Physical examination and health assessment 6th edition jarvis solutions manual

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Jarvis: Physical Examination & Health Assessment, 6th Edition Chapter 8: Assessment Techniques and the Clinical Setting Instructor’s Manual ANNOTATED LEARNING OBJECTIVES At the completion of this chapter, the student will: •

Describe the use of inspection as a physical examination technique.

Inspection is critical observation of the patient in a systematic, deliberate manner that begins as a “general survey” the moment the practitioner first meets the patient. It is the first technique used in the performance of a physical assessment. While conducting an inspection, the practitioner uses the patient’s body as his or her own control to determine symmetry between the right and left sides of the body. Good lighting, adequate exposure and, at times, the use of special instruments aid in the completion of a good inspection.

•

Describe the use of palpation as a physical examination technique.

Palpation is the use of touch to determine the texture, size, consistency, and location of body parts. Temperature, moisture, change in size, vibrations, pulsations, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain may also be found.

•

Relate the parts of the hands to palpation techniques used in assessment.

Fine tactile discrimination is best achieved with the fingertips. Position, shape, and consistency of an organ or mass are determined through the use of the opposition of the fingers and thumb. Temperature is best determined with the dorsa (back) of the hands and fingers. Vibration is assessed with the base of the fingers (metacarpophalangeal joints) or ulnar surface of the hand.

•

Differentiate between light, deep, and bimanual palpation.

Light palpation is used to evaluate surface characteristics and identify any areas of tenderness. Deep palpation is used to palpate an organ or mass deeper within a body cavity.

Bimanual palpation is the use of both hands to envelop or capture certain body parts or organs, such as the kidneys.

•

Describe the use of percussion as a physical examination technique.

Percussion is the technique of striking a part of the body with short, sharp taps of the fingers.

Location, size, position, and density of the underlying organs can be assessed through noticing the change in percussion sounds elicited. Percussion is used most frequently to assess the thorax and abdomen.

•

Describe direct and indirect percussion.

Direct percussion, most commonly used to assess the adult sinuses and thorax of an infant, is the technique of striking the finger or hand directly against the body. With indirect percussion the examiner’s interphalangeal joint is placed firmly against the patient’s skin

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with the remainder of the hand lifted off the skin. The middle finger of the dominant hand is used as the striking force (plexor). The striking finger, using the action of the wrist, hits directly at right angles to the stationary finger on the portion in contact with the skin surface.

Note: To elicit the best tones and to avoid pain, short fingernails are a must.

•

Identify the components of a percussion note.

Amplitude is the intensity of the sound produced. The louder the sound is, the greater the amplitude is. Both the force of the blow and the structure’s ability to vibrate affect the amplitude. Pitch or frequency describes the number of vibrations per second. More rapid vibrations produce a high-pitched tone, whereas slower vibrations yield a low-pitched tone.

Quality or timbre is a subjective difference resulting from a sound’s distinctive overtones.

Duration is the length of time the note lingers.

•

Describe the use of auscultation as a physical examination technique.

Auscultation (listening to sounds produced by the body) is done with both the unassisted sense of hearing and with special instruments, usually a stethoscope. Sounds heard with the ear alone include speech, percussion tones, difficult breathing, coughing, and loud abdominal sounds. Areas most commonly assessed with a stethoscope are the heart, blood vessels, lungs, and abdomen. Because the stethoscope does not amplify sound but blocks out extraneous room sounds, a quiet environment is required. The examiner listens for the presence or absence of sound and the quality of sound heard.

•

Identify the equipment needed for the screening physical examination.

All equipment needed should be obtained and laid out in an organized fashion before beginning the examination. The equipment typically used is listed, and in-depth descriptions of the otoscope and ophthalmoscope are provided.

•

Discuss appropriate infection control measures used to prevent spread of infection.

A stethoscope and other equipment can become a common vehicle for transmission of infection. Designate a “clean” versus a “used” area for handled equipment. All equipment carried by the examiner should be cleaned with alcohol between patients. The single most important step to decrease the risk of microorganism transmission is thorough handwashing after physical contact with patients or body fluids. Standard precautions are used for all patients, and transmission-based precautions are used with patients who have documented or suspected transmissible infections. As the examiner enters the room, he or she should wash hands in the patient’s presence.

•

Discuss developmental care needed for patients.

Special consideration is given to position and preparation of patients. The order of developmental stage must be considered in determining the sequence of the examination. For children, a less threatening approach is needed, and parents are encouraged to be present for infants, toddlers, and preschoolers. Privacy is essential for other age groups and must be maintained. The examination must be paced to meet the possible slowed pace of the aging person. A mini database may be needed for patients in distress.

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KEY TERMS Amplitude (intensity) Auscultation Bell Diaphragm Doppler sonometer Duration Fetoscope Goniometer Inspection Nosocomial infection Ophthalmoscope Otoscope Palpation Pelvimeter Percussion Pitch (frequency) Quality (timbre) Resonance Standard precautions Stethoscope Transmission-based precautions Tympany Quality and Safety Education for Nurses (QSEN) Teaching Strategies This strategy can be used in the clinical, classroom, online, or simulation lab setting. For simulation lab, the facilitator should divide learners into groups of three. Learners can also videotape a presentation via a cell phone and post it to the discussion board online. Actual patients would be used in the clinical setting, and the facilitator would observe demonstration.

Provide the skills checklist to learners in advance or include in course syllabus. Using the skills performance checklist, have learners demonstrate techniques used in physical examination.

Peer review of checklist should be completed prior to testing.

Instruct students to come to the laboratory in shorts and t-shirts. Working in pairs, have students practice the techniques used in a physical examination. Be sure to observe each student, especially for hand position with indirect percussion and the proper use of the stethoscope.

Learning Objectives • The learner will apply guidelines from chapter text to simulation or clinical patient.

• The learner will implement and demonstrate correct physical assessment techniques.

• The learner will discuss and evaluate ways to improve rapport with patient and family.

• The learner will engage in peer review process.

Competency Category(s) Patient-centered care Teamwork and collaboration Informatics

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Learner Setting(s) Classroom or clinical Online or web-based presentation Skills or simulation lab Strategy Type Simulation exercises Course syllabus Audio visual aids Testing and evaluation Learning Activities • Obtain two large Styrofoam™ cups with lids. Fill one with water or sand. Leave the other empty. Have students percuss the tops of the two cups. Although the sounds are exaggerated, it will allow students to begin to differentiate between the sound heard over an air-filled organ and a solid organ. It also allows the instructor to observe the percussion technique of the student.

• Arrange for each student to observe a physical examination performed by an experienced practitioner.

• Bring examination equipment to class or laboratory and allow students to practice handling the equipment. Examples may include otoscope, ophthalmoscope, Doppler sonometer, tuning fork, and pulse oximeter.

• Discuss techniques that enhance the comfort of the patient and improve the quality of findings during a physical examination, for example, wetting the hair on the chest of a man to decrease the interference with sound transmission, having a warm room to increase the physical comfort of the patient, and providing sufficient lighting and privacy. Advise students to avoid bumping tubing together and to focus on one sound at a time when auscultating the chest.

• Discuss standard precautions and infection control issues for the protection of both the patient and the examiner.

• Have students purchase a stethoscope for personal use. Review the use of the diaphragm and bell, discuss the fit of the earpieces, and look at the length of the tubing. Having scissors handy might also be helpful because some less expensive scopes come with very long tubing.

A length of 12 inches is usually recommended. Discuss modifications needed for pediatric and elderly patients.

• Have students practice listening to heart sounds with both the bell and the diaphragm of their stethoscopes. Ask them to write down the differences they perceive when listening to the same sound with both devices.

• Asking students to work in pairs, have them listen to each other’s breath sounds first with the shirts off then with the shirts on. Have them compare the differences in sound quality.

CRITICAL THINKING EXERCISES Application to Clinical Practice For each of the following situations, have students discuss the developmental, age, socioeconomic, cross-cultural, and infection control considerations that should be addressed

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when applicable. Ask students to discuss the technique(s) used to obtain the data or identify factors that may alter the data obtained.

• P. G. is a patient recovering from an abdominal resection performed yesterday. On the chart the nurse has written, “Abdomen soft, nontender, B. S. [bowel sounds] present in all four quadrants. Abdominal dressing dry with no drainage.”

• L. J. has come to the dermatology clinic complaining of itching. The health care provider charts “erythematous areas 1 cm to 2 cm on dorsal surface of left hand.”

• P. C. is recovering from an appendectomy. History includes use of one pack of cigarettes a day. The nurse has come to complete a postoperative assessment at the beginning of the afternoon shift. When the nurse asks to turn down the television, P. C. responds, “No, I have to see my soap operas.”

• O. W. has been admitted for general malaise. Interview reveals a history of excessive intake of alcohol for 20 years. The nurse documents “dullness to percussion in right quadrant from fifth intercostal space to 4 cm below the costal margin, + fluid wave.”

• F. N. has come to the clinic with complaints of pain in her right great toe. The practitioner documents “V. S. [vital signs]: BP. 180/98, P. 78, R. 20, T. 99.6º F; small ulcer on the plantar surface of right great toe 3 cm in diameter; necrotic edges with yellow center, thick, purulent, foul-smelling drainage; complains of pain to touch.”

• The night nurse is making initial rounds on assigned postoperative patients. J. K. had an open reduction of a hip fracture this morning. The patient has a cast, a Foley catheter, and an IV running. Write a note that would reflect pertinent findings for this patient.

• A 75-year-old patient is admitted from a nursing home for pneumonia. He has been bedridden for 2 years and has multiple pressure ulcers over his sacrum. He is unable to turn himself and is incontinence of both urine and stool. The nurse needs to auscultate his breath sounds and heart sounds.

• A 9-year-old boy is brought to the emergency department with wheezing and extreme shortness of breath. His mother states that he was running the mile at school during P.E. and forgot to take his inhaler.

• A newborn infant has had three episodes of projectile vomiting and has a noticeably distended abdomen. His mother says that he “acts hungry but can’t eat” and cries all the time.

WEBSITES OF INTEREST • American Association of Occupational Health Nurses, http://www.aaohn.org • Association of Professionals in Infection Control and Epidemiology, Inc., http://www.apic.org • The Auscultation Assistant, http://www.wilkes.med.ucla.edu/inex.htm • Centers for Disease Control and Prevention, http://www.cdc.gov • Auscultation.com, http://auscultation.com/

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Instructor’s Manual

8-6 PERFORMANCE CHECKLIST Assessment Techniques―Essential Behaviors Yes

No

Comments

Gather equipment Provide private, warm, comfortable environment Wash hands Provide proper lighting Describe each step Inspection Palpation Light palpation Deep palpation Bimanual palpation Percussion Direct Indirect Auscultation Bell of stethoscope Diaphragm of stethoscope Proceed in a head-to-toe fashion Summarize findings with patient Developmental care Document findings

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.