Chapter 2. Patient Assessment Show A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system. A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take. Checklist 17: Head-to-Toe Assessment
What physical examination techniques should the nurse use for palpation?Palpation
Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. Because your hands are your tools, keep your fingernails short and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last.
Which of the following techniques is used for palpation?Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation.
What technique should the nurse use for palpation of the abdomen?Place the palmar aspect of the fingers on your dominant hand flat and together on your patient's abdomen. Using a light, gentle, dipping motion, palpate for abnormalities, such as muscle guarding, rigidity, or superficial masses. Palpate clockwise, lifting your fingers as you move from one location to another.
Which of the following can a nurse assess by palpation?Nurses apply varying degrees of pressure on the patient with different parts of their hands. Palpation allows nurses to assess for texture, tenderness, temperature, moisture, pulsations and the presence of masses.
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