NUR012 Health Assessment: Physical Examination

• İstinye University was founded in 2015 by the 21st Century Anatolian Foundation
• İstinye University aims to be among the distinguished universities in Turkey and the world
• The university aims to provide high-quality and accessible healthcare to the community

Physical Examination Methods

• Lecturer: Asst. Prof. Tuğba PEHLİVAN
• Email: [email protected]
• Department: HSF / Nursing (English)
• Lecture: NUR012-Health Assessment

Outline

• Topics include:
• Infection control and related issues
• Hand hygiene
• Standard precautions
• Cardinal techniques of physical assessment:
• Inspection
• Palpation
• Percussion
• Auscultation
• Equipment

Learning Objectives

• Demonstrate knowledge of precautions for infection control and safety
• Identify specific characteristics of inspection
• Describe the qualities and characteristics of light and deep palpation
• Explain the physical properties of sound and sound conduction
• Describe the techniques of direct and indirect percussion
• Describe the qualities of auscultation to be assessed with the stethoscope
• Demonstrate knowledge of the equipment used during the physical examination
• Document findings from the four basic examination modes: inspection, palpation, percussion, and auscultation

Infection Control and Related Issues

• Healthcare environments have a multitude of threatening organisms
• Nurses use infection control principles before, during, and after physical assessments
• Practices include diligent hand hygiene and standard precautions

Hand Hygiene

• Hand hygiene is the most important action for infection prevention
• Prevent contact transmission

Hand Hygiene Details

• Nails must be short; artificial nails are not recommended
• Gloves are used when contact with blood, body fluids, secretions, excretions, and contaminated items is possible
• Change gloves before going to the next patient
• Health care personnel should never wear gloves in the hallway

Standard Precautions

• Standard precautions help reduce the transmission of pathogens
• Always perform hand hygiene
• Clean and reprocess shared patient equipment
• Use personal protective equipment (PPE) with risk of body fluid exposure
• Follow respiratory hygiene and cough etiquette
• Use and dispose of sharps safely
• Perform routine environmental cleaning
• Use aseptic technique
• Handle and dispose of waste and used linen safely

Cardinal Techniques of Physical Assessment

• Inspection means conscious observation of the patient
• Palpation involves using hands to feel the firmness of body parts
• Percussion is using tapping motions with the hands to produce sounds
• Auscultation involves using a stethoscope to hear movements of air or fluid in the body

General Considerations

• Drape to protect privacy
• Individualize each assessment for the patient's cultural, religious, and social beliefs
• Consider that anxious patients may not disclose private or uncomfortable information
• Ask patients about their preferences before starting the physical assessment
• Less invasive assessments should be done first, with the most personal assessments at the end

Inspection Explained

• Inspection is the first technique of the overall general survey and for each body part
• Initial inspections focus on overall characteristics such as age, gender, and level of alertness
• Body size and shape, skin color, hygiene, posture, and level of discomfort or anxiety are also key
• Inspection is always performed, for every body system

Inspection Details

• Data during this initial phase help nurses to form an overall impression of the situation's acuity
• Patient cues during inspection might indicate a problem that needs further assessment

Inspection Requirements

• Adequate exposure of each body part is necessary, but drape appropriately
• Adequate lighting is essential to observe color, texture, and mobility
• Nurses should ask patients for permission to examine body areas

Palpation

• Assess for texture, position, temperature, edema, location, moisture, shape, size, pain, and vibration

Aspects of Palpation

• Palpation should begin with a gentle and slow technique
• Nurses should observe nonverbal indicators of discomfort such as furrowed brows or grimacing

Palpation Techniques

• Finger pads facilitate fine discrimination
• The palmar surface of fingers and joints are best for assessing firmness, contour, and pain
• The back of the hand (dorsal) is most sensitive to temperature

Palpation and Vibratory Tremor

• Palpate with the ulnar, or outside, surface of the hand to feel vibratory tremors as patients speak

Principles of Light Palpation

• Light palpation allows the patient to become familiar with the touch
• Tender or painful areas should not be palpated until the end
• Alert the patient about what will happen and gain permission to proceed

Warming the Hands and Nails

• Warm the hands under running water or gently rub them together
• Short and smooth nails are necessary to avoid causing discomfort

Relaxing During Palpation

• A gentle, calm, and easy touch can assist patients to relax

Uses of Light Palpation

• Light palpation is appropriate for surface characteristics assessments, such as texture and surface lesions
• Place the finger pads of the dominant hand on skin and slowly move fingers in circular areas of about 1 cm in depth
• An example of this is breast self-examination

Moderate to Deep Palpation

• Moderate palpation facilitates the assessment consistency of abdominal consistency
• Assess the shape and size of abdominal organs

Firm Pressure and Palpation Details

• Use the palmar surfaces of the fingers
• Apply a firm pressure to depress approximately 1 to 2 cm

Performing Deep Palpation

• Place the extended fingers of the nondominant hand over the dominant hand
• Use the same circular motion to palpate 2 to 4 cm

Percussion Overview

• Percussion facilitates the determination for tenderness
• Percussion tones are conducted into the patient’s body

Vibrations and Sound

• Percussion may utilize tapping fingers on a patient in a similar fashion like a drumstick on a drum

Percussion Techniques

• Percussion through dense tissue will create quiet tones
• Percussion traveling through aur will create loud tones

Percussion Tones and Anatomical Regions

• Percussion over the lungs or air-filled stomach will generate the loudest tones
• Percussion over a bone or dense tissue should have quiet tones

Percussion Techniques

• Direct percussion involves tapping the fingers directly on the patient’s skin
• Indirect percussion involves the examiner’s nondominant hand
• The ulnar surface of the fist is used to percuss the kidneys, gallbladder, or liver for tenderness

Percussion Mechanics

• The motion of the striking finger should be quick, forceful, and snappy
• To facilitate good contact, nails must be short and smooth

Percussion Wrist Action

• Downward action is from the wrist, not the shoulder or elbow
• To avoid dampening the sound, immediately withdraw all body parts not performing a movement

Percussion and the Hands

• Those with short fingers/hands tap more forcefully than those with longer fingers and/or hands

Percussion Sounds

Auscultation

• Auscultation reveals organ movement and body tissues

Auscultation Details

• Descriptors vary according to the body part auscultated
• Descriptors will deviate according to the quality of auscultation

Auscultation Sounds

Auscultation

• A stethoscope is used

Stethoscope Use

• Bell for low frequency
• Diaphragm for high

Stethoscope Fitting

• Eartips must fit snugly in the ear canal to maximize comfort
• Earpieces must point forward in the same direction as the nose

Equipment

• Collect items before disturbing the patient

Required Equipment

• Scale
• Thermometer
• Blood Pressure instruments
• Stethoscope
• Gloves
• Penlight and/or flashlight