1 Examination Techniques and Equipment

2 Precautions to Prevent Infection

3 Objectives Upon completion of this unit, the student will be able to: Identify precautions taken to prevent infection Differentiate among the four cardinal techniques of physical assessment Assess the general status of the patient Record obtained data systematically and completely Differentiate instruments used during physical assessment

4 Precautions to Prevent Infection Universal precautions (UP) Body substance isolation (BSI) Standard precautions Transmission-based precautions • Precautions to Prevent Infection

5 Universal Precautions (UP) Applies blood and body fluid precautions to all persons Emphasizes prevention of needle-stick injuries and use of gloves, gowns, masks, and eye coverings Precautions cover blood and body fluids implicated in transmission of disease and body fluids contaminated with blood • Precautions to Prevent Infection

6 Body Substance Isolation (BSI) Isolation of all moist and potentially infectious body substances from all patients Gloves primary means of prevention Blood Borne Pathogens and Needle stick Prevention • Precautions to Prevent Infection

7 Standard Precautions (UP and BSI) Designed to reduce pathogen transmission in hospitals for all hospitalized patients Applies to blood, all body fluids, non-intact skin, and mucous membranes Use of hand washing, gloves, mask, face shield, gown Standards for equipment, environmental control, and patient placement • Precautions to Prevent Infection

8 Transmission-Based Precautions Designed for care of specific infected patients Applies to pathogens spread by air, droplet, dry skin, or contaminated surfaces CDC Infection control guidelines • Precautions to Prevent Infection

9 Latex Allergy

10 Latex Allergy Occurs when the body’s immune system reacts with proteins found in latex Can cause rash, itching, blisters, asthma, GI symptoms, lung damage, anaphylaxis Health care workers at risk due to exposure to gloves and other latex-based supplies Patients with multiple procedures/surgeries and children with spina bifida at increased risk • Latex Allergy

11 Examination Technique Inspection Palpation Percussion Auscultation

12 Patient Positions and Draping Seated Supine Prone Dorsal recumbent Lateral recumbent Lithotomy Sims • Examination Technique

13 Inspection Process of observation beginning with first exposure to patient and continuing through history and physical examination Guidelines: Adequate lighting Unhurried and careful inspection Validation of findings with patient • Examination Technique

14 Palpation Use of hands and fingers to gather information through touch Guidelines: Keep fingernails short Have warm hands Be gentle in approach Use appropriate hand surface Use correct palpation depth • Examination Technique

15 Percussion One object striking against another produces vibrations and sound waves Tapping finger causes vibrations by impact on underlying tissues Sound waves arise from vibrations and produce percussion tones Tone is related to density of underlying tissue • Examination Technique

16 Percussion Tones Tympany–loud, high, drum-like Hyperresonance–very loud, low, booming Resonance–loud, low, hollow Dullness–soft, moderate, thud-like Flatness–soft, high, dull • Examination Technique

17 Percussion Techniques Immediate (direct)–Finger strikes directly against body Mediate (indirect)–Middle finger of dominant hand is hammer; middle finger of non-dominant hand is placed on body and struck Fist–Non-dominant hand is placed on body and struck with fist of dominant hand • Examination Technique

18 Auscultation Listening to sounds produced by body Guidelines: Perform last in examination sequence Stethoscope is placed on naked skin Listen for presence/characteristics of sound Listen to one sound at a time Take time to identify characteristics of sound Don’t anticipate next sound • Examination Technique

19 Measurement of Vital Signs

20 Measurement of Vital Signs Pulse: measure of heart rate Respiration: measure of inspiration and expiration Blood pressure: indirect measurement of cardiovascular function Temperature: indirect measure of body’s core temperature Pain: the universal distress signal • Measurement of Vital Signs

21 Pulses Note rate, rhythm, and amplitude Palpable pulses Carotid Brachial Radial Femoral Popliteal Dorsalis Pedis Posterior Tibialis

22 Respirations Normal Range Note pattern (rhythm) and chest movement

23 Blood Pressure Assess lying, sitting, standing Compare left side to right side Normal ranges History of Blood Pressure

24 Temperature May be assessed orally, rectally, axillary, tympanic, temporal Normal ranges

25 Measurement of Height and Weight

26 Measurement of Height and Weight Adult: measured with standing platform scale with height attachment Infant: weight on platform scale; height on measuring device with rigid headboard and movable footboard Child (when able to stand): stature-measuring device • Measurement of Height and Weight

27 Instrumentation

28 Instrumentation: List Used in Physical Examination Tuning fork Percussion hammer Tape measure Stethoscope Ophthalmoscope Snellen visual chart Near vision charts Amsler grid Otoscope Nasal speculum • Instrumentation

29 Stethoscope Required for amplification in auscultation Four types Acoustic Magnetic Electronic Stereophonic • Instrumentation

30 Ophthalmoscope System of lenses and mirrors with light source and apertures enables visualization of interior structures of eye. Lenses vary in powers of magnification. Magnification ranges from -20 to +40 and can be dialed up or down to compensate for myopia or hyperopia in both examiner and patient. • Instrumentation

31 Visual Acuity Charts Snellen alphabet Acuity of far vision is screened. Graduated letters. Smallest complete line patient can see is recorded. Reading is recorded as a fraction (20/20 normal). The larger the denominator, the poorer the vision. Tumbling E • Instrumentation

32 Near Vision Charts Rosenbaum and Jaeger charts Series of numbers, E, X, and O in graduated sizes Acuity recorded as distance equivalents (20/20) or Jaeger equivalents (J-2) Newsprint–ability to read without difficulty at normally held distance • Instrumentation

33 Amsler Grid Tests for macular degeneration Grid of perpendicular straight lines with central black dot as fixation point Individual views grid one eye at a time and reports any line distortion or scotoma • Instrumentation

34 Otoscope Illumination for viewing external auditory canal and tympanic membrane Speculum attached to otoscope head directs beam of light down ear canal Pneumatic attachment used to evaluate fluctuating capacity of tympanic membrane • Instrumentation

35 Nasal Speculum Used with penlight to visualize lower and middle turbinates of nose Guidelines: Open blades by squeezing handles of instrument. Stabilize speculum with index finger to avoid contact of blades with nasal septum. Tilt patient’s head at various angles. • Instrumentation

36 Tuning Fork Tuning forks screen for auditory function and vibratory sensation Activated fork produces vibrations that create a particular frequency of sound wave Auditory evaluation estimates hearing loss by noting which vibrating tuning forks can be heard (500 to 1000 Hz) Vibratory sense is measured by holding vibrating fork against a bony prominence (100 to 400 Hz) • Instrumentation

37 Percussion Hammer Used to test deep tendon reflexes (DTRs) Hammer held loosely between thumb and index finger and a tendon is tapped to elicit a reaction Finger may also be used as percussion hammer, especially in pediatric examinations • Instrumentation

38 Tape Measure Used to determine circumference, length, and diameter in metric units and inches Non-stretchable for accuracy and pliable for circumference Tape pulled closely without causing depression of skin Serial measures obtained by placing tape in same location every time • Instrumentation

39 Recommendations for Student Equipment Purchase Penlight Stethoscope Centimeter tape measure • Instrumentation

40 General Inspection

41 General Impression Impressions of general health state Observable signs of problems Body Development

42 Gait Posture Body Position Body Movements Gait

43 Voice Voice quality Manner of speech Word Choices

44 Odors Body odor Breath odor

45 References Seidel, H., Ball, J., & Benedict, G. (2006). Mosby’s Guide to Physical Examination (6th ed.). St. Louis, MO: Elesevier