assessment

• Normal findings for skin moisture include moisture in skin folds and the axillae, which varies with environmental temperature, humidity, body temperature, and activity
• Deviation from normal skin moisture can manifest as excessive moisture (e.g., in hyperthermia) or excessive dryness (e.g., dehydration)
• Normal skin inspection should reveal the absence of bruising or bleeding on the skin
• Deviation from normal skin vascularity can include ecchymosis (collection of blood in the subcutaneous tissues causing purplish discoloration) or petechiae (small hemorrhagic spots caused by capillary bleeding)
• Assessment findings for skin color can vary from light to deep brown, ruddy pink to light pink, and yellow overtones to olive
• Deviations from normal skin color can present as pallor (paleness of the skin), jaundice (yellow color of the skin), cyanosis (bluish or grayish skin), or erythema (redness of the skin)
• Normal skin color inspection should generally be uniform except in areas exposed to the sun, with lighter pigmentation in areas like palms, lips, and nail beds in dark-skinned individuals
• Skin is part of the integumentary structure assessed, along with nails, hair, and scalp, through observation and palpation
• Auscultation is a type of assessment requiring a stethoscope to listen to sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract
• Guidelines for auscultation include eliminating distracting noise, exposing the body part being auscultated, using the diaphragm for high-pitched sounds and the bell for low-pitched sounds, placing earpieces into the outer ear canal, and angling binaurals down toward the nose
• Techniques of indirect percussion involve placing the middle finger of the nondominant hand on the body part being percussed, using the pad of the middle finger of the other hand to strike the middle finger, delivering two quick taps, and listening carefully to the tone
• Auscultation is a type of assessment requiring a stethoscope to listen to sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract
• Techniques of Indirect Percussion:

  • Place the middle finger of your nondominant hand on the body part to be percussed
  • Keep other fingers off the body part
  • Use the pad of your middle finger of the other hand to strike the middle finger of your nondominant hand
  • Withdraw your finger immediately to avoid damping the tone
  • Deliver two quick taps and listen carefully to the tone
  • Use quick, sharp taps by quickly flexing your wrist, not your forearm
• Percussion: Indirect or Mediate is the most commonly used method, tapping produces a sound or tone that varies with the density of underlying structures
• Percussion: Blunt is used to detect tenderness over organs by placing one hand flat on the surface and using the fist of the other hand to strike the back of the hand flat on the body surface
• Percussion Purposes:

  • Eliciting pain
  • Determining location, size, and shape
  • Determining density
  • Detecting abnormal masses
  • Eliciting reflexes
• Bimanual Palpation involves using two hands, placing one on each side of the body part being palpated
• Three different parts of the hand are used during palpation:

  • Fingerpads
  • Ulnar/palmar surface
  • Dorsal surface
• Order of Physical Assessment: Cephalocaudal (head to toe) - least invasive to most invasive: Inspection, Palpation, Percussion, Auscultation (except for abdomen)
• General considerations for examining older adults:

  • Some positions may be difficult due to decreased joint mobility and flexibility
  • Allow rest periods if needed
  • Older clients may process information at a slower rate, so explain procedures clearly and slowly