When observing a patient for symptoms of dehydration, the nurse should observe which assessment

WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.

1. Inspection

Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Assess for color, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system.

2. 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.

Types of palpation

Light palpation

Figure

• ▪ Use this technique to feel for surface abnormalities.
• ▪ Depress the skin ½ to ¾ inch (about 1 to 2 cm) with your finger pads, using the lightest touch possible.
• ▪ Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.

Deep palpation

Figure

• ▪ Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.
• ▪ Depress the skin 1½ to 2 inches (about 4 to 5 cm) with firm, deep pressure.
• ▪ Use one hand on top of the other to exert firmer pressure, if needed.

3. Percussion

Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient's body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas.

Types of percussion

Direct percussion

This technique reveals tenderness; it's commonly used to assess an adult's sinuses.

Figure

• ▪ Using one or two fingers, tap directly on the body part.
• ▪ Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort.

Indirect percussion

This technique elicits sounds that give clues to the makeup of the underlying tissue. Here's how to do it:

Figure

• ▪ Press the distal part of the middle finger of your nondominant hand firmly on the body part.
• ▪ Keep the rest of your hands off the body surface.
• ▪ Flex the wrist of your nondominant hand.
• ▪ Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient's skin.
• ▪ Listen to the sounds produced.

4. Auscultation

Auscultation involves listening for various lung, heart, and bowel sounds with a stethoscope.

Getting ready

• ▪ Provide a quiet environment.
• ▪ Make sure the area to be auscultated is exposed (a gown or bed linens can interfere with sounds.)
• ▪ Warm the stethoscope head in your hand.
• ▪ Close your eyes to help focus your attention.

How to auscultate

• ▪ Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient's skin, using enough pressure to leave a slight ring on the skin afterward.
• ▪ Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient's skin, just hard enough to form a seal. Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low-pitched sounds.
• ▪ Listen to and try to identify the characteristics of one sound at a time.

Source: Health Assessment made Incredibly Visual!, Lippincott Williams & Wilkins, 2007.