Physical Assessment

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Chapter 5. Physical Assessment

Physical assessment skills include inspection, palpation, percussion, and auscultation. (The sequence in abdominal assessment is inspection, auscultation, percussion, and palpation.) The acquisition of these skills requires patience, practice, and continual refinement. A more detailed discussion of these skills can be found in a textbook of adult assessment skills.

Guidelines for Inspection

▪ Inspection is a simple but highly skilled technique.

▪ Inspection involves the use of sight, hearing, and smell in a systematic assessment of infants and children.

▪ Inspection is essential at the beginning of the health assessment to detect obvious health concerns and to establish priorities.

▪ Inspection should be thorough and should involve each area of the body.

▪ Body parts are assessed for shape, color, symmetry, odor (Table 5-1), and abnormalities.

**Table 5-1** Significance of Common Body Odors
Odor	Significance
Acetone or fruity odor	Might indicate diabetic acidosis
Ammonia	Might indicate urinary tract infection
Fecal odor (breath or diaper area)	Associated with soiled diapers, fecal incontinence, bowel obstruction
Foul-smelling stool	Might indicate gastroenteritis, cystic fibrosis, malabsorption syndromes
Halitosis	Associated with poor oral hygiene, dental caries or abscess, throat infection, sinusitus, constipation, foreign body in nasal passage
Musty odor	Associated with infection underneath a cast or dressing
Sweet, thick odor	Might indicate Pseudomonas infection

▪ Careful inspection requires good lighting.

Guidelines for Palpation

▪ Palpation involves the use of fingers and palms to determine temperature, hydration, texture, shape, movement, and areas of tenderness. Palpation can be light or deep. Light palpation is used to assess skin temperature, texture, and hydration; overt, large, or superficial masses; fluid and muscle guarding; and superficial tenderness. Light palpation is performed with the dominant hand, fingers together. The fingerpads are placed on the skin in a plane parallel to the area and the skin is depressed gently and lightly (about 1 cm or 0.4 inches) in a circular motion. If the child is ticklish, lift the hand fully off the skin before moving to another area. Deep palpation is used to assess the position of organs or masses, as well as their consistency, shape, mobility, and areas of discomfort. It is frequently used in abdominal and reproductive assessments. Deep palpation involves depressing the skin to a depth of approximately 4 to 5 cm (1.5 to 2 inches).

▪ Warm hands before beginning palpation.

▪ Keep fingernails short.

▪ Palpate areas of tenderness or vulnerability last. If pain is experienced during palpation, discontinue palpation in that area immediately.

▪ Palpate with fingertips for pulsation, size, shape, texture, hydration, and mobility and consistency of organs.

▪ Palpate with palms for vibration.

▪ Palpate with back of hand for temperature.

▪ Use conversation or games to relax child during palpation. Muscle guarding related to tension can obscure findings. Observe reactions to palpation rather than asking, “Does it hurt?”

▪ The nurse can assist the ticklish child by first placing the child’s hands on the skin and gradually sliding hands over those of the child or by having the child keep his or her hands over the nurse’s during examination.

▪ Move firmly and without hesitation.

Guidelines for Percussion

▪ Percussion involves the use of tapping to produce sound waves, which are characterized regarding intensity, pitch, duration, and quality (Table 5-2).

**Table 5-2** Percussion Sounds
Percussion Sound	Intensity	Pitch	Duration	Quality	Body Region Where Sound Might Be Heard
Tympany	Loud	High	Moderate	Drumlike	Gastric bubble, air-filled intestine (simulate by tapping puffed-out cheeks)
Resonance	Moderate to loud	Low	Long	Hollow	Lungs
Hyperresonance	Very loud	Very low	Long	Booming	Lungs with trapped air, lungs of a young child
Dullness	Soft to moderate	High	Moderate	Thudlike	Liver, fluid-filled space (e.g., stomach)
Flatness	Soft	High	Short	Flat	Muscle

▪ Percussion can be direct or indirect.

Direct percussion involves striking the body part directly with one or two fingers.

Indirect percussion involves a pleximeter and a plexor.

Place the middle finger (pleximeter) of the nondominant hand gently against child’s skin.

Strike the distal joint of the pleximeter with the tip of the middle finger (plexor) of the dominant hand (Figure 5-1).

Figure 5-1Percussion. Note position of fingers.

The blow to the pleximeter should be crisp, and the plexor must be perpendicular.

The wrist movement is essential to percussion and must be a snapping motion.

The nail of the plexor should be short.

▪ Percuss from resonance to dullness.

Guidelines for Auscultation

▪ Auscultation is the process of listening for body sounds.

▪ The bell (cupped portion) of the stethoscope is used for low-pitched sounds (e.g., cardiovascular sounds), and the diaphragm (flat portion) is used for high-pitched sounds (e.g., those found in the lung and bowel).

▪ The diaphragm of the stethoscope is placed firmly against the wall of the body part. The examiner must avoid pressing too firmly, causing the skin to flatten and vibrations to decrease. Resting the heel of the hand on the child will assist in avoiding heavy pressure. Place the bell lightly on the skin surface. If it is placed too firmly, it stretches the skin, causing it to act like a diaphragm.

▪ The examiner should practice identifying normal sounds before trying to identify abnormal ones.