Transcript Percussion (contd.)

Techniques and Equipment for
Physical Assessment
DSN Kevin Dobi, MS, APRN
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Standard Precautions apply in all health care settings:
 Hand hygiene is the single-most important
component to reduce infection transmission.
 Utilize personal protective equipment as necessary.
 Proper management of patient care equipment is
essential.
Be mindful of latex allergies:
 Health care professionals are at risk for developing
latex allergies because of frequent exposure.
 Patients may also have a latex allergy – Ask!
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Inspection
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Palpation
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Percussion
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Auscultation
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Physical exams begin with inspection:
 Visual exam of 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 is draped appropriately to maintain modesty
while allowing sufficient exposure for exam;
adequate lighting is essential.
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Patient should be thoroughly observed with a critical
eye.
Concentration without distraction avoids overlooking
potentially important data.
Inspection may seem easy to master, but practice is
necessary to develop skill.
Use of equipment may facilitate inspection of certain
body systems:
 Penlight, otoscope, ophthalmoscope, and vaginal
speculum.
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Use of hands to feel texture, size, shape, consistency,
location of certain parts, and identify painful or tender
areas.
Requires nurse to move into personal space.
Gentle touch, warm hands, and short nails to prevent
discomfort or injury to patient:
 Touch has cultural symbolism and significance.
 State purpose, manner, and location of touching.
 Wear gloves when palpating mucous membranes or
other areas where contact with body fluids is
possible.
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Palmar surface of fingers and finger pads are more
sensitive than fingertips.
 Better to determine position, texture, size,
consistency, masses, fluid, crepitus.
Ulnar surface of hand to fifth finger is most sensitive to
vibration.
Dorsal surface is better for assessing temperature.
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Using palmar surfaces of fingers may be light or deep
and controlled by amount of pressure.
Light palpation accomplished by pressing to a depth of
approximately 1 cm, used to assess skin, pulsations,
and tenderness.
Deep palpation accomplished by pressing to a depth of
4 cm with one or two hands: used to determine organ
size and contour.
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Bimanual technique of palpation uses both hands, one
anterior and one posterior, to entrap an organ or mass
between fingertips to assess size and shape.
Light palpation should always precede deep palpation
because deep palpation may cause tenderness or
disrupt fluids, which may interfere with collecting data
by light palpation.
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Percussion performed to:
 Evaluate size, borders, and consistency of internal
organs.
 Detect tenderness.
 Determine extent of fluid in a body cavity.
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Direct percussion
 Strike finger or hand directly against patient’s body
 Evaluate adult sinus by directly tapping finger on
sinus
 Elicit tenderness over kidney by striking
costovertebral angle (CVA) directly with fist
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Indirect percussion requires both hands; methods can
vary by system being assessed.
Place the distal aspect of the middle finger of the
nondominant hand against the skin over the organ
being percussed and strike the distal interphalangeal
joint with the tip of the middle finger of the dominant
hand.
Force of the downward snap of the striking finger
comes form rapid flexion of the wrist.
Rebound quickly to avoid muffling of the vibration.
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Tapping produces a vibration deep in body tissue, with
subsequent sound waves.
Percuss two or three times in one location before
moving to another.
Stronger percussion is needed for obese or very
muscular patients because thickness of tissue can
impede vibrations.
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Five percussion tones:
 Tympany is loud, high-pitched sound heard over
abdomen.
 Resonance is heard over normal lung tissue.
 Hyperresonance is heard in overinflated lungs, as in
emphysema.
 Dullness is heard over liver.
 Flatness is heard over bones and muscle.
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Auscultation is listening to sounds within body; nurse
commonly uses stethoscope to facilitate auscultation.
Stethoscope is used for auscultation to block out
extraneous sounds when evaluating condition of heart,
blood vessels, lungs, and intestines.
Listen for sound and characteristics: Intensity, pitch,
duration, and quality.
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Concentrate; sounds may be transitory or subtle:
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Selective listening is isolating specific sounds, such as air
during inspiration, or a single heart sound.
Optimize quality of auscultation findings:
Best to auscultate in quiet room where noises cannot
interfere.
 Stethoscope must be placed directly on skin because
clothes obscure or alter sounds.
 If patient is cold and shivers, involuntary muscle
contractions may interfere with normal sounds.
 Friction of body hair rubbing against diaphragm could be
mistaken for abnormal lung sounds (crackles).
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Position depends on type of exam and condition of
patient:
 Sitting and supine positions are most common.
Appropriate draping in positions with adequate
exposure is needed for exam.
Inability of patient to assume position may be a
significant finding about physical condition and may
require accommodation.
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Equipment is used to facilitate collection of data.
Equipment used varies depending on type of exam and
problem being assessed and provides:
 Measurements: Temperature, weight, visual acuity.
 Facilitation of examination technique: Inspection,
auscultation, percussion, or palpation.
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Measure body temperature; three types:
 Electronic: Calculates and displays temperature on
digital screen within 15 to 30 seconds.
 Tympanic: Temperatures are obtained by placing a
probe into ear; studies have shown widely varying
results.
 Temporal artery: Utilizes infrared technology;
studies demonstrate a high level of accuracy.
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Auscultates sounds within body not easily audible to
human ear.
Four types of stethoscopes:
 Acoustic – most common
 Magnetic
 Electric
 Stereophonic
The acoustic stethoscope transmits sound waves from
the source through the tube to the ears:
 Does not magnify sound but blocks extraneous
sound, making difficult sounds easier to hear.
 Four components: Earpieces, binaurals, tubing, and
head with diaphragm and bell.
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Earpieces may be hard or soft.
 Should fit snugly and completely fill ear canal.
Binaurals are tubes of metal that connect stethoscope
tubing to ear pieces.
 Allow ear pieces to be angled toward nose to project
sound toward tympanic membrane.
Tubing usually firm polyvinyl no longer than 12 to 18
inches (30 to 46 cm).
 Tubing longer than 18 inches may distort sounds.
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Head includes two components:
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Diaphragm is flat surface with rubber or plastic ring:
 Used to hear high-pitched sounds such as breath sounds, bowel
sounds, and normal heart sounds.
 Structure screens out low-pitched sounds
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Bell constructed in concave shape:
 Used to hear soft, low-pitched sounds such as extra heart sounds or
vascular sounds (bruit).
 Should be pressed lightly on skin with just enough pressure to
ensure a complete seal around bell.
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A special type of acoustic stethoscope, a fetoscope, is used to
auscultate fetal heart:
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Fetoscope has a metal attachment that rests against the head of
nurse and aids in conduction of sound so that heart tones are
heard more easily.
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Measures arterial blood pressure indirectly
(noninvasively).
Sphygmomanometer consists of gauge to measure
pressure, a cuff enclosing an inflatable bladder, and
bulb with valve used to inflate and deflate bladder
within cuff .
Cuff sizes vary.
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It is necessary to ensure the correct size is utilized for accurate
results.
Stethoscope is used to auscultate blood pressure.
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A noninvasive blood pressure (NIBP) monitor is an
electronic device attached to the cuff
 It senses blood flow vibrations and converts them to
electric impulses transmitted to digital readout.
 Readout indicates blood pressure, mean arterial pressure,
and pulse rate.
 It is not capable of determining quality of pulse, such as
rhythm or intensity.
 It may be programmed to repeat measurements on a
scheduled basis and to sound an alarm if measurements
are outside of desired limits.
 It is an especially useful feature for patients requiring
frequent blood pressure monitoring.
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Highly accurate noninvasive measurement estimates
arterial oxygen saturation in blood.
Consists of LED probe emitting light waves that reflect
off oxygenated and deoxygenated hemoglobin
molecules circulating in blood.
Reflection used to estimate percentage of oxygen
saturation in arterial blood and pulse rate.
 Sensor taped to ear, finger, or toe.
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Measure body height and weight.
Standing platform used for older children and adults:
 Sensitive to 0.25 pound (0.1 kg)
 Attachment for height measurement.
 Electronic scales display digital readout.
Infant platform scale in ounces and grams.
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Snellen chart is wall chart placed 20 feet from patient:
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11 lines of letters decreasing in size.
Letter size indicates visual acuity from 20 feet.
Tests one eye at a time.
Provides visual acuity number.
Top number = distance from chart.
Bottom number = distance person with normal vision
should be able to read line.
E chart used for young children and
non–English-speaking patients:
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Scored same as Snellen.
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Jaeger and Rosenbaum charts are commonly used to
evaluate near vision:
 Rosenbaum consists of numbers, Es, Xs, and Os in
graduated sizes.
 Held 14 inches away, one eye tested at a time.
 Visual acuity is measured same as Snellen.
 Jaeger equivalent is shown on same chart.
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Ophthalmoscope is an instrument consisting of series
of lenses, mirrors, and light apertures to inspect
internal eye structures:
 Head consists of lens selector dial and aperture
settings.
 Lens selector dial adjusts lenses that control focus;
unit of strength for each lens is diopter.
 Positive and negative lenses compensate for myopia
or hyperopia in both nurse’s and patient’s eyes and
permit focusing at different places within patient’s
eye.
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Aperture permits light variations during exam:
 If patient’s pupils have been dilated, the large light
may be used for internal eye examination.
 Small light may be used if patient’s pupils are very
small or if pupils have not been dilated.
 Red-free filter shines green beam and facilitates
identification of pallor of disc; hemorrhages appear
black.
 Slit light permits exam of anterior of eye and
elevation or depression of a lesion.
 Grid light facilitates an estimate of size, location, and
pattern of fundal lesion.
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Otoscope consists of magnification lens, light source,
and speculum inserted into auditory canal to inspect
external auditory canal and tympanic membrane.
Choose largest size speculum that fits into patient’s ear
canal.
Pneumatic attachment produces small puffs of air
against tympanic membrane to evaluate fluctuation of
tympanic membrane in children.
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Provides focused light source for inspection.
Penlight has many uses during a physical assessment.
Used to illuminate inside of mouth or nose, highlight a
lesion, or evaluate pupillary constriction.
Light transmitted from otoscope may be substituted as
a focused light source.
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Provide accurate measurement for various findings.
Small metric ruler with millimeter and centimeter
markings is useful for measuring lesions or other
marks on the skin.
Use transparent ruler.
Tape measure, with inches on one side and centimeters
on reverse, is useful in various situations, such as when
measuring length of an infant or circumference of
extremity.
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Spreads opening of nares to inspect internal surfaces of
nose.
Two instruments may be used as a nasal speculum:
 Simple nasal speculum is used in conjunction with
penlight to inspect lower and middle turbinates of
the nose.
 Gently squeezing handle of speculum causes blades of
speculum to open and spread nares.
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Second type is broad-tipped, cone-shaped device
that is placed on the end of an otoscope.
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Tuning fork has two purposes: Auditory screening and
assessment of vibratory sensation.
High-pitched tuning fork with frequency of 500 to 1000
hertz (Hz) should be used to estimate hearing loss in
range of normal speech (300 to 3000 Hz).
For neurologic vibratory evaluation, a pitch between
100 and 400 Hz should be used.
Sharply strike tuning fork on heel of hand.
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Used to test deep tendon reflexes.
Percussion (reflex) hammer consists of a triangular
rubber component on end of a metal handle:
 Flat surface commonly used when striking tendon
directly.
 Pointed surface used to strike tendon directly or to
strike a finger, which is placed on a small tendon
such as patient’s biceps tendon.
 Neurologic hammer can also be used to test deep
tendon reflexes; similar to percussion hammer, but
the rubber striking end is rounded on both sides.
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Doppler uses ultrasonic waves to detect and amplify
difficult-to-hear vascular sounds such as fetal heart
tones or peripheral pulses.
Coupling gel is applied to patient’s skin; then
transducer is slid over skin surface until blood flow is
heard in earpieces.
 As blood in vessels ebbs and flows, Doppler picks up
and amplifies subtle changes in pitch; the resulting
sound that the nurse hears is a swishing, pulsating
sound.
 Volume control may further amplify sound.
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Determines degree of flexion or extension of joint.
Two-piece ruler jointed in middle with a protractortype measuring device.
Placed over joint; as individual extends or flexes joint,
degrees of flexion and extension are measured on
protractor.
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Measure thickness of subcutaneous tissue to estimate
amount of body fat.
Different models may be used for different points on
body.
Most frequent location is posterior aspect of triceps.
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Spreads walls of vaginal canal to inspect vaginal tissue
and cervix.
Three types with two blades and handle:
 Graves’ has variety of sizes and blade lengths.
 Pedersen has blades as long as Graves’ but narrower
and flatter to aid inspection.
 Pediatric, or virginal, is smaller in all dimensions.
Patient should be forewarned about clicking and
snapping sounds of opening speculum.
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Basic screening for hearing acuity.
Fast, simple test to detect problems.
Tones created at different frequencies (1000 to 5000
Hz).
Patient responds to hearing of tone by raising finger.
Light indicates tone sound, and patient should respond
at the same time.
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Used to test lower extremity sensation.
Small, flexible wire-like device attached to handle and
bends at 10 g of pressure.
 Used to assess sensation on various parts of foot, to
touch intact skin only.
 Inability to feel suggests reduced peripheral
sensation.
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Used to differentiate characteristics of tissue, fluid, and
air in specific body cavity.
Strong light source with narrow beam at distal section
of light.
Room darkened, light placed against skin over body
cavity:
 Light is transmitted differently through air, fluid, or
tissue with different glowing red hues.
 Character of glowing light hues determines if area
under surface is filled with air, fluid, or tissue.
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Used to detect fungal infection of skin; used with
fluorescent dye to detect corneal abrasions.
Black light effect:
 Fungal infections exhibit fluorescent yellow-green or
blue-green color.
Darkened room enhances clinical interpretation of
lesion colors.
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Used to assist identification of skin lesions.
Small handheld magnification device assists with
inspection; some come with battery-powered light
source.
Magnification and lighting facilitate inspection of
wounds, skin lesions, and parasites.
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The nurse is preparing the room for the dermatologist. The
nurse knows that the patient may have a fungal infection
on the left leg. Which tool is not part of the setup for this
assessment?
A. Wood’s lamp
B. Magnifier
C. Monofilament
D. Ruler
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Collection of objective data from a patient with a swollen
left elbow includes which piece of equipment?
Magnifier
Blood pressure cuff
Snellen chart
D. Goniometer
A.
B.
C.
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