Physical Assessment strategies & Technique.pptx

Physical Assessment strategies & Technique.pptx

1. Physical Assessment Strategies and T echniques T rimeste r 1, 2022- 2023 Ass.Lect. MUSTAFA ISMAEEL

2. Learning Objectives Apply standard precautions and infection control to the examination process. Correctly obtain baseline data and describe the meaning of the findings. Differentiate various types of equipment used for physical examination. Describe the purpose and the correct use of various types of equipment used for physical examination. Identify the four basic techniques techniques applied during a physical examination. Describe the purpose of various techniques used during physical examination. Demonstrate correct application of the various techniques used during physical examination. 27- 2

3. Assessment Interview Health history Physical examination

4. Introduction A head to toe physical assessment is a vital aspect of nursing  should be done each time you encounter a patient for the first time. It includes: the assessment of physical, emotional, and mental aspects of all body systems as well as the environmental issues affecting the patient.

5. Physical Assessment Requires: √ Technical skills √ A knowledge base The skills are performed √ One skill at a time √ In a specific order 5

6. Planning for Physical Assessment Explain Equipment The environment (setting) and the client Use all senses; sight, smell, touch, and hearing 6

7. Preparing the Physical Environment Set the room temperature at a warm comfortable, quiet, private level. Provide sufficient lighting . Reduce noise ( such as radio, TV or people talking) Remove distracting objects. 27- 7

8. Preparing the Physical Environment Maintain the distance between you and the patient at 4 to 5 feet (twice an arm's length). Arrange equal-status seating. Avoid sitting behind a desk or bedside table placed so that it looks like a barrier. Avoid standing. 27- 8

9. Standard Precautions during physical examination Wash hands Wear a clean gloves Wear mask and eye protection Follow hospital policy and standard of infection control Change the linens between patient and another Prevent injuries due to blood borne pathogens

10. Equipment for PE Platform scale with height Otoscope- ophthalmoscope attachment. Skin fold calipers Nasal speculum Sphygmomanometer Tongue depressor Stethoscope with bell and diaphragm end-pieces Vaginal speculum Lubricant Clean gloves Thermometer Skin- marking pen. Penlight Flexible tape measure Tuning fork Reflex hammer

11. Equipment needed

12. Sitting/ seated The client can sit on the edge of a chair or bed  cover lap & legs This position is good for evaluating what ? (Ball et al. 2015, p. 32)

13. Supine The client can lie down on back with the legs together on the examination table. Arms at the side. A small pillow may be placed under the head to promote comfort This position is good for evaluating what ?

14. Dorsal Recumbent The client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. This position is good for evaluating what ? For rectal and genital areas exam.

15. SIMS' Position The client lies on his or her right or left side with the lower arm placed behind the body and the upper arm flexed at the shoulder and elbow. This position is good for evaluating what ? For rectum exam or rectal temperature.

16. Standing Position The client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess? posture, balance, gait and the male genitalia .

17. Prone Position The client lies down on his or her abdomen with the head to the side. This position is good for evaluating what ? Special maneuvers as part of musculoskeletal exam.

18. Knee- Chest Position [Lateral Recumbent] The client kneels on the examination table with the weight of the body supported by the chest and knees. A90- degree angles should exist between the body and the hips. A small pillow may be used to provide comfort. This position is good for evaluating what ? Listening to the heart or palpating the spleen

19. Lithotomy Position The client lies on his or her back with the hips at the edge of the examination table and the feet supported by stirrups. This position is good for evaluating what ? For pelvic examination

20. Infants and children The Toddler and Preschool child The school- age child Adolescent The aging adult The Ill person Developmental Consideration

21. Definition of PE Physical examination: the process by which a nurse investigates the body of a patient for signs of disease Purposes of PE It follows taking the medical history and account of the symptoms as experienced by the patient.

22. Using your senses in PE Vision: Smell: Hearing Touch:

23. Physical examination skills . 1. Inspection 3. Percussion 2. Palpation 4. Auscultation

24. Physical Examination: Four basic techniques Always first − do not rush Focused inspection − takes time & yields a surprising amount of data Slow and systematic technique Start with light palpation − surface characteristics Deep palpation, bimanual palpation Need: stethoscope − diaphragm and bell Tapping the patient’s skin − short, sharp strokes Stationary hand Striking hand Palpation Inspection Percussion Auscultation 24

25. N.B. The sequence of the physical techniques are inspection, palpation, percussion, and auscultation for all system Except the abdominal system  Starts by inspection, auscultate, percuss and palpate

26. 1. Inspection Is the concentrated watching Is done first to the patient as a whole; then for each body system Begins the moment you first meet the person; then as you proceed through the examination

27. 1. Inspection: Principles Take time to observe Position and expose body parts for optimal viewing Ensure good lighting & warm temperature Compare the right and left side of the body Inspect for size, shape, color, symmetry, pattern, location, position consistency, movement, behavior, odors

28. 1. Inspection: Equipment Otoscope Ophthalmoscope Penlight Nasal Speculum Vaginal speculum

29. 2. Palpation Applies senses of touch and feel Using touch to √ detect variations in normal √ investigate abnormalities √ assess various parts of the body √ helps to confirm findings that are noted on inspection Should be √ slow & √ systematic Approach: √ Gentle, calm approach starting with light palpation

30. 2. Palpation… In palpation you assess the following characteristics: Texture: Quality, Surface, rough / smooth Temperature: warm / cold Moisture: dry / wet, moist Mobility: fixed / movable / still/ vibrating Consistency: soft / hard / fluid filled Pulse strength: strong/weak/ thready/ bounding Size: small / medium / large Shape: well defined / irregular Degree of tenderness organ location, swelling, masses, degree of tenderness, measurement of chest rising

31. 2. Palpation Remember : Use dry, warm hands Any tender areas should be palpated last Be alert; short nails

32. Palpation: hand parts Learn to use the various parts of the fingers. Each one best for what purpose? Fingertips Grasping action of fingers & thumb Dorsal (backs) of hands & fingers Base of fingers or ulnar surface of hand

33. Palpation: Sense of Touch FINGERTIPS- √ Fine tactile discrimination- skin texture, swelling, lumps DORSA of hands √ Temperature detection BASE of fingers or ULNAR surface of hands √ vibration

34. Types of palpation Light palpation Moderate palpation Deep palpation Bimanual palpation

35. Warm your hand Palpate any tender area Last Avoid any situation could cause internal injury or pain.

36. P alpa t ion : T yp es of Palpation Light Palpation: feel for pulses, check muscle tone, assess for tenderness, surface skin texture, temperature and moisture Moderate Palpation : Depress the skin surface from 1- 2 cm. To palpate the body organs and masses - note the → size, → consistency and → mobility of the structure.

37. Palpation… Deep Palpation : surface depres sion between 2.5- 5 cm  = to identify abdominal organs or structures that are: → covered by thick muscles and abdominal masses

38. Palpation… Bimanual Palpation: use two hands → placing one on each side of the body part (e.g., uterus, spleen, and breast) → use one hand to apply pressure and other to feel the structure Bimanual palpation to capture certain body parts as breast, kidney, uterus

39. 3. Percussion Percussion: tapping (rhythm) the person's skin with short, sharp strokes to produce sound waves and assess underlying structures. The strokes produce a palpable vibration and characteristic sound that indicate: The location, size and density of underlying organ

40. Percussion = the striking of the body surface with short, sharp strokes in order to produce: √ palpable vibrations and √ characteristic sounds It relies on the senses of √ touch and √ hearing It maps out the location and size of an organ To determine / detect: √ tissue density & √ the presence of air, fluids, or solids √ abnormal superficial mass Inflamed underlying structure  Produces pain Using the hammer  Produces the deep tendon reflex

41. 3- Percussion… The goal is to Determine Location Identify organ shape & position Determine density Detecting abnormal masses Elicit pain Eliciting reflexes

42. Percussion Stationary Hand 1 Striking Hand 2 3 4

43. CHARACTERISTIC OF PERCUSSION NOTES

44. Position of Stationary Hand to Percuss Position of Striking Finger to Percuss Percussion

45. Types of Percussion Direct (immediate) Blunt Indirect (mediate) .

46. 3 Types of Percussion: direct vs. indirect vs. blunt Direct Percussion one hand is used & the striking finger of the examiner touches the surface being percussed Indirect Percussion two hands are used & the plexor (middle finger) strikes the finger of the examiner's other hand, which is in contact with the body surface being percussed Blunt Percussion the ulnar surface of the hand or fist is used in place of the fingers to strike the body surface either directly or indirectly

47. Types of Percussion… 3. Indirect (mediate). It involves both hands. The striking hand contact stationary hand fixed on the person's skin  this yields a sound and a restrained vibration.

48. Normal percussion sounds As density increases, the sound of the tone becomes quieter. Solid tissue  a soft tone Fluid  a louder tone Air  an even louder tone

49. Percussion: Characteristics of the sound waves Intensity (amplitude) √ a loud or soft sound √ the louder the sound the greater the amplitude Pitch ( frequency) : the number of vibration per second Quality (timbre), a subjective difference due to a sound’s distinctive tones. Duration √ The length of time the note linger Tones √ Resonance √ Flatness √ Dullness √ Tympani √ Hyper- resonance Remember √ use dry, warm hands √ your nails must be short √ keep the room quiet

50. Indirect Percussion Term Definition Intensity (Amplitude) How loud or soft a sound is Duration Length of time Pitch (frequency) Number of vibration (or cycles) per second Quality (timbre) A subjective difference in sound as a result of the sound’s distinctive overtones

51. Normal percussion sounds Sound Intensity Pitch length quality Example of origin Resonance (heard over part air) Loud Low Long Hollow Normal Lung Hyper resonance (heard over mostly air) Very Loud Low Long Booming Emphysema Tympany (heard over air) Loud High Moderate Drum like Gastric bubble Dullness (Heard over more solid tissue) Medium Medium Moderate Thud like Pleural effusion, liver Flatness Heard over very dense tissue) Soft High Short Flat Muscle, bone, sternum, thigh

52. Percussion: Tones vs. Sounds Tones Sounds Resonanc e Heard over : lung Clear and hollow Heard over : part air and part solid. A hollow sound - over normal lung Hyper-resonance: Heard over mostly air. A booming sound - lung with emphysema Tympany Heard over : stomach Musical and drum like Heard over : air- filled viscous A musical or drum like sound produced by stomach Puffed out cheek, gastric bubble. Dullness Heard over : liver Muffled (quiet) thud (dull sound) Heard over : more solid tissue. Thud sound produced by dense structures such as liver, enlarged spleen, or a full bladder. Flatness Heard over : bone Dead stop Heard over : very dense tissue. An extremely dull sound like that produced by very dense (thick) structures such as muscle or bone

53. 4. Auscultation Listening to sounds produced by organs such as: Heart sounds Lungs sounds (movement of air through the Resp. tract) Blood vessels (movement of blood through the cvs) Intestines (movement of the bowel) It is essential to know: – the characteristics of normal sounds WHY : to evaluate your findings

54. Auscultation: Stethoscope √ does not magnify sounds but blocks out extraneous room sounds √ amplify sounds How to Use √ Keep instrument clean √ Warm chest- piece before using √ Ear pieces − point toward your nose √ Better to listen under a gown than through a gown √ Close eyes during listening for more concentration √ Friction of the end piece from a man’s hairy chest cause a crackles sound = mimics an abnormal breath sound Remember: Become familiar with bell & diaphragm Avoid your own “artifact”

55. 4- Auscultation Components vs. Type of Sound Diaphragm best for high pitched sounds Press firmly on body part Heart sound Lungs sound Bowel sound Bell best for soft, low- pitched sounds Press lightly over body part Abnormal sounds Extra heart sounds or murmur Bruit (Blood vessels)

56. The sounds detected using auscultation are classified according to: Intensity (loud or soft) Pitch (high or low) Duration (length) Quality (musical, crackling, raspy) 4. Auscultation

57. Standard Precautions Review Guidelines ( P. 140, Table 8- 2) Take all steps to avoid any possible transmission of infection between patients or between patient and examiner S I NGL E MO S T I MPO R T ANT S TE P  t o d ec r ease ri s k o f m ic r oo r g a n i s m t r a ns m i ss i on = to wash your hands

58. REMEMBER: First Impressions Start with vital sign assessment Determine level of consciousness and orientation Assess affect and mood Assess grooming and hygiene Inspect skin surfaces

59. SITTING Warm Comfortable Quiet Private Well lit

60. EQUIPMENT To complete assessment steps, the nurse must use special equipment

61. CLEAN VS. USED

62. A SAFER ENVIRONMENT Hand hygiene Before and after every physical patient encounter; After contact with blood, body fluids, secretions, and excretions After contact with any equipment contaminated with body fluids After removing gloves

63. Summary Introduction Preparing the Physical Environment Standard Precautions during physical examination Equipment for PE Positioning the client Developmental Consideration Physical Examination: Four basic techniques References

64. When performing a physical assessment, the technique the nurse will always use first is: palpation. inspection. percussion. auscultation. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: consider this a normal finding. palpate this area for an underlying mass. reposition the hands and attempt to percuss in this area again . consider this an abnormal finding and refer the patient for additional treatment.

65. References Jarvis, C. (2016). Physical examination & health assessment (7 th ed.) St. Louis, Missouri: Saunders Elsevier. (Chapter 8) Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S. & Stewart, R.W. (2015). Seidel’s guide to physical examination (8 th ed.). St. Louis, Missouri: Mosby, Saunders/ Elsevier. (Chapter 3)