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Difficulty: MediumTechniques of Physical Assessment

A clinical charge nurse is evaluating a new graduate nurse who is performing physical assessments on a medical-surgical unit. Which of the following assessment techniques by the new graduate nurse demonstrate correct practice? Select all that apply.

  1. Using the bell of the stethoscope lightly against the skin to auscultate for low-pitched extra heart sounds.Answer
  2. Utilizing the dorsal surface of the hand to accurately assess a client's bilateral lower extremity skin temperature.Answer
  3. C
    Auscultating for bowel sounds after performing deep palpation on a client reporting abdominal cramping.
  4. D
    Delegating the initial physical assessment of a client newly admitted from the emergency department to an unlicensed assistive personnel (UAP).

Answer

The correct techniques are using the bell of the stethoscope lightly against the skin to auscultate for low-pitched extra heart sounds, and utilizing the dorsal surface of the hand to assess skin temperature.
Correct physical assessment relies on applying the right tools and techniques for the targeted body system. The bell of the stethoscope is specifically designed to transmit low-pitched sounds (such as extra heart sounds and bruits) and must be placed lightly against the skin. Additionally, the dorsal (back) surface of the hand is highly sensitive to temperature changes, making it the proper anatomical surface for assessing a client's skin temperature.

Step-by-Step Solution

1
Evaluate the instrument use principle for auscultation.
The bell of the stethoscope is appropriate for low-pitched sounds (like S3/S4 or bruits) when applied lightly. The diaphragm is used for high-pitched sounds (like breath or normal heart sounds) when applied firmly.
Correct stethoscope usage ensures accurate detection of specific normal and abnormal physiological sounds.
2
Analyze the palpation technique for skin temperature.
The dorsal surface (back) of the hand is the most sensitive to temperature variations and should be used to assess skin warmth.
The skin on the back of the hand is thinner, making it ideal for detecting subtle temperature differences compared to the thicker palmar surface.
3
Review the abdominal assessment sequence.
The correct sequence is inspect, auscultate, percuss, and palpate. Palpating first is incorrect because it can artificially stimulate bowel motility.
Maintaining the correct sequence prevents the mechanical alteration of bowel sounds, ensuring baseline findings are accurate.
4
Determine the appropriateness of delegating the initial assessment.
Initial physical assessments for newly admitted clients require clinical judgment and cannot be safely delegated to a UAP.
Safe delegation principles mandate that the RN must retain tasks involving initial assessment, care planning, and evaluation.

Key Concept

Correct execution of physical assessment requires understanding specific instrument principles (e.g., stethoscope bell vs. diaphragm), proper anatomical use (e.g., dorsal hand for temperature), maintaining appropriate assessment sequences, and ensuring tasks requiring clinical judgment are not improperly delegated.
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Topics

Techniques of Physical Assessment

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