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Difficulty: MediumTechniques of Physical Assessment

A community health nurse is conducting a home visit for an 88-year-old client who was recently discharged from the hospital. The client's family reports that the client has developed new-onset urinary incontinence and a decreased appetite over the past 48 hours. The nurse is accompanied by a home health aide (UAP). Which of the following actions by the nurse indicate appropriate practice? Select all that apply.

  1. Assesses the client's hydration status by gently pinching the skin over the sternum to check for turgor.Answer
  2. B
    Instructs the home health aide to conduct the initial physical assessment of the client's skin integrity.
  3. C
    Reassures the family that the sudden development of urinary incontinence is an expected physiological change for this age.
  4. Uses the bell of the stethoscope to lightly auscultate the client's carotid arteries for the presence of bruits.Answer
  5. E
    Begins the abdominal examination by palpating the four quadrants for tenderness before auscultating for bowel sounds.

Answer

The appropriate actions are assessing skin turgor over the sternum and using the bell of the stethoscope to auscultate for carotid bruits.
Checking skin turgor over the sternum accounts for normal age-related skin elasticity loss on the extremities, and using the bell of the stethoscope correctly targets low-pitched vascular sounds like bruits. Both actions represent safe and accurate physical assessment techniques.

Step-by-Step Solution

1
Identify correct physical assessment techniques for older adults.
Skin turgor is assessed over the sternum or clavicle, and the bell of the stethoscope is used for low-pitched vascular sounds.
Age-related skin changes necessitate specific landmark choices, and stethoscope components are designed for specific sound frequencies.
2
Evaluate the proposed sequence for abdominal assessment.
The correct sequence is inspect, auscultate, percuss, and palpate.
Palpating before auscultating can artificially stimulate bowel motility, creating false assessment data.
3
Apply principles of safe delegation and recognize signs of geriatric pathology.
Initial assessments cannot be delegated, and sudden acute symptoms are pathological.
The RN is responsible for clinical judgment, and sudden incontinence in an older adult strongly suggests an acute issue like an infection, rather than normal aging.

Key Concept

Physical Assessment Techniques and Geriatric Considerations
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Topics

Techniques of Physical Assessment

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