8. Assessment Techniques

8. Assessment Techniques - 8. ASSESSMENT and the CLINICAL...

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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 Always begins the moment you meet the person. It is close, careful scrutiny of the person as a whole, then of each body system. body Meet Maggie Train yourself to do this technique slowly Requires good lighting, adequate exposure and good Requires equipment such as an otoscope, ophthalmoscope, penlight, nasal and vaginal specula. penlight, ASSESSMENT TECHNIQUES ASSESSMENT TECHNIQUES 2. Palpation: It applies your sense of 2. Palpation 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 The 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. structures. The strokes yield a palpable vibration and a The 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 Signals structure by a characteristic tone. structure Detects an abnormal mass if it is fairly Detects 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 Elicits flamed, as with sinus areas or over the kidney kidney Elicits a deep-tendon reflex when using a Elicits reflex hammer reflex 2 methods of percussion: Direct and methods Indirect Indirect Direct percussion there is direct contact Direct against the body against ASSESSMENT TECHNIQUES ASSESSMENT This is used in the infant while percussing the This 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 9-1) (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 Know one. one. Never listen through a gown Moisten chest hair to minimize false Moisten crackles. crackles. 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 With abnormal sounds. abnormal Ask yourself :What am I actually hearing?... Ask 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 Bell: heart murmurs heart ASSESSMENT TECHNIQUES ASSESSMENT Setting; Warm and comfortable, quiet, private, Setting; and well lit. (may also use gooseneck lamp) and No interruptions No outside noises Exam table should be accessible for use on both Exam sides sides 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 stethoscope, thermometer… stethoscope, (see page 166) (see ASSESSMENT TECHNIQUES ASSESSMENT Standard Precautions 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 Prevent pathogens 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 Standard: touching, eye shield when drainage/splashes are evident, non-sterile gowns for splashes gowns Airborne: Same as standard, but wear Airborne: respiratory equipment for suspected of airborne droplets (TB, measles,varicella) airborne Droplet: Same as standard and with Droplet: patients with history of H-flu, meningitis patients Use gloves ,mask, gown for higher Use 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! Try Show confidence! Be unhurried! Practice on fellow students and have your Practice subjects try to act as the patient subjects Observe those that are experienced ASSESSMENT TECHNIQUES ASSESSMENT Hands On: Start with measuring height, Hands weight, vital signs, visual acuity weight, Change into gown (leave underpants on) Wash hands in patients presence Explain each step to him/her Make slow deliberate, and methodical Make movements movements 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) use Offer teachings as you proceed Reassure patient as you examine them At the end of your exam, summarize At everything everything 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 May some steps some By 9-12 mos. infant is acutely aware of By surroundings, so parents must be in few view. 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 Sequence: is asleep to listen to heart, lungs and abdomen 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 During toddler sit knee to knee. toddler An arm of the parent may encircle the An child’s head ASSESSMENT TECHNIQUES ASSESSMENT Preparation: Use a security blanket or a teddy Preparation: bear bear Greet the child and parent by name. It is Greet essential to focus first on the parents; this allows the child to adjust to you. the 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 understanding Explain steps exactly Do not allow choices when there is none Be slow Play games Play Give feedback and compliment him Examine thorax, abdomen extremities and genitals first Examine 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 modesty Preparation: Break the ice with small talk Child should undress himself Demonstrate equipment 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 Preparation: too advanced to them either too Ripe for learning as positive attitudes are Ripe long lasting Promote health teaching!! long Apprise them of the wide variety of growth Apprise 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 may Arrange the sequence to allow as few Arrange position changes as possible Allow for rest periods Go at a slow pace Sequence : Head to toe Remember: aging years contain more stress; Remember: loss, illness, financial loss ect loss, ASSESSMENT TECHNIQUES ASSESSMENT The Ill Person :Alter the position to The 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.

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