sitting:
  • The client should sit upright on the side of the examination table or on the edge of a chair or bed.
  • Good for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities.
  • Full expansion of the lungs and assessing symmetry of upper body parts is possible.
• Supine:
  • The client lies down with legs together.
  • A pillow for comfort may be used.
  • For clients with breathing issues head may need to be raised
  • Abdominal muscles relax and provides access to peripheral pulse sites.
  • Areas assessed are Head, neck, chest, breasts, axillae, heart, abdomen, lungs and all extremities.
• Dorsal Recumbent:
  • The client lays with knees bent, the legs separated and & feet flat on the table/bed.
  • Used for assessment of the head, neck, chest, breasts, axillae, heart, abdomen, lungs, extremeties & pulses.
  • NOT to be used in assessing the abdomen.
• Prone:
  • The client lies down on the abdomen with head to the side.
  • Assess the hip joint & the back.
  • Clients with cardiac & respiratory cannot use the position.
• Sim's:
  • the client lies on the right or left side with the lower arm placed behind the body & the upper arm flexed at the shoulder & elbow.
  • The lower leg is slightly flexed at the knee while the upper leg is flexed at a sharper angle & pulled forward.
  • Assessing Rectal and vaginal area.
  • Clients with Joint problems & elderly may have difficulty assuming & maintaining this position.
• Knee-Chest Position:
  • Used to examine the rectum.
  • The client kneels on the examination table with the weight of the body supported by chest & knees.
  • a 90-degree angle should exist between body and hips.
  • arms stay placed overhead
  • Small pillows may be used to provide comfort.
  • This position requires a lot of trust and is uncomfortable.
• Lithotomy Position:
  • The client lies on his back with hips at the edge of the examination table & feet supported by stirrups.
  • Commonly used for examining genitalia, tracts and the rectum.
  • Clients need assistance and may feel.
  • Embarrassed.