Chapter 005

Techniques and Equipment for Physical Assessment Chapter 5

Techniques: Inspection • Visual examination of body (movement/posture; including smell) • Component of every body system – Appropriate draping: sufficient exposure; adequate lighting

• Preconceptions may hinder: critical eye • May seem easy; practice needed to develop and master • Instruments facilitate process – Penlight to increase light to area, tangential lighting

Techniques: Palpation • Sensation of hands to feel texture, size, shape, consistency, location of certain parts, painful/tender areas • Need to move into personal space • Touch—gentle, warm hands, short nails – Cultural symbolism and significance – State purpose of touch; manner and location

• Gloves worn: mucous membranes, body fluids

Techniques: Palpation • Palmar surface of fingers/finger pads more sensitive than fingertips – Position, texture, size, consistency, masses, fluid, crepitus

• Ulnar surface, vibration; dorsal surface, temperature • Palmar surfaces of fingers: light/deep (light before deep) • Bimanual technique

Techniques: Percussion • Evaluate size, borders, consistency, tenderness, extent of fluid • Direct: striking finger/hand directly against body – Sinuses, CVA tenderness

• Indirect: both hands required; methods vary by system being assessed – Hand/finger between client and examiner striking – Plexor/pleximeter – Wrist action: rapid flexion, relaxed; forearm stationary

Techniques: Percussion • Striking produces vibrations (sound waves) – Obese/muscular individuals: stronger percussion – Dense tissue: quiet sounds

• Five percussion tones – – – – –

Tympany: loud, high pitched (abdomen) Resonance: lung Hyperresonance hyperinflated lung Dullness: liver Flatness: bone, muscle

Techniques: Auscultation • Listening for sounds – Some sounds audible without assistance: stridor, wheezing, abdominal gurgling – Stethoscope used for assistance; block out extraneous sounds; evaluating heart, lungs, intestines • Bell: low-pitched sounds; lightly against skin (vascular sounds, extra heart sounds) • Diaphragm: high-pitched sounds; firmly against skin (breath/bowel sounds) – Sounds: intensity, pitch, duration, quality – Selective listening

Techniques: Auscultation • Optimize quality of sounds – Quiet room – Placed directly on skin; clothes obscure/alter sounds – Warm stethoscope: involuntary muscle contractions interfere with normal sounds – Client cold, may shiver: involuntary muscle contractions interfere – Friction of body hair/tubing bumped produces interference

Positioning • Position depends on type of exam and condition of client – Sitting/supine most common

• Appropriate draping in positions: adequate exposure needed during exam • Inability to assume position may be significant finding about physical condition– requires accommodation

Equipment Used During the Examination Process • Facilitates data collection • Equipment used dependent on type of exam/presenting problem • Provides either measurement or facilitates exam technique

Equipment: Thermometers • Assess functional states of body’s tissues and cells • Two types – Electronic: temperature-sensitive probe • Probe-covered/digital display (C or F) • Speed (advantage): 15 to 30 seconds/less accurate – Tympanic: increasing popularity (quick, clean, painless) • Temperature-sensitive probe: inserted into ear; temp of blood flow near TM (core temp) • C or F • Accuracy?: studies report varied results

Equipment: Stethoscope • Hear sounds within body not easily heard with ear • Several types: acoustic most common • Sound waves transmitted through tube to ear – Not magnify sound: blocks extraneous sound making difficult sounds easier to hear – Four components: earpieces, binaurals, tubing, head

Equipment: Stethoscope • Earpieces: hard/soft – Fit snugly, fill ear canal

• Binaurals: adjust angle – Earpieces pointed toward nose

• Tubing – Thick, firm rubber: no longer than 12 to 18 inches – If longer, sounds distorted – Decorative fabric on tubing source of infection

Equipment: Stethoscope • Head: two parts (heavy enough to lie on body without being held) – Diaphragm: flat surface with rubber/plastic ring edge • High-pitched sounds (breath, heart, bowel)

– Bell: concave shape • Low-pitched sounds (extra heart, bruits) • Held lightly in place [if held firm, functions as diaphragm]

– Sized according to age (interchangeable endpieces)

• Fetoscope: fetal heart tones

Equipment: Blood Pressure Measurement Equipment • Measure arterial blood pressure • Indirect measurement/noninvasive • Sphygmomanometer: (manual inflation/ stethoscope) – Aneroid: glass-enclosed gauge, not as reliable – Mercury: upright manometer filled with mercury; most reliable (mercury hazard)

• NIBP: electronic device on BP cuff – Blood flow vibrations converted to electrical impulses – BP/pulse/MAP: can’t determine pulse quality

Equipment: Blood Pressure Measurement Equipment • Blood pressure cuffs: disposable/reusable – Bladder that inflates – Correct size: cuff width 40% circumference of arm used • Too wide, underestimate; too narrow, overestimate

– Adult: two sizes; standard for most adults; if obese, thigh cuff – Pediatrics: different sizes (cover two thirds of upper arm)

Equipment: Pulse Oximetry • Noninvasive measurement: estimate arterial oxygen saturation in blood • LED probe reflects off oxygenated/ deoxygenated Hgb for estimation of O2 percentage/pulse • Cutaneous sensor taped to ear, finger, toe • Highly accurate • “Fifth vital sign”

Equipment: Scales • Measure body height/weight • Older children/adults—standing platform – Sensitive to 0.25 pound (1 kg) – Height with attachment

• Electronic scale: converted to digital readout • Infants: platform scale (oz/g) – Height with mat/board

Equipment: Visual Acuity and Screening • • • •

Snellen chart: wall chart 20 feet from client 11 lines of letters decreasing in size Letter size: visual acuity read from 20 feet Test one eye at a time – Record visual acuity number – Top number = distance from chart – Bottom number = distance person with normal vision should be able to read line

Equipment: Visual Acuity and Screening • Colors of horizontal line (red/green): color perception • Which line longer: field perception • E chart: children, non–English-speaking clients (scored same as Snellen)

Equipment: Visual Acuity and Screening • Assess client’s near, or close-up, vision • Two charts – Rosenbaum: numbers, E’s, X’s, O’s in graduated sizes – 14 inches away: one eye at a time – Visual acuity measured same as Snellen – Jaeger equivalent: 20/20 = Jaeger 2

• If no chart, read newspaper – 14 inches away, able to read without difficulty

Equipment: Doppler • Amplifies sounds too difficult to hear with acoustic stethoscope • Ultrasonic waves (fetal heart tones, pulses) • Gel/transducer slid over skin until blood flow heard • Blood ebbs/flows: changes in pitch amplified – Swishing, pulsating sound

Equipment: Goniometer • Determine degree of flexion or extension of joint • Two-piece ruler, jointed, with protractor type of measuring device • Placed over joint – either flexion or extension and degree measured on protractor

Equipment: Calipers for Skinfold Thickness • Measure thickness of subcutaneous tissue to estimate amount of body fat • Different models for different points on body. • Most frequent location: posterior aspect of triceps

Equipment: Vaginal Speculum • Spread walls of vaginal canal to visualize vaginal tissue and cervix • Three types, all with two blades and handle (reusable or disposable) – Graves’: variety of sizes and blade lengths – Pedersen’s: blades as long as Graves’; narrower and flatter (aids visualization) – Pediatric (virginal): smaller in all dimensions

• Plastic or metal differ in ease and positioning

Equipment: Audiometer • Basic screening for hearing acuity • Fast, simple test to detect problems • Tones created at different frequencies (1000-5000 Hz) • Client to respond to hearing of tone (raise finger) • Light indicates tone sound; client should respond at same time

Equipment: Monofilament • Lower extremity sensation • Small, flexible wire (attached to handle) bends at 10 g pressure – Unable to feel – suggests reduced peripheral sensation – Should feel when various parts of foot touched [intact skin]

• Screening tool for high-risk individuals: diabetics with peripheral neuropathy

Equipment: Transilluminator • 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 source transilluminated under skin surface – Light transmitted differently if air, fluid, or tissue (different glowing red tones)

Equipment: Wood’s Lamp • Detect fungal infection of skin, or used with fluorescein dye to detect corneal abrasions • Black light effect – Fungal infection: fluorescent yellow-green or blue-green

• Room darkened to enhance clinical interpretation of color

Principles of Infection Control • Standard precautions apply to all clients • Assessment safe but still potential for infection transmission – Handwashing/personal protective equipment – Protect client/health care worker from each other, client to client – Standard precautions; CDC guidelines

Principles of Infection Control • Latex allergy on increase; reaction to proteins in latex rubber • Amount of exposure unknown: increased exposure leads to increased risk – Health care providers at risk due to frequent exposure – Nonlatex gloves – Clients may also have allergy • Children: spina bifida • Multiple medical procedures/surgeries: GU

– Routinely ask clients

Age-Related Variations: Newborns and Infants • Head/chest circumference to assess growth and development • Recumbent length, weight, head circumference plotted to assess/evaluate growth (compare with established norms) • Weight – Platform scale: nearest half ounce or 14 g – 5 lb 8 oz to 8 lb 13 oz – Lose 10% first week, gain back 10 to 14 days, doubled by 4 to 5 months, tripled by 12 months

Age-Related Variations: Newborns and Infants • Recumbent length – Infant measuring mat; rigid headboard/footboard – If not available, improvise

• Head circumference – Every visit to 2 years, yearly to 6 years – Largest circumference above eyebrows/pinna, occipital prominence (twice); nearest 1/8 inch – Plotted on growth curve: 1 inch larger than chest • Increasing  increased intracranial pressure • Less than 5th percentile  microcephaly

Age-Related Variations: Newborns and Infants • Chest circumference – Only measured if abnormal head or chest size – Measured at nipples between inspiration and expiration – At birth less than or equal to head circumference; 1 to 2 years, approximately equal to head circumference

Age-Related Variations: Newborns and Infants • Vital signs • Temperature – Wide variations: less effective heat control – Safest: axillary, tympanic

• Pulse and respiration – Same qualities as adult; taken when quiet – Apical pulse for full minute and respirations – Diaphragmatic breathers; full minute due to normal irregularity

Age-Related Variations: Children • Height and weight – Platform with movable headboard/measuring tape – Recorded/plotted on growth charts (inches/cm) – Weight monitoring essential • Comparison with population standard (percentile) • Measurements continue until 18 to 20 years of age

Age-Related Variations: Children • Head and chest circumference – Head measured until 2 years—every visit • Annually until 6 • At 2, head two thirds adult size • Compared with population standard

– Chest: between 5 months and 2 years chest circumference approximate head circumference – After 2, chest larger than head

Age-Related Variations: Children • Vital signs • Temperature: electronic, TM – Glass not until older than 5; younger than 5, axillary with glass safe and accurate – Rectal: last resort (inserted 1 inch)

• Blood pressure—AHA recommends annually from 3 to adolescence – Explain to child – 4th Korotkoff sound for diastolic pressure

Age-Related Variations: Adolescents • Weight and height: annually • Before puberty differences in composition minimal • Adolescent growth spurt: gender differences (skeletal, lean body mass, fat stores)

Age-Related Variations: Older Adults • Weigh less, shorter – Greater than 80, decrease due to muscle wasting/chronic disease – Total body water decreases – Subcutaneous fat redistribution – Decreased bone formation: shortening of vertebrae, thinning of vertebral disks – Kyphosis/flexion of knees or hips: arms/legs look longer, out of proportion

Age-Related Variations: Older Adults • Vital signs – Lower temperature – High blood pressure: arteriosclerosis, diabetes (less compliance) – Rigid aorta: increased systolic pressure