Orientation to Patient’s Assessment: Vital Signs/ Pain Assessment
Taking a Pulse
Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and ejects
blood into the aorta. Assessment of pulse characteristics provides clinical data regarding the heart’s pumping
action and the adequacy of peripheral artery blood flow.
Taking a Radial (Wrist) Pulse
1. Wash hands.
2. Inform client of the site(s) at which you will measure pulse.
3. Flex client’s elbow and place lower part of arm across chest.
4. Support client’s wrist by grasping outer aspect with thumb.
5. Place your index and middle finger on inner aspect of client’s wrist over the radial artery
and apply light but firm pressure until pulse is palpated (see Figure 15).
6. Identify pulse rhythm.
7. Determine pulse volume.
8. Count pulse rate by using second hand on watch (see Figure 16). For a regular rhythm, count number of beats for 30 seconds and multiply by 2. For an irregular rhythm, count number of
beats for a full minute, noting number of irregular beats.
Figure 15 Place index and middle fingers over radial artery.
Figure 16 Count pulse rate for 30 seconds .Multiply by two.
9. Wash hands.
10. Raise client’s gown to expose sternum and left side of chest.
11. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.
12. Put stethoscope around your neck.
13. Locate apex of heart:
• With client lying on left side, locate suprasternal notch.
• Palpate second intercostal space to left of sternum.
• Place index finger in intercostal space, counting downward until fifth intercostal space is
located.
• Move index finger along fourth intercostals space left of the sternal border and to the
fifth intercostal space, left of the midclavicular line to palpate the point of maximal impulse
(PMI) (see Figure 17).
• Keep index finger of nondominant hand on the PMI.
14. Inform client that you are going to listen to his heart. Instruct client to remain silent.
15. With dominant hand, put earpiece of the stethoscope in your ears and grasp diaphragm
of the stethoscope in palm of your hand for 5–10 seconds.
16. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear
lub-dub sound (see Figure 18).
17. Note regularity of rhythm.
18. Start to count while looking at second hand of watch. Count lub-dub sound as one beat:
• For a regular rhythm, count rate for 30 seconds and multiply by 2.
• For an irregular rhythm, count rate for a full minute, noting number of irregular beats.
19. Share your findings with client.
20. Record by site the rate, rhythm, and, if applicable, number of irregular beats.
21. Wash hands.
Figure 17 Palpating the apical pulse
.
Figure 18 Place diaphragm of stethocope over the PMI to hear the heart rate.
PULSE POINT ASSESSMENT CRITERIA
PULSE POINTS
Temporal: over temporal bone, superior and lateral to eye
Carotid: bilateral, under lower jaw ieck along media edge of sternocleidomastoid muscle
Apical: left midclavicular line at fourth to fifth intercostals space
Brachial: inner aspect between groove of biceps and triceps muscles at antecubital fossa
Radial: inner aspect of forearm on thumb side of wrist
Ulnar: outer aspect of forearm on finger side of wrist
Femoral: in groin, below inguinal ligament (midpoint between symphysis pubis and anterosuperior iliac
spine)
Popliteal: behind knee, at center in popliteal fossa
Posterior tibial: inner aspect of ankle between Achilles tendon and tibia (below medial malleolus)
Dorsalis pedis: over instep, midpoint between extension tendons of great and second toe
BLOOD PRESSURE MEASUREMENT
Purpose: To measure the arterial blood pressure.
Blood pressure measurement requires three pieces of equipment: the sphygmomanometer, the cuff, and the stethoscope. Together they may be used to measure blood pressure. (Fig 12,13)
There are three types of sphygmomanometers. Two types, aneroid and mercury, attach to a blood pressure cuff bladder and require manual cuff inflation. A stethoscope must be used in conjunction with these devices to actually assess the blood pressure. The third type is electronic and assesses the blood pressure without the use of a stethoscope.
1. An aneroid sphygmomanometer is a glass-enclosed circular gauge containing a needle that registers in millimeter calibrations. The gauge is attached to the blood pressure cuff bladder . This gauge needs periodic calibration to ensure accurate measurement.
A mercury sphygmomanometer is an upright manometer tube containing mercury. The pressure created in the bladder of the cuff moves the column of mercury up against the force of gravity. Millimeter calibrations mark the height of the mercury column .
An electronic sphygmomanometer operates by sensing circulating blood flow vibrations and converting these vibrations into electric impulses. These impulses in turn are translated to a digital readout. The readout generally consists of blood pressure, mean arterial pressure, and pulse rate. The device is not capable of determining quality of the pulse, such as rhythm or intensity. The device may be programmed to repeat the measurements on a scheduled periodic basis and
to alarm if the measurements are outside of the precalculated limits. This is especially useful for clients requiring frequent blood pressure monitoring. No stethoscope is required when the electronic device is used .
Blood pressure cuffs are either disposable and made of a latex substance or reusable and made of a textured fabric . The type of cuff used depends on the clinical situation. All cuffs have a bladder that inflates during blood pressure measurement and a cuff that secures the bladder on the arm. When selecting a blood pressure cuff it is important to select the correct size for the client. Ideally the bladder of the cuff should be 40%, or one third to one half, of the circumference of the limb. On most cuffs, range lines are indicated to assess proper size. When a correctly sized cuff is applied, the cuff edge should lie between the range lines . Adult cuffs come in two widths. The standard cuff (4 2/3 to 5 1/6 inches) is adequate for most adults. If the adult is large or obese, an oversized cuff (6 to 6 1/3 inches) may be used. If the adult has an extremely obese arm, a thigh cuff can be used. For children, there are many different sizes of cuffs. The width of the cuff should cover two thirds of the child’s or infant’s upper arm. For both children and adults, if the cuff is too wide, it will underestimate the blood pressure; if it is too narrow, it will overestimate the blood pressure.
Fig. 12 A, Aneroid sphygmomanometer. B, Mercury manometer tube.
Fig. 13 Blood pressure cuffs.
Physical Assessment
A dynamic health assessment is the foundation of all nursing care and physical assessment is part of every
holistic health evaluation. Assessment is the first step of the nursing process. It involves the orderly collection
of objective information about the client’s health status. Objective data are observable, measurable, and
verifiable by more than one person. A fundamental systematic approach is used based on a combination
of head-to-toe and body systems assessments, which are expanded as appropriate to the client’s situation
and setting. By using a systematic approach, you ensure that signs are not overlooked and that time is
used efficiently. Through the process of data collection, meaningful information, including health status,
actual and potential health problems, and areas of focus for priority health promotion, is identified. The
process of physical assessment is utilized in outpatient, inpatient, and/or home health services.
A complete yet organized assessment is obtained by using a combination of head-to-toe and body-systems
approach in conjunction with the use of the four basic techniques, inspection, palpation, percussion,
auscultation (IPPA):
• Inspection: Observation (see, smell); actually starts during the health history and continues
throughout the exam; always comes first (before you touch or listen), but continues concurrently
with PPA as well. Note general observations and then specifics of each area proceeding from the
outside to the inside.
• Palpation: Touching; light (
Assesses position, texture, size, consistency, fluid, crepitus, form, structure, vibration, or temperature.
• Percussion: Tactile sensation and sound (to
more solid: higher pitch, softer intensity, shorter duration; more air: lower pitch, louder intensity,
longer duration; expected percussiootes: tympanic (gastric bubble), hyperresonant (emphysematous
lungs), resonant (healthy lung), dull (liver), flat (muscle).
• Auscultation: Listening direct (naked ear) and indirect (acoustical stethoscope or Doppler amplification).
Analyzes intensity, pitch,duration, quality, and location. The bell analyzes low-pitched sounds
and the diaphragm analyzes high-pitched sounds.A combined body systems and body area approach
focuses assessment by groupings:
• General Appearance: Examine appearance in the following groups: (1) skin, hair, and nails; (2)
head, face, and lymphatic; (3) eye, ear, nose, mouth, and throat; (4) neck and upper extremities;
(5) chest, breasts, and axillae; (6) thorax and lungs/respiratory system; (7) heart and cardiovascular
system; (8) abdomen/GI system; (9) genitalia/ GU system and anus.
• Lower Extremities: Musculoskeletal system (MBJB: muscles, bones, joints, and back assessment).
• Neurological: Reflex, sensory, cranial, cerebral, cerebellar, neurodevelopmental, neuropsychiatric.
Internal genitalia, rectum, and prostate examinations are usually included in advanced assessment
and will not be addressed here.
The IPPA organization can be combined by cephalo-caudal (head-to-toe), general-to-specific,
medial-to-lateral, and external-to-internal approaches within each category. The physical assessment
is always correlated with the health history as well as with other assessments, such as laboratory or diagnostic data and/or developmental, psychosocial, family, and cultural assessment data..
Figure
F. Tuning forks and reflex hammers; G. Cotton swabs and cotton balls; H. Sharp items used to assess sharp and dull sensations
The stages of physical assessment are:
1. Organize equipment. (see Figure 1)
2. Review client history
3.
4. Explain plan and procedure.
5. Assist client to sitting position if possible.
6. Examine client.
7. Present findings if appropriate. Ask for additional information. Answer client’s questions.
8. Schedule follow-up assessments, tests, or other appointments as needed.
9. Clean, replace, and discard equipment appropriately.
10. Wash hands.
Measurements and Overall Observations
11. Obtain baseline measurements and compare with normal data. Remember that normal values
vary with age and normal temperatures do not rule out illness, especially with very young
and elderly clients. Check height,weight, head circumference (check normal values based on age percentiles for infants to 24 months), and temperature (palpate skin temperature during examination as well).
12. Measure the heart rate, rhythm, and volume, the respiratory rate and rhythm, and the blood
pressure bilaterally.
13. Check anthropometric measurements prn, body mass index (BMI), etc.
14. Assess the overall appearance of the client in a “once over” evaluation before you begin the
detailed examination. Look for clues to poor health such as level of consciousness, personal
hygiene, nutritional status, posture, gait, symmetry, appearance, and appropriateness of
clothing. Listen to the quality and appropriateness of speech. Observe if the client makes eye
contact and how comfortable the client is with interpersonal interaction. Assess whether age is congruent with appearance. Observe body fat, stature, motor movements, and body and breath odors. Assess dress, grooming, personal hygiene, mood, manner, speech, and facial expressions.
Finally, during your “once over,” look for signs of distress, as evidenced by breathing patterns, speech, facial expressions, perspiration, tension, guarding, bracing, and anxiety.
Skin, Hair, and Nails Examination
15. Take a moment to assess initially and continue assessment as you perform the remainder of
the exam.
• Inspect: color, vascularity, lesions, ulcers, scars, hair distribution, nail shape and configuration,
nail bed angles.Measure, describe draw and/or stage abnormals.
• Palpate: moisture, temperature, texture, turgor, capillary refill (normal capillary refill is less than 3 seconds), edema.
Head, Face, and Lymphatics Examination
16. Inspect and palpate the head, face, and lymph nodes (see Figure 2) . Proceed front to back.
17. Head: Examine scalp, hair, and cranium (frontalparietal-temporal-occipital). Examine fontanelles and sutures iewborns to 24 months.Head should be normocephalic and symmetrical with no acromegaly,hydrocephalus, craniosynostosis, premature closure of sutures, masses, depressions, tenderness, or infestations.
18. Lymph nodes: Examine preauricular, postauricular, occipital, submental, submandibular, anterior cervical chain, posterior cervical chain, tonsillar, supraclavicular, and parotid. Lymph
nodes should be less than one centimeter in size and nontender.Note that children may
have multiple nodes less than one centimeter, especially postauricular, but these will be
small, nontender, and movable.
19. Temporomandibular joint: Observe the motion of opening and closing the jaw. It should
articulate smoothly without crepitus, clicking, or tenderness. There should be no sign of in-
flammation.
20. Face:Observe for shape,symmetry,and expression. Have the client smile,frown,raise eyebrows,
wrinkle forehead,show teeth,purse lips, puff cheeks,press tongue into cheek,“cluck” tongue and whistle.Inspect,percuss,and palpate frontal and maxillary sinuses.Use a wisp of cotton to assess tactile sensation over the trigeminal nerve sites and mandible bilaterally. Facial features should be symmetrical with a nasolabial fold present bilaterally. Clients of Asian descent may have slanted eyes with inner epicanthal folds.Normal sounds should be resonant. No pain should be present on percussion or palpation. Abnormal findings include edema, disproportionate structures, or involuntary movements.
Figure 2 Palpation of lymph nodes
Eye, Ear,Nose,Mouth, and Throat Examination
21. Examine the eyes. Inspect and palpate external structures, including brows, lids, lacrimal gland,
and puncta. Inspect eye position and palpebral fissures. Examine bulbar and palpebral onjunctivae,
sclera, cornea, and iris. Assess for a corneal touch reflex.
22. Extraocular mobility: Check for Hirschberg’s corneal light reflex using the cover-uncover
test. Check the six cardinal fields of gaze. Examine pupils, including size, shape, response to
light and accommodation, both direct and consensual. Examine the lens and retinal structures.
First check for a red reflex with the ophthalmoscope set on “0.”Move the diopter wheel to “
to focus on anterior ocular structures and “2”to focus on posterior structures. Locate the retina,
vessels, optic disk, and macula.
23. Have the client identify an object, such as your finger, as it enters the visual fields from
each of four directions. Normal movement is temporal 90 degrees, nasal 60 degrees, superior
50 degrees and inferior 70 degrees
24. Check for visual acuity, including near and far sight, primary colors, and Ishihara plates
25. Examine the ears. Inspect and palpate the external ear, including alignment, pinna, tragus,
lobule, and neck mastoid muscle.Observe the shape, color, and size of the ear.
26. Proceed with an otoscopic assessment, starting with the ear canal. Identify landmarks, the
tympanic membrane, and observe tympanic membrane movement.Use tympanometry if
needed to confirm visual findings.
27. Check the client’s hearing acuity. Note responses to normal sounds. In an infant, observe for a startle reflex/bell response. In adults conduct a voice/whisper or watch-tick test at 1–2 feet.
Conduct Weber and Rhinne tests at 512 Hz.
28. Examine the nose. Inspect and palpate for nasal patency. Have the client inhale and exhale
through each nostril. Observe the external surface, nasal mucosa, turbinates, and septum.
29. Have the client identify common odors.
30. Examine the mouth, including the teeth, tongue and throat (see Figure 3).
Figure 3 The mouth examination includes the teeth, tongue, throat, oral mucosa, and salivary glands.
31. Inspect and count teeth.
32. Inspect and palpate lips and frenula, gums, buccal mucosa, tongue protrusion and frenulum,
salivary glands, hard and soft palates, tonsils, uvula position and movement, and arches.
Inspect the naso-oro-pharynx.
33. Conduct gag reflex response, and taste tests for sweet, sour, bitter, and salt.
34. Examine the neck. Inspect and palpate the trachea. Check that the trachea runs midline
down the neck by examining the trachea at the suprasternal notch.
35. To examine the thyroid, observe the anterior neck slightly extended, then have the client flex
the neck and swallow. Palpate the anterior neck, then palpate forward from the posterior. Identify
tracheal rings, isthmus, thyroid cartilage, and gland lobes as the client is swallowing.
36. Palpate the temporal and carotid pulses. Assess the quality, character, rhythm, and
strength of the pulse.
Upper Neuromuscular Examination
37. Inspect and palpate muscles, bones, and joints. In general, evaluate from the periphery to the
center of the body. Observe the configuration, symmetry, size, tone, and range of motion (ROM). Assess strength using resistive
38. Examine the cervical spine. Flex, extend,move lateral, and rotate the spine. Examine the spine
for resistive strength by pushing your hand against the side of the client’s face. Push left,
right, back on the forehead, forward on the occiput, and down on the top of the head.
39. Examine shoulders. Flex, hyperextend, abduct, adduct, turn in internal and external rotation,
shrug, and push/pull against the shoulders.
40. Examine elbows. Flex, extend, rotate, push, and pull each elbow.
41. Examine wrists. Flex, extend, and rotate each wrist.
42. Examine hands by having the client grasp your hands with his.
43. Examine fingers. Abduct, adduct the fingers. Perform finger thumb opposition with counting
and position sense.
44. Examine the epitrochlear lymph nodes, brachial and radial pulses, and bicep, tricep, and brachioradialis reflexes.
Chest and Breast Examination
45. Inspect and palpate the breast, nipple, and areola. Palpate the axillary lymph nodes.
46. Calculate the Tanner stage of sexual maturity if appropriate.
47. Repeat breast and axillae examination while the client is in the supine position.
Back and Posterior Lung Examination
48. Inspect and palpate the skin.
49. Recheck the thyroid from the posterior position.
50. Examine the cervical and thoracic spine (see Figure 4), the scapulae, and the rib cage.
Observe the posterior thoracic expansion. Estimate the anteroposterior-to-transverse
chest ratio. A normal ratio is 1;2.
51. Feel for the presence of fremitus posteriorly and laterally. Compare sides.
Figure 4 Examine the cervical and thoracic spine for alignment, flexion, and symmetry with the rib cage and scapulae.
52. Use indirect percussion at a minimum of four sites, preferably in regular intervals every
from top to bottom of lung fields.Move from superior to inferior and from lateral to spine.
53. Auscultate the lungs (see Figure 4) using a side-to-side sequence and moving down
2–5 cm at a time. Listen to inspiration and expiration at each site. Listen for vocal fremitus
while the client makes “
Thorax, Lungs, and Respiratory Examination
54. Stand in front of the client.
55. Inspect and palpate the anterior chest. Observe position, chest movement, size, shape,
and symmetry of the clavicles and ribs.
56. Listen to the respiratory rate, including rhythm and depth of respirations. Compare
rate with normal respiratory rates for the age of the client.
Figure 5 Auscultate the lungs, listening to inspiration and expiration at each site.
Figure 6
57. Observe the diaphragmatic excursion, intercostals spaces (ICS), respiratory muscles, respiratory effort, and expansion.Watch for pursed lips, cyanosis, or a cough. Note that abdominal
breathing is normal from birth to the second year of age.
58. Feel for fremitus along the lung apexes and bases.
59. Use indirect percussion at intervals over intercostals spaces moving superior to inferior and
collateral to spine. Percuss lung apexes and bases, and the cardiac border if appropriate.
Note percussion should be resonant over the lung, flat over bone, and dull over organs.
60. Auscultate the anterior lung fields, using the same progression as the palpation procedure.
Avoid listening over bone and breast tissue. Observe intensity, pitch, ratio, quality (see
Figure 5, 6, 7). Listen for vocal fremitus during “
Figure 7 Auscultate the anterior lung fields. Listen for abnormal sounds, including rales, rhonchi, or wheezes.
Heart and Cardiovascular System Examination
61. Inspect and palpate the precordium. Identify the point of maximal intensity (PMI) at mitral
area located at the left fifth intercostal space and confirm synchrony with the carotid pulse.
PMI may not be palpable in large and muscular persons.
62. Auscultate with the client sitting, then leaning forward. Listen with the diaphragm and then
the bell.
63. Examine all valvular landmarks at least twice. First locate and identify the S1, S2, S3, and S4
heart sounds.Then listen for other sounds (murmurs, rubs, clicks, etc.). Auscultate in an orderly
fashion from the apex to the base of the heart (or vice versa).
before the tricuspid valve.Use the bell to listen for a possible S3 sound (see Figure 8).
physiologic splitting of S2, which indicates closure of the semilunar valves at this site is normal.
In the aortic area identify that S2 is louder than S1 with diaphragm.
67. Assess the epigastric, axillary, and Erb’s point areas.
68. Summarize the character of S1 and S2 sounds. Note the presence or absence of S3 and S4 (gallop), murmurs, rubs, clicks, or snaps.
69. Assist client to left lateral position to continue the cardiac examination.
70. Auscultate mitral and tricuspid sites with the bell.
71. Assist client to return to supine position and continue cardiac examination.
72. Inspect and palpate the precordium. Identify the PMI at the mitral area and confirm synchrony
with carotid pulse. Assess apical, carotid, temporal, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses (see Figure 9). Percuss the cardiac borders if needed.
Auscultate the heart in supine position with bell, then with diaphragm. Check the mitral, tricuspid,
Figure 8
pulmonic, aortic, and ectopic areas. Auscultate with bell for bruits at carotid and temporal pulse sites.
73. Raise head to 30–45 degree angle and inspect the jugular vein distention (JVD).
Figure 9 Assess for unusual symmetry, pulsations, volume, or thrills of pulses.
Abdominal Examination
74. Inspect the size, contour, and symmetry of the abdomen.The normal abdomen is flat (except
in young children), symmetrical, without scars, striae, masses, nodules, peristalsis (except in
very thin individuals), or rectus ridge (except in young or thin individuals). Note pigmentation,
scars, striae, masses, nodules, the condition of the umbilicus, and any respiratory or peristaltic
movement. Check the rectus abdominus muscle by having the client raise his head.
75. Auscultate with the diaphragm and then the bell. Listen for bowel sounds in each of the
four quadrants. Right lower quadrant (RLQ), right upper quadrant (RUQ), left upper quadrant
(LUQ), and left lower quadrant (LLQ).
76. Percuss the RLQ, RUQ, gastric bubble, spleen, bladder, LLQ, LUQ, and liver span (see Figure 10). Note the spleen, located between the sixth and tenth rib,may go undetected.The gastric
air bubble (LUQ) is lower pitched than tympany of the intestine.The tympany changes to
dull at lower edge of liver, and lung resonance changes to dull at upper edge of liver.You may
try to percuss the kidney posteriorly while the client is sitting, if needed.
77. Palpate all four quadrants superficially first then deep and rebound palpations to identify
any discomfort, tenderness, or abnormalities. Check superficial abdominal reflexes in the
LLQ, LUQ, spleen (use bimanual palpation), RLQ, RUQ, liver, aorta, kidney (use bimanual
technique), and bladder (see Figure 10). Evaluate for guarding on expiration.
78. Check femoral pulses and superficial and deep inguinal nodes.
External Genitalia Examination
79. Assist client to modified or full lithotomy position.
80. Inspect and palpate deep inguinal nodes.
81. Observe pubic hair distribution, color, and texture. Check the femoral and inguinal areas for
hernias.
82. Calculate the Tanner stage of sexual maturity if appropriate.
83. Check skin and look for abnormalities. In the female, examine the mons pubis, labia majora,
labia minora, clitoris, urethral meatus, vaginal introitus, and perineum.
shaft), scrotum (transilluminate if hydrocele suspected), scrotal rugae, testicles, epididymis,
spermatic cord, and external inguinal ring.
Figure 10 Percuss the abdomen to assess size and location of internal organs.
85. Examine the anus.You may need to return the
client to the left lateral position to aide in visualization.
Inspect and palpate the sacrococcygeal
area and anal mucosa.
Lower Extremity and Musculoskeletal Examination
86. Assist client to supine position.
87. Inspect and palpate the skin. Look at the skin color, check that capillary refill is less than 3
seconds, observe hair distribution, veins, temperature, and texture of skin. Observe the size, shape, isometric muscle contraction, tone, and strength (using resistive ROM) of muscles.
88. Inspect the joints. Palpate from periphery to center.Observe contour, periarticular tissue,
neutral anatomic position, ROM (active and palpate passive), and strength (resistive motion).
Also evaluate the hips. Have the client do a straight leg raise.Move the hips knee to chest, internal rotation, external rotation, abduction, and adduction. Listen carefully for a hip click in infants (Ortolani sign). Assess the knees. Check the tibiofemoral joints by flexing the knee 90 degrees and with thumbs palpate tibial margins and collateral ligament. Check knee flexion, extension, and
strength. For the ankles and feet, palpate the Achilles tendon, at-rest, in dorsiflexion and plantar flexion, eversion and inversion. Check toe flexion, abduction, and adduction. Palpate metatarsophalangeal joints and interphalangeal joints. Check popliteal, posterior tibial, and dorsalis
pedis pulses.
Neurological Examination
89. Assist client to sitting position.
90. Check for deep tendon biceps, triceps, brachioradialis (if not done previously), patellar, and
Achilles reflexes. Check infantile reflexes, including rooting, suck, palmer grasp, tonic neck, stepping, plantar grasp, moro, Gallant and Landau. Check the Babinski’s reflex. A positive Babinski’s reflex is normal until walking or 18 months of age.
91. Examine the client’s sensory abilities. Check for responses to skin sensations. Begin distally and move proximally. Touch fingers, hands, lower arms and toes, feet, legs, and abdomen as necessary. Be careful not to be “predictable.” Alter the rate and rhythm of stimulation.
Compare right to left and proximal to distal sensations. Check exteroceptive sensation, including
light touch (use a cotton wisp), and sharp and dull (use a hair pin or paper clip). If the
sharp/dull evaluation was abnormal, check temperature sensation as well. Check the propioceptive sensations of vibration, motion, and position. Check the cortical sensations of stereognosis
(coin, button, key, paperclip, etc.; different object in each hand), and graphesthesia. If needed, examine two-point discrimination and extinction. Normal distances vary with the body part tested. For example, fingers are approximately
92. Review and recheck the cranial nerves:
CN I: Olfactory
CN II: Optic
CN III:Oculomotor
CN IV:Trochlear
CN V:Trigeminal motor and sensory
CN VI: Abducens
CN VII: Facial motor and sensory
CN VIII: Acoustic cochlear and vestibular
CN IX: Glossopharyngeal motor/sensory
CN X:Vagus motor and sensory
CN XI: Spinal accessory
CN XII: Hypoglossal
93. Evaluate the client’s mental status. Check level of consciousness, orientation to person, time,
place, general appearance, behavior, affect, speech, content, memory, logic, and abstract
reasoning (describe proverb), judgment, spatial perception (copy figures, identify familiar
sounds, identify right versus left body parts). Mentally summarize the mental status from
earlier observations during the examination.
94. Examine cerebellar status: Conduct a finger-tonose test (have the client use the index finger
to touch your finger, held
Have client repeat this movement, gradually increasing the speed. Observe for the client’s ability to cross the midline. Look for tremor, overshoot, and undershoot. Repeat with the other hand.
Conduct a RAHM (rapid alternating hand movements) and note if the client exhibits smooth pronation-supination with increasingly rapid speed.Have the client touch fingers-to-thumb, and note if he can touch thumb to each of the fingers of the same hand in rapid succession from index to fifth finger and back. Note that ability depends on age. Have the client touch heel-to-shin, foot
taping (RAFM), and foot “figure 8”movement tests. Determine whether the client can run heel down the shin of the opposite leg. Look for smooth rapid ankle extensions and rotation.
95. Assist client to standing position.
96. Inspect and/or palpate posture,weight-bearing and standing spine alignment, spinous
processes, paravertebral muscles, and ROM (flexion, lateral bending, rotation, hyperextension).
Do a Romberg test. Balance on the one foot for 10 seconds. Repeat heel-to-shin test,
and have client hop on each foot and do shallow knee bends.
97. Assess mobility by having the client perform a casual gait, toe and heel walk, tandem walk
(forward and backward), step right, step left, walk briskly, and do jumping jacks (if client’s
condition permits).
98. Recheck heart and respiratory sounds after exercising.
99. Compare the client’s status to age-appropriate standards for activities of daily living
(ADLs), gross and fine motor function, speech and language, and personal-social interaction.
100. Evaluate for psychiatric symptoms, including disturbed affect, aversive eye contact, symptoms
of depression or anxiety, disrupted or confused thought processes, indications of delusional thoughts, and indications of suicidal thoughts.
Counting Respirations
Respiratory assessment is the measurement of the breathing pattern. Assessment of respirations provides
clinical data regarding the pH of arterial blood. Normal breathing is slightly observable, effortless, quiet, automatic, and regular. It can be assessed by observing chest wall expansion and bilateral symmetrical
movement of the thorax or by placing the back of the hand next to the client’s nose and mouth to feel the expired air. When assessing respiration ascertain the rate, depth, and rhythm of ventilatory movement. The
nurse should assess the rate by counting the number of breaths taken per minute. Note the depth and
rhythm of ventilatory movements by observing for the normal thoracic and abdominal movements and symmetry in chest wall movement. Normal respirations are characterized by a rate ranging from 12 to 20
breaths per minute. One inspiration and expiration cycle is counted as one breath. The nurse can observe the rise and fall of the chest wall and count the rate by placing the hand lightly on the chest to feel it rise and fall. Count the number of respirations for a 30-second interval and multiply by 2 if respirations are regular and even. If the client is experiencing any respiratory difficulty, count the rate for a full minute. When the chest wall moves, so do the lungs, because the lungs are attached to the inner wall of the thoracic cavity by the outer layer of the pleura (lining of the chest cavity). The movement of the chest wall should be even and regular, without noise and effort. On inspiration the chest changes shape and expands as the rib cage is raised and the diaphragm is lowered. Before inspiration, the pressure inside the chest cavity is negative (24.5 to
exercise when respirations are increased in depth and rate. Sighing is a protective physiologic mechanism
for expanding small airways not used with normal breathing. The nurse can also observe alterations in the
movement of the chest wall: costal (thoracic) breathing occurs when the external intercostal muscles and
the other accessory muscles are used to move the chest upward and outward; diaphragmatic (abdominal)
breathing occurs when the diaphragm contracts and relaxes as observed by movement of the abdomen.
Dyspnea refers to difficulty in breathing as observed by labored or forced respirations through
the use of accessory muscles in the chest and neck to breathe. Dyspneic clients are acutely aware of their
respirations and complain of shortness of breath (see Figure 19).
Respiratory alterations may cause changes in skin color as observed by a bluish appearance to the
nailbeds, lips, and skin. The bluish color (cyanosis) results from reduced oxygen levels in the arterial
blood. Changes in the level of consciousness (restlessness, anxiety, and dyspnea) may also occur with decreased oxygen levels. Clients with orthopnea may assume a forward-leaning position or may have to
stand to increase the expansion capacity of the lungs. Metabolic alterations such as diabetic ketoacidosis
can cause Kussmaul’s respirations, which are abnormally deep but regular. Apnea is the cessation of breathing for several seconds. Persistent apnea is called respiratory arrest. Irregular rhythm with alternating periods of apnea and hyperventilation is called Cheyne-Stokes respirations (see Figure 20). The cycle begins with slow, shallow breaths that gradually increase to abnormally deep and rapid respirations, which then gradually slow and return to shallow breathing followed by apnea. This is common in dying patients (see Figure 21).
Figure 19 Observe the movement of the chest wall and assess the quality and depth of respiration. Place your hand
below the diaphragm to feel if the patient is using his diaphragm, instead of expanding his chest wall, to bring air into the lungs.
Figure 21 When assessing respirations, observe skin color and level of consciousness as well as respiratory rate and
rhythm.
Figure 20
Adult Physical Assessment
THE PATIENT HISTORY
GENERAL PRINCIPLES
- The first step in caring for a patient and in soliciting active cooperation is to gather a careful and complete history.
- In all patient concerns and problems, an accurate history is the foundation on which data collection and the process of assessment are based.
- The comprehensiveness of the history elicited will depend on the information available in the patient’s record and the reliability of the patient.
- Time spent early in the nurse-patient relationship gathering detailed information about what the patient knows, thinks, and feels about the problems will prevent time-consuming errors and misunderstandings later.
- Skill in interviewing will affect both the accuracy of information elicited and the quality of the relationship established with the patient. This point cannot be overemphasized; the reader is encouraged to consult other sources for detailed discussion of techniques of health interviewing.
- The purpose of the interview is to encourage an exchange of information between the patient and the nurse. The patient must feel that his words are understood and that concerns are being heard and dealt with sensitively.
INTERVIEWING TECHNIQUES
- Provide privacy in as quiet a place as possible and see that the patient is comfortable.
- Begin the interview with a courteous greeting and an introduction. Address the patient as Mr., Mrs., or Ms. and shake hands if appropriate. Explain who you are and the reason for your presence.
- Make sure that facial expressions, body movements, and tone of voice are pleasant, unhurried, and nonjudgmental, and that they convey the attitude of a sensitive listener so the patient will feel free to express his thoughts and feelings.
- Avoid reassuring the patient prematurely (before you have adequate information about the problem). This only cuts off discussion; the patient may then be unwilling to bring up a problem causing concern.
- At times, a patient gives cues or suggests information, but does not tell enough. It may be necessary to probe for more information to obtain a thorough history; the patient must realize that this is done for his benefit.
- Guide the interview so the necessary information is obtained without cutting off discussion. Controlling a rambling patient is often difficult but, with practice, it can be done without jeopardizing the quality of the information gained.
IDENTIFYING INFORMATION
Purposes
- To eliminate confusion about the patient’s identity and obtain the information required for contacting the patient if the need arises
- To provide you with an introduction to the patient and some indication of his habits, lifestyle, and beliefs, which may be explored in greater depth in the personal and social history
- To initiate a relationship based on recognition of the importance of the informant’s role in sharing in the care of the patient (when this is the case)
Types of Information Needed
- Date and time
- Patient’s name, address, telephone number, race, religion, birth date, and age
- Name of referring practitioner
- Insurance data
- Name of informant—the patient may be the person giving the history; if not, record the name, address, telephone number, and relationship to the patient of the person giving the history
- Accuracy and reliability of informant—this is a judgment based on the consistency of responses to questions and on a comparison of information in the history with your own observations in the physical examination
Method of Collecting Data
- Careful interviewing of the patient or caregiver will provide most of the information.
- The patient’s hospital or clinic record may also be a valuable source.
- Repeat information wheecessary to verify accuracy (eg, to ensure that there has beeo change in address or telephone number).
- Assume a direct and professional manner.
- Explain the reasons why the information is needed to help put the patient at ease.
CHIEF COMPLAINT
Purposes
- To allow the patient to describe his own problems and expectations with little or no direction from the interviewer
- To identify the overriding problem for which the patient is seeking help
- Adults with chronic conditions often have numerous complaints.
- If possible, focus on a single problem or concern—the one most important to the patient.
- To identify the patient’s feelings about symptoms (The patient may show fear, guilt, or defensiveness in this first statement.)
Types of Information Needed
A brief statement of the patient’s primary problem or concern in the patient’s own words, including the duration of the complaint. Example: “hacking cough Г— 3 weeks.”
Method of Collecting Data
- Ask the patient a direct question such as, “For what reason have you come to the hospital?” or “What seems to be bothering your most at this time?”
- Avoid confusing questions such as, “What brings you here?” (“The bus.”) or “Why are you here?” (“That’s what I came to find out.”)
- Ask how long the concern or problem has been present; for example, whether it has been hours, days, or weeks. If necessary, establish the time of onset precisely by offering such clues as “Did you feel this way a month (6 months or 2 years) ago?”
- Let the patient speak freely without offering your opinion until he has had an opportunity to identify the problem as clearly as possible.
- Write down what the patient says using quotation marks to identify patient’s words.
HISTORY OF PRESENT ILLNESS
Purposes
- To amplify the description of the chief complaint and to clarify its relationship to other symptoms and events
- To complete a symptom analysis by carefully describing a symptom or problem that may be a clue to future diagnosis
Types of Information Needed
- A detailed chronological picture beginning with the time the patient was last well (or, in the case of a problem with an acute onset, the patient’s condition just before the onset of the problem) and ending with a description of the patient’s current condition.
- If there is more than one important problem, each is described in a separate, chronologically organized paragraph in the written history of present illness.
- The outline for reporting the present illness will vary with each case.
Method of Collecting Data
- Investigate the chief complaint by eliciting more information through the use of the pneumonic “OLD CARTS”:
- Onset (setting, circumstances, rapidity, or manner in which it began)
- Location (exact place where the symptom is felt, radiation pattern)
- Duration (how long; if intermittent, the frequency and duration of each episode)
- Character/course (nature or quality of the symptom, such as sharp pain, interference with activity, how it has changed or evolved over time; ask to describe a typical episode)
- Aggravating/associated factors (medications, rest, activity, diet; associated nausea, fever, and other symptoms)
- Relieving factors (lying down, having bowel movement)
- Treatments tried (pharmacologic and nonpharmacologic methods attempted and their outcomes)
- Severity (the quantity of the symptom; for example, how severe on scale of 1 to 10)
- Alternately, use the pneumonic PQRST: provocative/palliative factors, quality/quantity, region/radiation, severity, timing.
- Obtain OLD CARTS data for all the major problems associated with the present illness, as applicable.
- Clarify the chronology of the illness by asking questions and summarizing the history of present illness for the patient to comment on.
- In the case of acute infections, inquire about possible exposure or an incubation period.
- In both acute and chronic illnesses, note whether the patient has experienced a change in function or activity due to illness.
- Get the patient’s subjective appraisal of whether the symptom or problem is getting better or worse.
- Organize the information for recording or presentation.
PAST MEDICAL HISTORY
Purposes
- To determine the background health status of the patient, including present status, recent health conditions, and past health conditions
- To identify any change in the patient’s normal pattern of health as well as clues that may aid in diagnosing the present illness
- To serve as a basis for nursing care planning for holistic patient care
Types of Information Needed
- General health and lifestyle patterns—sleeping pattern, diet, stability of weight, usual exercise and activities, use of tobacco, alcohol, illicit drugs
- Acute infectious diseases—measles, mumps, whooping cough, chickenpox, pneumonia, pleurisy, tuberculosis, scarlet fever, acute rheumatic fever, rheumatic heart disease, tonsillitis, hepatitis, polio, sexually transmitted disease (STD), tropical or parasitic diseases, any other acute infectious problem the patient describes
- Immunization—polio, diphtheria, pertussis, tetanus, measles, mumps, rubella, haemophilus influenza type b, hepatitis B, hepatitis A, pneumococcal influenza, varicella, Lyme, and last purified protein derivative or other skin test, abnormal or unusual reactions (give date when possible)
- Operation—indications, diagnosis, dates, hospital, surgeon, complications
- Previous hospitalizations—physician, hospital data (year), diagnosis, treatment
- Injuries—type, treatment, outcome
- Major acute and chronic illnesses (any serious or prolonged illnesses not requiring hospitalization)—dates, symptoms, course, treatment
- Medications—prescription drugs from all providers (including ophthalmologist and dentist); nonprescription drugs including vitamins, supplements, and herbal products; include dosage, length of use, and adherence
- Allergies—environmental allergies, food allergies, drug reactions; give type of reaction (hives, rhinitis, local reaction, angioedema, anaphylaxis)
- Obstetric history (may appear in review of systems)
- Pregnancies, miscarriages, abortions
- Describe course of pregnancy, labor, and delivery; date, place of delivery
- Psychiatric history (may appear in review of systems)—treatment by a mental health provider, diagnosis, date, place, medications
Method of Collecting Data
- Begin by explaining the purpose and type of questions you will be asking; for example, “I am now going to ask you some questions about your past health.”
- Explain that these questions are important to obtain an accurate picture of all the events that affected or that did not affect the patient’s health in the past.
- Use direct questions; for example, “How would you describe your general health?” and then proceed with more specific queries, such as “Has your weight been stable over the past 5 years?”
Purposes
- To present a picture of the patient’s family health, including that of grandparents, parents, brothers, sisters, aunts, and uncles. It also involves the health of close relatives because some diseases show a familial tendency or are hereditary.
- To describe the health of the patient’s spouse and children because this may give clues about possible communicable disease problems. It also will be important in determining what sort of condition a family is in and how this affects the patient.
Types of Information Needed
- Age and health status (or age at and cause of death) of maternal and paternal grandparents, parents, siblings
- History, in immediate and close relatives, of heart disease, hypertension, stroke, diabetes, gout, kidney disease or stones, thyroid disease, pulmonary disease, blood problems, cancer (types), epilepsy, mental illness, arthritis, alcoholism, obesity
- Genetic disorders, such as hemophilia or sickle cell disease
- Age and health status of spouse and children
Method of Collecting Data
- Begin with an explanation of what you are asking and why because the patient may not understand the purpose of your questions. For example: “I am going to ask about the health of your immediate family and relatives. It is important to know if there are any conditions that tend to or could occur in your family, or in you as a member of the family.”
- Ask direct questions.
- Begin with the patient’s siblings.
“Do you have any brothers and sisters?”
How old are they and what is the state of their health?”
- List each sibling separately, giving age and state of health.
REVIEW OF SYSTEMS
Purposes
- To obtain detailed information about the current state of the patient and any past symptoms, or lack of symptoms, patient may have experienced related to a particular body system
- May give clues to diagnosis of multisystem disorders or progression of a disorder to other areas
Types of Information Needed
Subjective information about what the patient feels or sees with regard to the major systems of the body.
- Skin—rash, itching, change in pigmentation or texture, sweating, hair growth and distribution, condition of nails, skin care habits, protection from sun
- Skeletal—stiffness of joints, pain, deformity, restriction of motion, swelling, redness, heat (If there are problems, ask the patient to specify any activities of daily life that are difficult or impossible to perform.)
- Head—headaches, dizziness, syncope, head injuries
- Eyes—vision, pain, diplopia, photophobia, blind spots, itching, burning, discharge, recent change in appearance or vision, glaucoma, cataracts, glasses or contact lenses worn, date of last refraction, infection
- Ears—hearing acuity, earache, discharge, tinnitus, vertigo, history of tubes or infection
- Nose—sense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain or therapy, use of nose drops or sprays (type and frequency)
- Teeth—pain; bleeding, swollen or receding gums; recent abscesses, extractions; dentures; dental hygiene practices, last dental examination
- Mouth and tongue—soreness of tongue or buccal mucosa, ulcers, swelling
- Throat—sore throat, tonsillitis, hoarseness, dysphagia
- Neck—pain, stiffness, swelling, enlarged glands or lymph nodes
- Endocrine—goiter, thyroid tenderness, tremors, weakness, tolerance to heat and cold, changes in hat or glove size, changes in skin pigmentation, libido, easy bruising, muscle cramps, polyuria, polydipsia, polyphagia, hormone therapy, unexplained weight change
- Respiratory
- Pain in the chest and relationship to respirations
- Dyspnea, wheezing, cough, sputum (character, quantity), hemoptysis
- Last tuberculin test or chest X-ray and result (indicate where obtained)
- Exposure to tuberculosis
- Cardiovascular
- Presence of pain or distress and location (have patient point to location); radiation of pain; precipitating or aggravating causes; alleviating measures; timing and duration
- Palpitations, dyspnea, orthopnea (note number of pillows required for sleeping), history of heart murmur, edema, cyanosis, claudication, varicose veins
- Exercise tolerance (determine in relation to patient’s regular activities—how much can he do before stopping to rest?)
- Blood pressure (if known): last electrocardiogram (ECG) and results (indicate where obtained)
- Hematologic—anemia (if so, treatment received), tendency to bruise or bleed, thromboses, thrombophlebitis, any known abnormalities of blood cells
- Lymph nodes—enlargement, tenderness, suppuration, duration and progress of abnormality
- Gastrointestinal
- Appetite and digestion, intolerance to certain classes of foods
- Pain associated with hunger or eating, eructation, regurgitation, heartburn, nausea, vomiting, hematemesis
- Regularity of bowel movement (describe normal bowel habits and whether they have changed recently); diarrhea, flatulence, stools (color—brown, black, clay; tarry, fresh blood, mucus)
- Hemorrhoids, jaundice, dark urine, use of laxatives—type, frequency
- History of ulcer, gallstones, polyps, tumors
- Previous diagnostic tests—where, when, results
- Genitourinary—dysuria, pain, urgency, frequency, hematuria, nocturia, polydipsia, polyuria, oliguria, edema of the face, hesitancy, dribbling, loss in size or force of stream, passage of stones, stress incontinence, hernias, human immunodeficiency virus status, history of STD
- Males—puberty onset, sexual activity, use of condoms, libido, sexual dysfunction
- Females
- Menses—onset, regularity, duration of flow, dysmenorrhea, last period, intermenstrual bleeding or discharge, dyspareunia
- Libido, sexual activity, satisfaction with sexual relations
- Pregnancies (see “Past Medical History,” page 48)
- Methods of contraception, STD protection
- Breasts—pain, tenderness, discharge, lumps, mammograms, breast self-examination (techniques and timing with regard to menstrual cycle)
- Neurologic
- Mental status—history of loss of consciousness; orientation to time, place, person
- Memory—distant and recent
- Cognition, or ability of patient to conceptualize (very useful information in determining a health education plan for the patient)
- Incoordination, weakness, numbness, paresthesia, tremors, muscle cramps
- Psychiatric
- Patient’s description of personality—how patient views self
- Mood changes, difficulty concentrating, sadness, nervousness, tension, irritability, change in social interaction
- Obsessive thoughts, compulsions, manic episodes, suicidal or homicidal thoughts
- General constitutional symptoms—fever, chills, night sweats, malaise, fatigability, recent loss or gain of weight
Method of Collecting Data
- Begin by explaining to the patient—“I am going to ask you many questions about your body that will help in understanding your present problem.”
- Ask direct questions about each system, using terms that the patient understands.
- Whenever the patient complains or suggests a symptom, ask the questions outlined under method of collecting data about the present illness (onset, duration).
- Never assume that things are “OK” if the patient fails to mention something.
- Ask about every aspect of the function of a particular system and be sure to record the patient’s responses.
- Often, the fact that a body system has been free from any symptoms is as important as any symptoms that have been experienced.
- If necessary, memorize a list of questions for each system or use a list when interviewing the patient. Knowing what to ask about each system is based on knowledge of the function of each body system and of the way that normal function manifests itself.
PERSONAL AND SOCIAL HISTORY
Purposes
- To describe the patient’s life situation—may have a bearing on the present condition, overall health, or ability to cope
- To develop a plan of care that “fits” the patient. Here the interviewer finds out the many personal and family resources an individual has to aid in coping with the situation—both long-term and short-term
- To identify an opportunity for health promotion activities
- To determine if the patient’s occupation is directly or indirectly related to his condition
Types of Information Needed
- Personal status—birth place, education, armed service affiliation, position in the family, education level, satisfaction with life situations (home and job), personal concerns
- Habits and lifestyle patterns
- Sleeping pattern, number of hours of sleep, difficulty sleeping
- Exercise, activities, recreation, hobbies
- Nutrition and eating habits (diet recall for a typical day)
- Alcohol—frequency, amount, type; CAGE questionnaire for problem drinking:
- Have you ever thought you should Cut down on your drinking?
- Have you ever been Annoyed by criticism of your drinking?
- Have you ever felt Guilty about your drinking?
- Do you drink in the morning (ie, an Eye opener)?
- Caffeine—type and amount per day
- Illicit drugs (illegal or improperly used prescription or over-the-counter medications)
- Past and present use
- Type of drug and route (if I.V., history of needle sharing)
- Frequency and amount
- History of treatment, support group, program
- Tobacco—past and present use, type (cigarettes, cigars, chewing, snuff), pack years
- Sexual habits (can be part of genitourinary history)—relationships, frequency, satisfaction, number of partners in past year, STD and pregnancy prevention
- Home conditions
- Marital status, nature of family relationships
- Economic conditions—source of income; health insurance, Medicare, Medicaid
- Living arrangements and housing (owning or renting, heating, sewage, pets)
- Involvement with agencies (name, case worker)
- History of physical or sexual abuse
- Occupation—past and present employment and working conditions, including exposure to stress and tension, noise, chemicals, pollution
- Religion or faith—its importance in coping and health practices
Method of Collecting Data
- Begin by explaining that you are going to ask questions about the patient’s life situation to gain a clearer perspective of the patient’s condition and of how you might help.
- Your manner should be matter-of-fact, yet concerned. If you are uncomfortable asking the questions, most likely the patient will sense that and be uneasy answering them.
- A sensitive interviewer can ask most of the questions listed above in an initial interview without alienating the patient. For instance, ask “What has been your education?” instead of “How far have you gone in school?”
ENDING THE HISTORY
When you have completed the history, it is often helpful to say: “Is there anything else you would like to tell me?” or “What additional concerns do you have?” This allows the patient to end the history by saying what is on his or her mind and what concerns the patient most.
PHYSICAL EXAMINATION
GENERAL PRINCIPLES
- A complete or partial physical examination is conducted following a careful comprehensive or problem-related history.
- It is conducted in a quiet, well-lit room with consideration for patient privacy and comfort.
APPROACHING THE PATIENT
- When possible, begin with the patient in a sitting position so both the front and back can be examined.
- Completely expose the part to be examined but drape the rest of the body appropriately.
- Conduct the examination systematically from head to foot so as not to miss observing any system or body part.
- While examining each region, consider the underlying anatomic structures, their function, and possible abnormalities.
- Because the body is bilaterally symmetric for the most part, compare findings on one side with those on the other.
- Explain all procedures to the patient while the examination is being conducted to avoid alarming or worrying the patient and to encourage cooperation.
TECHNIQUES OF EXAMINATION AND ASSESSMENT
Use the following techniques of examination as appropriate for eliciting findings.
Inspection
- Begins with the first encounter with the patient and is the most important of all the techniques.
- Is an organized scrutiny of the patient’s behavior and body.
- With knowledge and experience, the examiner can become highly sensitive to visual clues.
- The examiner begins each phase of the examination by inspecting the particular part with the eyes.
Palpation
- Involves touching the region or body part just observed and noting whether these are tender to touch and what the various structures feel like.
- With experience comes the ability to distinguish variations of normal from abnormal.
- Is performed in an organized manner from region to region.
- By setting underlying tissues in motion, percussion helps in determining the density of the underlying tissue and whether it is air-filled, fluid-filled, or solid.
- Audible sounds and palpable vibrations are produced, which can be distinguished by the examiner. The five basic notes produced by percussion can be distinguished by differences in the qualities of sound, pitch, duration, and intensity. (See Table 5-1.)
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TABLE 5-1 Five Basic Notes Produced by Percussion |
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- The technique for percussion may be described as follows:
- Hyperextend the middle finger of your left hand, pressing the distal portion and joint firmly against the surface to be percussed.
- Other fingers touching the surface will damp the sound.
- Be consistent in the degree of firmness exerted by the hyperextended finger as you move it from area to area or the sound will vary.
- Cock the right hand at the wrist, flex the middle finger upward, and place the forearm close to the surface to be percussed. The right hand and forearm should be as relaxed as possible.
- With a quick, sharp, relaxed wrist motion, strike the extended left middle finger with the flexed right middle finger, using the tip of the finger, not the pad. Aim at the end of the extended left middle finger (just behind the nail bed) where the greatest pressure is exerted on the surface to be percussed.
- Lift the right middle finger rapidly to avoid damping the vibrations.
- The movement is at the wrist, not at the finger, elbow, or shoulder; the examiner should use the lightest touch capable of producing a clear sound.
Auscultation
- This method uses the stethoscope to augment the sense of hearing.
- The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 10 to
15 inches (25 to38 cm ), and the head should have a diaphragm and a bell. - The bell is used for low-pitched sounds such as certain heart murmurs.
- The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds such as breath sounds.
- Extraneous sounds can be produced by clothing, hair, and movement of the head of the stethoscope.
Adult Physical Assessment
EQUIPMENT
- Cotton applicator stick
- Flashlight
- Oto-ophthalmoscope
- Reflex hammer
- Safety pin
- Sphygmomanometer
- Stethoscope
- Thermometer
- Tongue blade
- Tuning fork
- Additional items may include disposable gloves and lubricant for rectal examination and a speculum for examination of female pelvis.
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