Podcast
Questions and Answers
Which part of the hand is MOST sensitive when performing palpation?
Which part of the hand is MOST sensitive when performing palpation?
It is necessary to wear gloves when palpating mucous membranes.
It is necessary to wear gloves when palpating mucous membranes.
True (A)
What are the 3 things that needs to be stated before palpation?
What are the 3 things that needs to be stated before palpation?
purpose, manner, location
When performing palpation, the nurse should use a ________ touch and keep their hands warm.
When performing palpation, the nurse should use a ________ touch and keep their hands warm.
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Match the following terms with their description:
Match the following terms with their description:
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Which of the following is NOT typically assessed during palpation?
Which of the following is NOT typically assessed during palpation?
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Touching a patient has the same cultural significance for everyone.
Touching a patient has the same cultural significance for everyone.
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Besides using the finger pads, what part of the hand is also used for palpation?
Besides using the finger pads, what part of the hand is also used for palpation?
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What does a nurse commonly use to perform auscultation?
What does a nurse commonly use to perform auscultation?
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Auscultation is used to measure body temperature.
Auscultation is used to measure body temperature.
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Name one position that is most common for patient examination.
Name one position that is most common for patient examination.
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Which part of the hand is most sensitive to vibration?
Which part of the hand is most sensitive to vibration?
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When auscultating, the stethoscope should be placed directly on the ______.
When auscultating, the stethoscope should be placed directly on the ______.
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The palmar surface of the fingers is best for assessing temperature.
The palmar surface of the fingers is best for assessing temperature.
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Which of the following is NOT a characteristic of sound that nurses evaluate during auscultation?
Which of the following is NOT a characteristic of sound that nurses evaluate during auscultation?
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What is the approximate depth of light palpation in centimeters?
What is the approximate depth of light palpation in centimeters?
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Electronic thermometers provide temperature readings instantly.
Electronic thermometers provide temperature readings instantly.
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Deep palpation is accomplished by pressing to a depth of approximately ______ cm.
Deep palpation is accomplished by pressing to a depth of approximately ______ cm.
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What kind of technology do temporal artery thermometers use?
What kind of technology do temporal artery thermometers use?
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What is the primary purpose of using a bimanual palpation technique?
What is the primary purpose of using a bimanual palpation technique?
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Match the type of thermometer to its method of temperature assessment:
Match the type of thermometer to its method of temperature assessment:
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Deep palpation should always precede light palpation.
Deep palpation should always precede light palpation.
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Match the descriptions with the correct type of palpation:
Match the descriptions with the correct type of palpation:
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When using indirect percussion, the distal aspect of the middle finger of the ______ hand is placed against the skin over the organ being percussed.
When using indirect percussion, the distal aspect of the middle finger of the ______ hand is placed against the skin over the organ being percussed.
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Flashcards
Vibration and Temperature Sensitivity
Vibration and Temperature Sensitivity
The ulnar surface of the hand, on the pinky side, is most sensitive to vibrations, while the dorsal surface of the hand, the back side, is better for assessing temperature.
What is Palpation?
What is Palpation?
Palpation involves using the fingers to feel the body for texture, size, shape, and consistency of different tissues.
What is Light Palpation?
What is Light Palpation?
Light palpation involves applying gentle pressure to a depth of about 1 cm, used to check the skin, pulses, and tenderness.
What is Deep Palpation?
What is Deep Palpation?
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What is Bimanual Palpation?
What is Bimanual Palpation?
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What is Percussion?
What is Percussion?
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What is Direct Percussion?
What is Direct Percussion?
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What is Indirect Percussion?
What is Indirect Percussion?
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Auscultation
Auscultation
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Stethoscope
Stethoscope
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Characteristics of sound
Characteristics of sound
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Selective Listening
Selective Listening
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Optimizing auscultation
Optimizing auscultation
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Thermometer
Thermometer
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Supine Position
Supine Position
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Inspection
Inspection
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Hand Hygiene
Hand Hygiene
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Standard Precautions
Standard Precautions
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Personal Protective Equipment (PPE)
Personal Protective Equipment (PPE)
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Palpation
Palpation
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Hand Sanitizer
Hand Sanitizer
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Hand Washing with Soap and Water Technique
Hand Washing with Soap and Water Technique
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Gentle Touch in Palpation
Gentle Touch in Palpation
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Study Notes
Infection Control Practices
- Standard Precautions apply in all healthcare settings
- Hand hygiene is critical for reducing infection transmission
- Personal protective equipment (PPE) should be used as needed
- Proper management of patient-care equipment is essential
- Healthcare professionals need to be aware of potential latex allergies
- Patients may also have latex allergies; ask about allergies
Hand Hygiene
- Alcohol-based hand sanitizers are the most efficient method for reducing germs
- Alcohol-based hand sanitizers are preferred for most clinical situations
- Wash hands with soap and water when visibly soiled, before eating, and after using the restroom
Routine Patient Care
- Use alcohol-based hand sanitizer immediately before touching a patient
- Use soap and water when hands are visibly soiled
- Use hand sanitizer or soap and water before and after tasks, like placing medical devices or handling other medical equipment
- Clean your hands before and after contact with blood or body fluids or contaminated surfaces
- Always wash or use sanitizer after removing gloves.
Hand Sanitizer Use
- Apply sanitizer to hands and rub together
- Rub all surfaces of hands until dry
- The process should take around 20 seconds.
Hand Washing with Soap and Water Technique
- Wet hands thoroughly with water
- Apply the recommended amount of soap to hands
- Rub hands together vigorously for at least 15 seconds, ensuring all surfaces are covered
- Rinse thoroughly with water
- Dry hands thoroughly with disposable towels.
- Avoid hot water to prevent drying the skin.
Glove Use
- Wear gloves when contact with blood, bodily fluids, or non-intact skin, or contaminated equipment is anticipated
- Hand hygiene is critical before and after wearing gloves, before and after touching the patient or the patient's environment.
- Change gloves, and perform hand hygiene, if the gloves are damaged.
- Change gloves when moving between soiled and clean body sites of the same patient, or if there is an indication.
Skin and Nail Care
- Use lotions and creams to prevent and reduce skin dryness.
- Use only hand lotions approved by your facility, as certain lotions can interfere with sanitization.
- Avoid using artificial fingernails or extensions during direct patient contact.
- Natural fingernails should be kept less than ¼ inch long.
Inspection (1 of 2)
- Physical exams begin with inspection: visual examination of the body, including movement and posture.
- Data obtained by smell are also a part of inspection.
- Examination of every body system includes technique of inspection.
- Patient must be draped appropriately to maintain modesty, while adequate lighting is essential for examination.
Inspection (2 of 2)
- Thoroughly observe the patient with a critical eye, without distraction.
- This avoids overlooking important details.
- Practice is necessary to develop inspection skill
- Use of equipment (penlight, otoscope, ophthalmoscope, vaginal speculum) facilitates inspection of specific body systems.
Palpation (1 of 4)
- Use hands to assess texture, size, shape, consistency, and location of body parts to identify painful or tender areas
- Gentle touch, warm hands, short nails, and respect for personal space, are needed to prevent discomfort or injury.
- Touching must have a clearly defined state purpose, manner, and area
Palpation (2 of 4)
- Palmar surface of fingers and fingertips provide more sensitivity to vibration than fingertips.
- They are good for texture, size, consistency, mass, fluid, and crepitus
- Ulnar aspect of the hand to the fifth finger is best for vibration palpation
- Dorsal surface is best for temperature assessment
Palpation (3 of 4)
- Light palpation done by pressing to a maximum of 1 cm to assess skin, pulsations, and tenderness,
- Deep palpation is done by pressing to a depth of 4 cm using one or two hands. Deep palpation is used to assess organ size and contour.
Palpation (4 of 4)
- Bimanual technique involves using both hands to palpate organs or masses
- Light palpation should always precede deep palpation
- Deep palpation may cause tenderness or disrupt fluids, which can hinder assessment through light palpation.
Percussion (1 of 5)
- Percussion assesses size, borders, and consistency of organs.
- It is a method for detecting tenderness.
- It is also helpful for determining the extent of fluid in a body cavity.
Percussion (2 of 5)
- Direct percussion involves striking a body part directly with a finger or hand.
- This technique is used to evaluate adult sinuses and elicit tenderness over the kidney at the costovertebral angle (CVA).
Percussion (3 of 5)
- Indirect percussion uses both hands to assess the body part
- Place the distal aspect of the nondominant middle finger on the body part in question
- The tip of the dominant middle finger strikes the distal interphalangeal joint on the second hand.
- Quickly rebound to avoid muffling the vibrations.
Percussion (4 of 5)
- Tapping produces vibrations in deep body tissue with subsequent sound waves.
- Two or three taps are needed in one location before moving to another site.
- Stronger percussion may be needed for obese or muscular patients to overcome tissue impedance.
Percussion (5 of 5)
- Five main percussion tones exist:
- Tympany: Loud, high-pitched sound, usually heard over the abdomen.
- Resonance: Heard over normal lung tissue
- Hyperresonance: Heard over overinflated lungs (e.g., emphysema)
- Dullness: Heard over the liver
- Flatness: Heard over bones and muscle
Auscultation (1 of 2)
- Auscultation involves listening to sounds within body using a stethoscope
- It minimizes unnecessary noises for better assessment
- Stethoscopes are used to detect sounds from the heart, blood vessels, lungs, or intestines
Auscultation (2 of 2)
- Concentrate on subtle variations and transitory sounds during auscultation, such as air during inspiration or a singular heart sound.
- Auscultation is best performed in a quiet setting, where noises do not interfere
- If the patient is shivering, this can create sounds that mask normal, or create abnormal sounds
- Consider that clothes can obscure or alter sounds during auscultation.
Patient Positioning
- Patient positioning depends on type of assessment and patient condition.
- Sitting and supine positions are commonly used positions
- Proper draping is needed for adequate exposure during examination
- Inability to assume a certain position can be a meaningful finding needing accommodation
Equipment Used During the Examination Process
- Equipment aids data collection during examination
- Equipment selection relies on type of examination and problem being assessed
- Measurements, tools, and techniques used during inspection, auscultation, percussion, and palpation should be considered
Thermometers
- Three main types exist:
- Electronic: Calculates and displays temperature on a digital screen within 15-30 seconds.
- Tympanic: Uses a probe placed in the ear; temperature readings can vary considerably
- Temporal Artery: Utilizes infrared technology; accurate readings are commonly noted
Stethoscope (1 of 3)
- Stethoscopes are to detect sounds in the body not readily noticeable without aid
- Acoustic stethoscopes are the most common
- There are also magnetic and electric stethoscopes
- The acoustic stethoscope transmits sound waves to the ears
Stethoscope (2 of 3)
- Earpieces can be either hard or soft, and should fit snugly in the ear canal
- Binaurals are metal pieces that connect the tubing to the earpieces
- Earpiece positioning should be angled to project the sound towards the tympanic membrane
- The tubing should be firmly attached and have a maximum of 12 to 18 inches in length
Stethoscope (3 of 3)
- The stethoscope head consists of two components:
- Diaphragm: used for high-pitched sounds(lung, normal heart, and bowel)
- Bell: used for lower-pitched sounds (extra heart sounds, bruits)
Equipment to Measure Blood Pressure
- Noninvasive blood pressure is measured using a sphygmomanometer;
- It has a gauge to measure pressure;
- A cuff encloses an inflatable bladder with a valve to inflate and deflate the bladder.
- It is crucial to select the correct cuff size to get accurate results.
- A stethoscope is used to listen to sounds created in the cuff during blood pressure readings
Automated Blood Pressure Devices
- Noninvasive blood pressure (NIBP) monitors are electronic devices attached to a cuff
- They sense blood flow vibrations, converting them into electric pulses, then sending the readings to a display screen
- Readouts include systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse rate.
- These devices lack ability to assess quality of pulse (e.g. rhythm or intensity)
- Some models can be programmed to provide regular readings and sound alarms if the readings fall outside of the desired range.
Pulse Oximetry
- Highly accurate noninvasive method that estimates arterial oxygen saturation using a LED probe emitting light waves.
- Light reflects off oxygenated and deoxygenated hemoglobin in the blood to create a reflection, estimating percentage of oxygen saturation and pulse rate.
- Sensors can be applied to the ear, finger or toe.
- Different parts of the body (foot, hand or thumb) are used for infants
Scales
- Scales are used for measuring height and weight.
- Standing platforms are used for adults and certain older children.
- Electronic readouts and attached components for measuring height are common
- Infant scales can be used in ounces and grams.
Visual Acuity and Screening (1 of 2)
- The Snellen chart is used for evaluating distant vision.
- The chart has various lines with letters of decreasing size placed 20ft away from the patient.
- The size of letters on the chart indicates the person's visual acuity in 20 feet.
- One eye is tested at one time during assessment.
- Top number = distance from chart, Bottom number = distance person with normal vision should read a line.
- E-chart is used for young children or non-English speaking patients.
Visual Acuity and Screening (2 of 2)
- Jaeger and Rosenbaum charts measure near vision
- Rosenbaum charts are similar to Snellen charts, but consist of numbers, Es, Xs and Os increasing in size from top to bottom
- The charts are held 14 inches away, and one eye is tested at a time.
Ophthalmoscope (1 of 2)
- The ophthalmoscope is a tool with lenses, mirrors, and light apertures to inspect the internal structures of the eye.
- The device's head consists of a lens selector dial to adjust lenses to control focus; the unit of strength for each lens is a diopter.
- A positive or negative lens will compensate for myopia or hyperopia in patients' and the examiner's eyes, allowing focus at varying distances within the patient's eye
Ophthalmoscope (2 of 2)
- The aperture permits variations in light during examination.
- A large aperture is used if the patient's pupils are dilated; a smaller aperture is used if the pupils are not dilated.
- A red-free filter is used in certain situations to identify disc pallor and hemorrhages.
- Slit light allows for assessment of the anterior of the eye and assessing elevations or depressions of lesions.
- Grid light can help estimate the size, location, and pattern of fundal lesions.
Otoscope
- The otoscope consists of magnification lenses, a light source, and a speculum.
- The speculum is inserted into the auditory canal to inspect the external auditory canal and tympanic membrane.
- The largest speculum size that fits into the patient's ear canal should be used.
- A pneumatic attachment may be used to evaluate tympanic membrane movement by inflating with small puffs of air in children.
Penlight
- Provides a focused light source for inspection during physical exams
- Use in a variety of situations, such as examining inside of the mouth or nose
- Identify lesions, and evaluate pupillary response
- Can be substituted for the otoscope for focused light, in certain situations
Ruler and Tape Measure
- Accurate measurement of various clinical findings
- Small metric rulers with millimeter and centimeter markings are useful for assessing lesions or other markings on the skin
- These tools are also useful for assessing the length of an infant or a limb's circumference.
Nasal Speculum
- Used to spread the nares to examine the nasal surfaces.
- Simple design with blades spreading the nares
- Used in conjunction with a penlight to assess lower and middle turbinates of the nose
- Second type of nasal speculum is a broad-tipped, cone-shaped device placed onto the end of an otoscope.
Tuning Fork
- Has two types of purposes: Hearing acuity and assessment of vibratory sensation.
- 500-1000 Hz for auditory testing (estimates hearing loss in range of normal speech - 300-3000 Hz )
- 100-400 Hz for neurologic vibratory assessments.
- Striking the tuning fork on the heel of the hand engages the fork
Percussion or Reflex Hammer
- Used to test deep tendon reflexes with a triangular rubber component on a metal handle.
- A flat surface is typically used to strike the tendon, whereas pointed surfaces are used for smaller tendons like the biceps.
- Neurologic hammers are akin to percussion hammers, differing mainly in the rubber striking surface, which is typically rounded on both sides.
- May also be used for deep tendon reflex testing.
Doppler
- Uses ultrasonic waves to amplify difficult-to-hear sounds, such as heart tones, or peripheral pulses.
- A coupling gel is placed onto the patient's skin, after which a transducer is applied.
- Audible sounds can be observed on an electronic display, and the nature or quality of the sound is indicative of the underlying condition
Goniometer
- Device to determine the degrees of flexion or extension of a joint.
- A two-piece ruler with a protractor in the center used to measure the joint degrees of flexion and extension.
Calipers for Skinfold Thickness
- Used to measure the thickness of subcutaneous tissue.
- Measurement can give an estimation of body fat percentages.
- There are various models that can be used to accurately measure specific locations on the body.
- Posterior aspect of the triceps is the most frequent point of measurement
Vaginal Speculum
- The vaginal speculum widens the walls of the vaginal canal for assessment of cervix and vaginal tissues
- Three primary types with differing sizes and blade lengths are available:
- Graves': Features various sizes and blade lengths
- Pedersen: Wider blades than Graves', but narrower and flatter
- Pediatric/Virginal: Smaller in all dimensions.
- The patient should be informed about the possible sounds of the speculum opening
Audioscope
- Used during hearing acuity assessments. (Basic screening tool that quickly determines hearing acuity)
- The device produces sound tones at different frequencies, often from 1000-5000 Hz
- Patients raise their finger when they hear the sound tone.
- The device produces an automatic tone to signal it is being used
Monofilament
- A small, wire-like device is used to test lower extremity sensation.
- Device is attached to a handle to assist
- Bends at around 10g of pressure
- Used to assess sensation on the foot. Used to assess intact skin only. Inability to feel pressure using the device suggests reduced peripheral sensation.
Transilluminator
- Method to distinguish features of tissue, fluid, and air inside a body cavity.
- A strong light source emits a narrow beam of light
- The room needs to be darkened to see results, during assessment.
- Different hues of light passing through tissue, fluid, and air is used to determine presence of air, fluid, or tissue in a body cavity.
Wood's Lamp
- Used to detect fungal infections of the skin
- Also used to detect corneal abrasions during examination.
- Black light examination:
- Fungi often exhibit a yellow-green or blue-green fluorescent color when viewed under a Wood's lamp.
- Using a dark room will enhance visibility during examination.
Magnification Device
- Aids in identification of skin lesions.
- Small, handheld device assists with inspection
- Some come with a battery-powered light.
- Magnification and lighting assist during the inspection of wounds, skin lesions, and parasites.
Question 1 Answer
- The correct answer is D. Ruler. A ruler is not typically used during fungal infection assessments
Question 2 Answer
- The correct answer is D. Goniometer. A goniometer would be used to measure range of motion of a joint, not for a swollen elbow
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Description
This quiz assesses your knowledge of nursing techniques involving palpation and auscultation. Test your understanding of proper touch, sensitivity of different hand parts, and assessment techniques used during patient examinations. Ideal for nursing students and professionals.
