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Difficulty: HardTechniques of Physical Assessment

A clinical nurse educator is observing a newly licensed nurse conduct a comprehensive physical evaluation on an older adult client admitted with an exacerbation of chronic obstructive pulmonary disease (COPD) and localized abdominal pain. Which actions by the newly licensed nurse demonstrate correct assessment technique? Select all that apply.

  1. Applying the bell of the stethoscope lightly against the skin to auscultate the carotid arteries for bruits.Answer
  2. Auscultating all four quadrants of the abdomen immediately following visual inspection of the abdominal contour.Answer
  3. Using the diaphragm of the stethoscope to auscultate posterior breath sounds in a side-to-side comparison pattern.Answer
  4. D
    Delegating the initial assessment of the client's capillary refill and pedal pulse amplitude to the unlicensed assistive personnel (UAP).
  5. E
    Documenting the presence of scattered basilar crackles as an expected, normal physiological change in the older adult client.
  6. F
    Performing deep palpation of the abdominal quadrants to assess for organomegaly before proceeding to light palpation.

Answer

The correct actions are applying the bell of the stethoscope lightly for carotid bruits, auscultating the abdomen immediately after inspection, and using the diaphragm of the stethoscope for side-to-side posterior lung auscultation.
Applying the bell of the stethoscope lightly is the correct technique for detecting low-pitched vascular sounds like bruits. In abdominal assessments, the proper sequence is inspection followed immediately by auscultation, because percussion and palpation can artificially stimulate bowel motility. For lung assessments, the diaphragm is firmly applied to listen to high-pitched breath sounds, moving in a side-to-side ladder pattern to compare symmetry between the lung fields.

Step-by-Step Solution

1
Evaluate the appropriate use of stethoscope components.
The bell is correctly used lightly for low-pitched vascular sounds (bruits), and the diaphragm is correctly used firmly for high-pitched sounds (breath sounds).
Applying the bell with too much pressure stretches the skin, effectively turning it into a diaphragm and masking low-pitched sounds.
2
Analyze the procedural sequence of the physical assessment.
Abdominal assessment requires auscultation immediately after inspection. Light palpation must precede deep palpation.
Percussion or palpation of the abdomen prior to auscultation can increase peristalsis, providing a false interpretation of bowel sounds. Deep palpation performed first can cause muscle guarding.
3
Assess delegation and clinical judgment principles regarding findings.
Assessment cannot be delegated to a UAP, and adventitious lung sounds (crackles) indicate pathology.
The registered nurse must independently perform initial physical assessments to establish a baseline and must accurately differentiate between expected age-related changes and disease processes.

Key Concept

Comprehensive Physical Assessment Techniques and Principles
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Topics

Techniques of Physical Assessment

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