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Unformatted text preview: 8. ASSESSMENT and the CLINICAL SETTING
8. ASSESSMENT and the CLINICAL SETTING
L Meneghini MSN RN CEN
09/21/09 ASSESSMENT TECHNIQUES
ASSESSMENT TECHNIQUES Cultivating your senses: 1st a statistic: 85% of what we’ve
learned is through your eyes.
learned Inspection: Always comes first (for obvious reasons) It
begins the moment you meet the person. It is close,
careful scrutiny of the person as a whole, then of each
Meet Maggie Train yourself to do this technique slowly Requires good lighting, adequate exposure and good
equipment such as an otoscope, ophthalmoscope,
penlight, nasal and vaginal specula.
penlight, ASSESSMENT TECHNIQUES
ASSESSMENT TECHNIQUES 2. Palpation: It applies your sense of
touch to assess texture, temperature,
moisture, organ location and size as well
as any swelling, vibration or pulsation,
rigidity or spasticity, crepitation, presence
of lumps or masses and presence of pain.
of Assessment Techniques
Assessment Techniques Fingertips: best for fine tactile discrimination.
Fingertips: Use a grasping action of fingers and thumb to
detect the position, shape, and consistency of
an organ or mass.
an The dorsa (backs) of hands and fingers- best for
determining temperature because skin is thinner
than the palm.
than Base of fingers – best for vibration.
Base ASSESSMENT TECHNIQUES
ASSESSMENT TECHNIQUES Your palpation technique should be slow and systematic
Your simply because the patient may stiffen when touched. Use a
calm gentle approach and make sure your hands are warm
calm Start with light palpation: to detect surface
characteristics. This also allows time for the patient to get use
to your touch When deep palpation is needed, do so intermittently. Avoid situations which may cause injury.
Avoid Bimanual palpation: requires use of both hands to
envelope or capture certain body parts such as the kidneys,
uterus, or adnexa. ASSESSMENT TECHNIQUES
ASSESSMENT TECHNIQUES 3.Percussion: is tapping the persons skin with
short, sharp strokes to assess underlying
structures. The strokes yield a palpable vibration and a
characteristic sound that depicts the location,
size, and density of the underlying organ.
size, ASSESSMENT TECHNIQUES
ASSESSMENT TECHNIQUES Why Percussion? It maps out the location and
Why size of an organ by exploring where the
percussion tone changes between the borders
of the organ and its neighbor.
of Signals the density (air, fluid, or solid) of a
structure by a characteristic tone.
structure Detects an abnormal mass if it is fairly
superficial; the percussion vibrations penetrate
about 5 cm deep- a deeper mass would give no
change in tone ASSESSMENT TECHNIQUES
ASSESSMENT Elicits pain: If the underlying structure is in
flamed, as with sinus areas or over the
kidney Elicits a deep-tendon reflex when using a
reflex 2 methods of percussion: Direct and
Indirect Direct percussion there is direct contact
against the body
against ASSESSMENT TECHNIQUES
ASSESSMENT This is used in the infant while percussing the
thorax or in the adult when percussing the
sinuses. Use a stationary hand and a striking
hand as described in Jarvis pg 163
hand A basic principle is that a structure with more air
basic (such as the lungs) produces a louder, deeper
and longer sound because it vibrates freely,
whereas a denser, more solid structure (such
as the liver) gives a softer, higher shorter
sound because it does not vibrate as easy
(table ASSESSMENT TECHNIQUES
ASSESSMENT 4.Auscultation: llistening to sounds
4.Auscultation istening produced by the body such as the heart
blood vessels, lungs and abdomen.
Know your stethoscope and use a good
Never listen through a gown
Moisten chest hair to minimize false
Avoid your own artifacts such as thumps. ASSESSMENT TECHNIQUES
ASSESSMENT Be familiar with wide range of sounds With experience, you will learn to decipher from
abnormal Ask yourself :What am I actually hearing?...
What should I be hearing at this spot?... Diaphragm: Best for high-pitched sounds such
as breath, bowel and heart sounds
as Bell: Best for soft low pitch sounds such as
heart ASSESSMENT TECHNIQUES
ASSESSMENT Setting; Warm and comfortable, quiet, private,
Setting; and well lit. (may also use gooseneck lamp)
No outside noises
Exam table should be accessible for use on both
HOB should be able to raise 45 degrees
Bedside table for equipment ASSESSMENT TECHNIQUES
ASSESSMENT Equipment: Have it readily available Platform scale, skinfold calipers, B/P cuff
(see page 166)
(see ASSESSMENT TECHNIQUES
Standard Wash hands Wear clean gloves Wear a mask and eye protection Wear a gown Take care of used pt. care equipment Follow facility policies ASSESSMENT TECHNIQUES
ASSESSMENT Take precautions with used linen Prevent injuries due to blood borne
pathogens Place in private room
There are 3 types of transmission-based
precautions: airborne, droplet, and contact Transmission –based precautions: Standard: Hand -washing gloves when
touching, eye shield when
drainage/splashes are evident, non-sterile
gowns for splashes
gowns Airborne: Same as standard, but wear
respiratory equipment for suspected of
airborne droplets (TB, measles,varicella)
airborne Droplet: Same as standard and with
patients with history of H-flu, meningitis
patients Use gloves ,mask, gown for higher
opportunity of splashes.
opportunity Contact : As above To transport pt. mask them. ASSESSMENT TECHNIQUES
ASSESSMENT General Approach: Remember the patient may
General be anxious and if experience is lacking on the
examiners part it may create some uneasiness
Try to be calm!
Practice on fellow students and have your
subjects try to act as the patient
Observe those that are experienced ASSESSMENT TECHNIQUES
ASSESSMENT Hands On: Start with measuring height,
Hands weight, vital signs, visual acuity
Change into gown (leave underpants on)
Wash hands in patients presence
Explain each step to him/her
Make slow deliberate, and methodical
Start by examining hands and nails
Start ASSESSMENT TECHNIQUES
ASSESSMENT Organize your steps Do not hesitate to write out the
Do examination sequence (some agencies
use a printed form)
Offer teachings as you proceed
Reassure patient as you examine them
At the end of your exam, summarize
Thank the patient when done ASSESSMENT TECHNIQUES
ASSESSMENT The Infant: Position: Make sure parents
are present and place neonate or young
infant on padded table
infant May also be held against parents chest for
some By 9-12 mos. infant is acutely aware of
surroundings, so parents must be in few
view. ASSESSMENT TECHNIQUES
ASSESSMENT Should be 1-2 hours after feeding Warm environment Leave on diaper Warm hands and stethoscope Use a soft, crooning voice Keep good eye contact; smile Keep movements smooth and deliberate Use a pacifier prn, offer bright toys ASESSEMENT TECHNIQUES
ASESSEMENT Sequence: Seize the moment when infant
is asleep to listen to heart, lungs and
abdomen Perform least disturbing step first
Save invasive steps for last!!!
Save ASSESSMENT TECHNIQUES
ASSESSMENT Toddler: May be difficult to examine Have parent hold in lap During abdomen exam have parent and
toddler sit knee to knee.
toddler An arm of the parent may encircle the
child’s head ASSESSMENT TECHNIQUES
ASSESSMENT Preparation: Use a security blanket or a teddy
Greet the child and parent by name. It is
essential to focus first on the parents; this allows
the child to adjust to you.
A 2 y.o. will need parents assistance to undress
Use clear firm direction
Offer limited options
Demonstrate on parents
Use praise ASSESSMENT TECHNIQUES
ASSESSMENT Preschooler: Position child on her/his lap
Preschooler: Position A 4 or 5 y.o. may feel comfortable on exam table
or Preparation; Verbal communication is important but
Preparation; understanding is limited
Explain steps exactly
Do not allow choices when there is none
Give feedback and compliment him
Examine thorax, abdomen extremities and genitals first
and the head, eyes, ears last.
and ASSESSMENT TECHNIQUES
ASSESSMENT School Age: Position on table Remember that they have a sense of
Remember modesty and privacy
Preparation: Break the ice with small talk
Child should undress himself
Comment on how the body works
Progress from head to toe ASSESSMENT TECHNIQUES
ASSESSMENT Adolescent: Position on table alone Preparation: Do not talk down to them or
too advanced to them either
too Ripe for learning as positive attitudes are
long lasting Promote health teaching!!
long Apprise them of the wide variety of growth
at that age
at Sequence: head to toe ASSESSMENT TECHNIQUES
ASSESSMENT Aging Adult: Position on exam table; a frail adult
Aging may need to be supine
Arrange the sequence to allow as few
position changes as possible
Allow for rest periods
Go at a slow pace
Sequence : Head to toe
Remember: aging years contain more stress;
loss, illness, financial loss ect
loss, ASSESSMENT TECHNIQUES
ASSESSMENT The Ill Person :Alter the position to
accommodate patient. For example the
person with SOB will need HOB up.
person A patient who is weak may want to lay flat. ...
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This note was uploaded on 05/31/2011 for the course NUR 326 taught by Professor Meneghini during the Fall '10 term at St. Xavier.
- Fall '10