Assessment Techniques and Safety in the Clinical Setting
2. Health history provides
Subjective data for health assessment
Objective data (the signs perceived by examiner through physical examination)
3. Skills performed one at a time, in this order
Inspection Palpation
Percussion Auscultation
4. Inspection
Close, careful scrutiny, first of individual as a whole and then of each body system
Begins when you first meet person with a general survey
As you proceed through examination, start assessment of each body system with inspection
Inspection always comes first Inspection requires
Good lighting Adequate exposure
Occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and
vaginal specula, to enlarge your view
5. Palpation
Palpation applies sense of touch to assess the following
,Texture
Temperature Moisture
Organ location and size Swelling, vibration, or pulsation Rigidity or spasticity Crepitation
Presence of lumps or masses Presence of tenderness or pain
6. Palpation Techniques
Different parts of hands are best suited for assessing different factors
Fingertips
best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of
lumps
Fingers and thumb
detection of position, shape, and consistency of an organ or
mass
Dorsa of hands and fingers
best for determining temperature because skin here is thinner than on palms
Base of fingers or ulnar surface of hand
best for vibration
7. Bimanual Palpation
requires use of both hands to envelop or capture certain body parts or organs, such as kidneys,
uterus, or adnexa, for more precise delimitation
, 8. Percussion
Tapping person's skin with short, sharp strokes to assess underlying structures
Percussion has following uses
Mapping location and size of organs
Signaling density of a structure by a characteristic note
Detecting a superficial abnormal mass Percussion vibrations penetrate about 5 cm deep
Deeper mass would give no change in percussion Eliciting pain if underlying structure is
inflamed Eliciting deep tendon reflex using percussion hammer
9. 2 Methods of Percussion can be done
Direct, sometimes called immediate, the striking hand directly contacts body wall
Indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on
person's skin
10. Ausculation
Listening to sounds produced by body
Most body sounds are soft and must be channeled through a stethoscope Stethoscope does not
magnify sound, but it blocks out extraneous sounds
Of all the equipment you will use, the stethoscope quickly becomes a personal instrument
Once you can recognize normal sounds, you can distinguish the abnormal sounds and "extra"
sounds
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