Nursing Assessment: Infection Control & Hygiene

• İstinye University was founded in 2015 by the 21st Century Anatolian Foundation
• The academic staff aims to provide students with a strong foundation

Objectives

• Students will demonstrate knowledge of infection control and safety
• Must identify characteristics of inspection
• The characteristics of light and deep palpation needs to be described
• The physical properties of sound and sound conduction must be explained
• Must describe direct and indirect percussion techniques
• It's important to describe the qualities of auscultation with a stethoscope
• Students must show knowledge of the equipment used
• Findings from inspection, palpation, percussion, and auscultation have to be documented

Infection Control

• Healthcare settings have many threatening organisms
• Nurses need to follow infection control before, during, and after assessments
• Practices include diligent hand hygiene and using standard precautions

Hand Hygiene

• Hand hygiene is the single most important action to prevent infection
• Contact transmission leads to spreading of disease
• Nails must be short; artificial nails are not recommended
• Gloves should be used when nurses touch bodily fluids or contaminated itmes
• Health care workers can not wear gloves from the room into the hallway
• Always change gloves between patients

Standard Precautions

• Standard precautions help reduce the transmission of pathogens
• Prevents the spread of disease

Physical Assessment Techniques

• Inspection involves observing the patient's appearance, behavior, and condition during examination.
• Palpation uses hands to feel the firmness of body parts like the abdomen.
• Percussion involves tapping the hands to produce sounds that reveal solid or air-filled spaces over the lungs.
• Auscultation employs a stethoscope to listen to air or fluid movements in the lungs and abdomen.

General Considerations

• Draping ensures patient privacy during assessments
• Assessments must be individualized based on a patient's culture, religion, and beliefs
• Anxious patients could find it difficult to disclose private information
• Patients should say if they have preferences, like a family member in the room during assessment
• Less invasive assessments are done first

Inspection Specifics

• It is the first technique used
• Used for an overall survey of the patient
• Focus on age, gender, level of alertness, hygiene, body shape, skin color+ level of discomfort
• Is the only one performed for every body system
• Data gives nurses information about the situation and its acuity
• Cues from the patient can show the need for further assessment
• Is essential to have adequate lighting
• Exposure of each body part is important

Palpation Specifics

• Use to assess texture, position, temperature, pain and moisture
• Should begin with a gentle, slow technique
• Nurses should observe nonverbal discomfort indicators like grimacing
• Finger pads facilitate fine discrimination, are the most mobile
• The back of the hand is more sensitive to temperature
• Palmar side can be used to check contour, position, size and pain
• The ulnar/outside surface of the hand can monitor for vibratory tremors

Light Palpation

• Allows the patient to be more comfortable with the touch
• Light palpation should include ensuring correct draping, alerting, and gaining permission
• Necessary to warm the hands or gently rub them together if the contact is cold
• Calm easy touch assists patients to relax
• Use if there is a surface lesion/inflamed skin
• Use your finger pads and move in 1cm motions in depth

Moderate to Deep Palpation

• Helpful to facilitate the assessment of abdominal organs
• Use the palmar surfaces of the fingers
• Pressure should be firm enough to depress approximately 1-2 cm.
• Deep palpation involves pressure from both hands
• Places non-dominant hand over dominant and palpate 2-4cm

Percussion Specifics

• Percussion produces sound or shows tenderness by tapping on the patient
• The sounds help give information on the patient
• Use fingertips to quickly move to allow better contact

Percussion Sounds

• Loudest sounds are over the lungs and stomach, softer tones happen over bone and dense tissue
• Tapping the fingers occurs directly on the patient's skin (direct percussion)
• Indirect, involves examiner using nondominant hand as a barrier

Auscultation Specifics

• Reveals sounds produced by the body
• Descriptors of these sounds qualities are different with auscultation.
• Should avoid tenderness and contact

Ausculation Sounds

• Blood pressure assessed at the arm
• Lung sounds are best assessed at thorax
• Abdominal sounds at the abdomen

Stethoscope

• Bell is used with light skin contact and hears low-frequency sounds
• Diaphragm requires more pressure to hear high-frequency sounds
• Perform regular disinfections
• It's important the ear tips fit the ear canal snuggly

Equipment

• All equipment should be collected before the examiner enters to increase trust