Physical Examination Methods - Istinye University

• Istinye University was founded in 2015 by the 21st Century Anatolian Foundation
• Istinye University aims to be among the distinguished universities in Turkey and the world, by contributing to the production of new information through education and research performance

Vision

• To expand the boundaries of science through the research of its faculty members
• To implement findings acquired from scientific developments for the welfare of society
• To provide quality and accessible health services to the community

Physical Examination Methods

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

Topics Covered

• 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

• Healthcare settings have lots of threatening organisms
• Infection control principles include diligence before, during, and after physical assessments
• Practices for infection control include diligent hand hygiene and use of standard precautions

Hand Hygiene

• The single most important action to prevent infection is hand hygiene
• Contact transmission involves touching

Nail and Hand Hygiene

• Nails must be kept short, artificial nails are not recommended
• Gloves are used to protect against touching blood, body fluids, secretions, excretions, and contaminated items
• Gloves should be changed before going to the next patient
• Healthcare workers should not wear gloves from the room into the hallway

Standard Precautions

• Standard precautions can reduce disease transmission
• Includes hand hygiene, using PPE, respiratory hygiene, aseptic technique, and safe waste disposal

Cardinal Techniques of Physical Assessment

• Inspection: The conscious observation of the patient for general appearance, behaviors, odors, and specifics related to the body system
• Palpation: Using hands to feel the firmness of body parts, such as the abdomen
• Percussion: Tapping motions with the hands, produce sounds that indicate solid or air-filled spaces
• Auscultation: Stethoscope to hear air or fluid movements in the lungs and abdomen

General Considerations

• Draping can protect patient privacy
• Individualize assessment according to cultural, religious, and social beliefs
• Anxious patients disclose less information for fear of being touched or abnormal findings
• Ask patients about preferences, such as having a family member or same gender examiner
• Start with less invasive assessments, most personal assessments at the end

Inspection Technique

• Involves the first technique for examining body parts
• Initial inspections focus on age, gender, alertness, body size and shape, skin color, hygiene, posture, and level of discomfort
• It is the only technique performed for every body system

Gathering Data

• Data gathered helps healthcare professionals form an impression of the situation and its acuity
• Cues from patient during inspection might indicate a problem needing further assessment
• Adequate exposure of each body part is a must
• Maintain patient privacy with appropriate draping
• Adequate lighting is essential for observing color, texture, and mobility
• Ask patients for permission to examine body areas

Palpation Assessment

• Used to assess vibration, texture, temperature, edema, moisture, shape, size and pain

Palpation Guidelines

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

Hand Use in Palpation

• Finger pads can help facilitate fine discrimination, because they are the most mobile part of the hand
• Palmar surface of the fingers and joints is best for assessing firmness, contour, position, size, pain, and tenderness
• Back of the hand dorsal is most sensitive to temperature

Vibration Detection

• With the ulnar, or outside, surface of the hand, vibratory tremors can be felt on the patient's chest during speech

Light Palpation

• Allows patient to become familiar to the touch
• Do not palpate tender or painful areas until the end
• Before beginning, ensure correct draping
• Alert the patient and get their permission

Light Palpation Execution

• Warm hands under before running water
• Short- smooth nails prevent discomfort
• Palpation is difficult when patient muscles are tensed
• Gentle, calm/ easy does assist in relaxaton

When and How to use Light Palpation

• Assess surface characteristics like texture, surface lesions or lumps or inflamed areas of skin
• Move the finger pads of the dominant hand on patient's skin in circular, using 1 cm depth

Moderate to Deep Palpation

• Aids consistency assessment through contour and shape
• Palmar surfaces used on fingers
• Enough pressure to depress approximately 1-2cm

Deep Palpation Technique

• Deep palpation involves pressure from both hands
• Places the extended fingers of the nondominant hand over the dominant hand and uses the same circular motion to palpate 2 to 4 cm

Percussion

• Determines sound and assesses tenderness by tapping fingers on the patient, similar to a drumstick

Percussion Mechanics

• Produced vibrations create tones conducted into the patient's body

Vibration Differences

• Dense tissue creates quieter tones
• Air creates louder tones

Percussion and Tones

• Loudest tones are over the lungs and empty stomach
• Quietest tones are over bone

Percussion Technique

• Direct percussion involves tapping the fingers directly on the patient’s skin
• Indirect percussion involves using the nondominant hand as a barrier between the dominant hand and patient

Using a Fist

• Ulnar surface of the fist is used to percuss the kidneys, gallbladder, or liver for tenderness

Percussion Movements

• Motion of striking finger should be quick, forceful, and snappy for a loud sound
• Use the tip of the finger
• Nails must be short and smooth to avoid tenderness and facilitate good contact

Percussion Technique Tips

• The downward motion uses wrist
• Dampening sound should be kept brief
• If there are individuals with small hands and fingers, strike forcefully than someone with bigger hands

Percussion Sounds: Hyperresonant

• Location: Emphysematous lungs

Percussion Sounds: Resonant

• Location: Healthy Lungs

Percussion Sounds: Tympanic

• Location: Gastric Bubble (stomach)

Percussion Sounds: Flat

• Location: Bone

Percussion Sounds: Dull

• Location: Liver

Auscultation

• Auscultation reveals sounds the body produces, from movement of organs

Technique Factors

• Can vary and depend on body part

Auscultation: Blood pressure

• Location: Arm

Auscultation: Lung sounds vesicular

• Location: Anterior and posterior thorax

Auscultation: Abdominal sounds

• Location: Abdomen

Auscultation: Heart sounds

• Location: Anterior thorax

Equipment Needed

• Stethoscope is needed
• Requires disinfection

Stethoscope Bell and Diaphragm

• The bell is used with light skin contact to hear low-frequency sounds
• The diaphragm is used with firm skin contact to hear high-frequency sounds

Using Eartips

• They must fit into the ear canal snugly but comfortably and should be tilted forward in direction as the nose

Patient Trust

• All equipment needed for the physical assessment should be collected before the examiner enters the room is needed to increase the patient's trust