Thursday, 25 June 2009

ASSESSMENT TECHNIQUES


To perform physical assessment, a nurse uses four basic techniques: inspection, palpation, percussion, and auscultation. Performing these techniques correctly helps elicit valuable information about the patient's condition.
Inspection requires the use of vision, hearing, touch, and smell. Special lighting and various equipment—such as an otoscope, a tongue blade, or an ophthalmoscope—may be used to enhance vision or examine an otherwise hidden area. Inspection begins during the first patient contact and continues throughout the assessment.
Palpation usually follows inspection, except when examining the abdomen or assessing infants and children. Palpation involves touching the body to determine the size, shape, and position of structures; to detect and evaluate temperature, pulsations, and other movement; and to elicit tenderness.
The four palpation techniques include light palpation, deep palpation, light ballottement, and deep ballottement. Ballottement is the technique used to evaluate a flowing or movable structure. The nurse gently bounces the structure being assessed by applying pressure against it and then waits to feel it rebound. This technique may be used, for example, to check the position of an organ or a fetus.
Percussion uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds, detect tenderness, or assess reflexes. Percussing for sound helps locate organ borders, identify organ shape and position, and determine whether an organ is solid or filled with fluid or gas.
Organs and tissues produce sounds of varying loudness, pitch, and duration, depending on their density. For example, air-filled cavities, such as the lungs, produce markedly different sounds from those produced by the liver and other dense organs and tissues. Percussion techniques include indirect percussion, direct percussion, and blunt percussion.
Auscultation involves listening to various sounds of the body—particularly those produced by the heart, lungs, vessels, stomach, and intestines. Most auscultated sounds result from the movement of air or fluid through these structures.
Usually, the nurse auscultates after performing the other assessment techniques. When examining the abdomen, however, auscultation should occur after inspection but before percussion and palpation. This way, bowel sounds can be heard before palpation disrupts them. Auscultation is best performed first on infants and young children, who may start to cry when palpated or percussed. Auscultation is most successful when performed in a quiet environment with a properly fitted stethoscope.
Equipment
Flashlight or gooseneck lamp, as appropriate • ophthalmoscope • otoscope • stethoscope.
Implementation
  • Explain the procedure to the patient, have him undress, and drape him appropriately.
  • Make sure the room is warm and adequately lit to make the patient comfortable and aid visual inspection.
  • Warm your hands and the stethoscope.

Inspection
  • Focus on areas related to the patient's chief complaint. Use your eyes, ears, and sense of smell to observe the patient.
  • To inspect a specific body area, first make sure the area is sufficiently exposed and adequately lit. Then survey the entire area, noting key landmarks and checking its overall condition. Next, focus on specifics—color, shape, texture, size, and movement. Note any unusual findings as well as predictable ones.
Palpation
  • Explain the procedure to the patient, and tell him what to expect such as occasional discomfort as pressure is applied. Encourage him to relax because muscle tension or guarding can interfere with performance and results of palpation.
  • Use the flattened fingerpads for palpating tender tissues, feeling for crepitus (crackling) at the joints, and lightly probing the abdomen. Use the thumb and index finger for assessing hair texture, grasping tissues, and feeling for lymph node enlargement. Use the back, or dorsal, surface of the hand when feeling for warmth.
  • Provide just enough pressure to assess the tissue beneath one or both hands. Then release pressure and gently move to the next area, systematically covering the entire surface to be assessed. (See Performing palpation.)
  • To perform light palpation, depress the skin, indenting ½Prime; to ¾Prime; (1 to 2 cm). Use the lightest touch possible because excessive pressure blunts your sensitivity.
  • If the patient tolerates light palpation and you need to assess deeper structures, palpate deeply by increasing your fingertip pressure, indenting the skin about 1½Prime; (4 cm). Place your other hand on top of the palpating hand to control and guide your movements.
  • To perform light ballottement, apply light, rapid pressure from quadrant to quadrant on the patient's abdomen. Keep your hand on the skin to detect tissue rebound.
  • To perform deeper ballottement, apply abrupt, deep pressure and then release it. Maintain fingertip contact.
  • Use both hands (bimanual palpation) to trap a deep, underlying, hard-to-palpate organ (such as the kidney or spleen) or to fix or stabilize an organ (such as the uterus) with one hand while you palpate it with the other.
Percussion
  • First, decide which of the percussion techniques best suits your assessment needs. Indirect percussion helps reveal the size and density of underlying thoracic and abdominal organs and tissues. Direct percussion helps assess an adult's sinuses for tenderness and elicits sounds in a child's thorax. Blunt percussion aims to elicit tenderness over organs, such as the kidneys, gallbladder, or liver. When percussing, note the characteristic sounds produced. (See Identifying percussion sounds.)
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  • To perform indirect percussion, place one hand on the patient and tap the middle finger with the middle finger of the other hand. (See Performing indirect percussion.)
  • To perform direct percussion, tap your hand or fingertip directly against the body surface.
  • To perform blunt percussion, strike the ulnar surface of your fist against the body surface. Or place the palm of one hand against the body, make a fist with the other hand, and strike the back of the first hand.
Auscultation
  • First, determine whether to use the bell or diaphragm of your stethoscope. Use the diaphragm to detect high-pitched sounds, such as breath and bowel sounds. Use the bell to detect lower-pitched sounds, such as heart and vascular sounds.
  • Place the diaphragm or bell of the stethoscope over the appropriate area of the patient's body. Place the earpieces in your ears, listen intently to individual sounds, and try to identify their characteristics. Determine the intensity, pitch, and duration of each sound, and check the frequency of recurring sounds.
Special considerations
  • Avoid palpating or percussing an area of the body known to be tender at the start of your examination. Instead, work around the area; then gently palpate or percuss it at the end of the examination. This progression minimizes the patient's discomfort and apprehension.
  • To assess the abdomen, inspect visually first. Then auscultate bowel sounds prior to palpation and percussion, which alter these sounds.
  • To pinpoint an inflamed area deep within the patient's body, perform a variation on deep palpation: Press firmly with one hand over the area you suspect is involved, and then lift your hand away quickly. If the patient reports that pain increases when you release the pressure, then you've identified rebound tenderness.
  • NURSING ALERT Suspect peritonitis if you elicit rebound tenderness when examining the abdomen.
  • If you can't palpate because the patient fears pain, try distracting him with conversation. Then perform auscultation and gently press your stethoscope into the affected area to try to elicit tenderness.
Complications
Palpation may cause an enlarged spleen or infected appendix to rupture.
Documentation
Document your assessment findings and the technique used to elicit those findings—for example, “right lower quadrant tenderness on deep palpation, no rebound tenderness.