INTRODUCTION TO PHYSICAL EXAMINATION

The health history described in the preceding discussions provides subjective data for health
assessment, the individual’s own perception of the health state. This topic presents objective
data, the signs perceived by the examiner through the physical examination.

The physical examination requires that the examiner develop technical skills and a knowledge
base. The technical skills are the tools to gather data. You will relate those data to your
knowledge base and to your previous experience. A sturdy knowledge base enables you to
look for, rather than merely look at. Consider a statement by German poet Goethe, “We see
only what we know.” To recognize a significant finding, you need to know what to look for.

You will use your senses – sight, smell, touch and hearing – to gather data during the physical
examination. The skills requisite for the physical examination are inspection, palpation,
percussion and auscultation. The skills are performed one at a time.

A. Preparation Guidelines

 Preparing the Physical Setting

- Comfortable, warm temperature – Provide a warm blanket of the room temperature

cannot be adjusted.

- Provide area free of interruptions from others – Close the door or pull the curtains if
possible, your time with the individual should be secure from interruptions from
other health care personnel.

- Quiet area free of distractions – Stop any distracting noises, such as radio,
television or other noisy equipment or people talking, that could make it difficult to
hear body sounds.

- Adequate lighting- Lighting with natural daylight is best (sunlight- when available).
However, good overhead lighting is sufficient. A portable lamp is helpful for
illuminating the skin or for viewing shadows or contours.

- Firm examination table or bed at a height that prevents stooping- Position the
examination table so that both sides of the person are easily accessible. The table
should be at a height at which you can stand without stooping and should be
equipped to raise the person’s head up to 45 degrees. A roll-up stool is used for the
sections of the examination for which you must be sitting.

- A bedside table/ tray to hold the equipment needed for the examination . – For the
examiner to lay out all the equipment.
Equipment Needed for Physical Examinations

During the examination, you do not want to be searching for equipment or have to leave the
room to find an item. Have all your equipment at easy reach and laid out in an organized
fashion. The following items are usually needed for a screening physical examination.

Equipment Needed Purpose

For All Examinations
Gloves To protect examiner in any part of the examination when
the examiner may have contact with blood, body fluids,
secretions, excretions, and contaminated items or when
disease-causing agents could be transmitted to or from
the client
For Vital Signs
Sphygmomanometer To measure diastolic and systolic blood pressure
Stethoscope To auscultate blood sound when measuring blood
pressure
Thermometer (oral, rectal, To measure body temperature
tympanic)
Watch with second hand To time heart rate, pulse rate
For Anthropometric Measurements
Skinfold calipers To measure skinfold thickness of subcutaneous tissue
Flexible tape measure To measure mid-arm circumference
Platform scale with height To measure height and weight
attachment
For Skin, Hair and Nail Examination
Ruler with centimeter markings To measure size of skin lesions
Magnifying glass To enlarge visibility of lesions
Wood’s light To test for fungus

*** A light filter that transmits ultraviolet rays, useful in

identifying fungi that are causative agent in certain skin
and scalp diseases
For Head and Neck Examination
Small cup of water To help client swallow during examination of the thyroid
gland

For Eye Examination

Penlight To test papillary constriction
Snellen Chart To test distant vision

***A device employed for testing for acuity of distance

vision; consists of block letters of varying sizes arranged
on wall charts. A person’s visual acuity is assessed
having him to stand 20 feet away from the chart.
Ophthalmoscope To view the red reflex and to examine the retina of the
eye

*** The ophthalmoscope illuminates the internal eye

structures. Its system of lenses and mirrors enables you
to look through the pupil at the fundus (background) of the
eye.
Cover Card To test for strabismus
Newspaper or Rosenbaum To test near vision
Pocket Screener
 For Ear Examination
Otoscope To view the ear canal and tympanic membrane

***The otoscope funnels light into the ear canal and onto
the tympanic membrane. The base serves as both the
power source by holding a battery and as the handle. To
attach the head, press it down onto the male adaptor end
of the base and turn clockwise until you feel a stop. To
turn the light on, press the red button rheostat down and
clockwise. Always turn it off after use to increase the life
of the bulb and battery. Five different sized specula are
available to attach to the head. (The short broad
speculum is for viewing the nares.) Choose the largest
one that will fit comfortably into the person’s ear canal.
Tuning Fork To test for bone and air conduction of sound
For Mouth, Nose, Throat and Sinus Examination
Penlight To provide light to view the mouth and throat and to
transilluminate the sinuses
Tongue depressor To depress tongue to view the throat, check looseness of
teeth, view cheeks and check strength of tongue
Piece of small gauze To grasp tongue to examine mouth
Otoscope with wide tip To view the internal nose
attachment
For Thoracic and Lung Examination
Stethoscope (diaphragm) To auscultate breath sounds
Marking pencil and centimeter To measure diaphragmatic excursion
ruler
For Heart and Neck Vessel Examination
Stethoscope To ausculatate heart sounds
(bell and diaphragm)
Two centimeter rulers To measure jugular venous pressure
For Abdominal Examination
Stethoscope To detect bowel sounds
Marking pencil and tape To mark area of percussion of organs to measure size
measure with centimeter
markings
Two small pillows To place under knees and head to promote relaxation of
abdomen
For Female Genitalia Examination
Vaginal speculum and lubricant To inspect cervix through dilatation of the vaginal canal
Slides or specimen container, To obtain endocervical swab and cervical scrape and
bifid spatula, cotton tipped vaginal pool sample
applicator
For Anus, Rectum, Prostate Examination
Lubricating jelly To promote comfort for client
Specimen container To test for occult blood
For Peripheral Vascular Examination
Stethoscope and To auscultate vascular sounds and measure blood
sphygmomanometer pressure
Flexible tape measure To measure size of extremities for edema
Cotton ball and paper clip To detect light, blunt and sharp touch
Tuning fork To detect vibratory sensation
Doppler ultrasound probe blood To detect pressure and weak pulses not easily heard with
a stethoscope
For Musculoskeletal Examination
Tape measure To measure size of extremities
Goniometer To measure degree of flexion and extension of joints
 For Neurologic Examination
Tuning Fork To test for vibratory sensation
Cotton wisp, paper clip To test for light, sharp, and dull touch and two-point
discrimination
Soap, coffee To test for smelling perception
Salt, sugar, lemon, pickle juice To test for taste perception
Tongue depressor To test for rise of uvula and gag reflex
Reflex hammer To test deep tendon reflexes
Coin or key To test for stereognosis (ability to recognize objects by
touch)

Preparing Oneself

Consider your emotional state and that of the person being examined. It is helpful to assess
your own feelings and anxieties before examining the client. Most patients view a physical
examination with at least some anxiety. They feel vulnerable, physically exposed,
apprehensive about possible pain and uneasy over what the examiner may find. At the same
time they often appreciate detailed concern for their problems and may enjoy the attention they
receive.

Mindful of such feelings, the examiner is thorough without wasting time, systematic without
being rigid, gentle yet not afraid to cause discomfort if this should be required. By listening,
looking, touch or smell, you examine each region of the body and at the same tie senses the
whole patient, notes the wince or worried glance, and calms, explains and reassures.

If anxiety can be reduced, the person will feel more comfortable and the data gathered will be
more closely describe the person’s natural state. Anxiety can be reduced by an examiner who
is confident and self-assured, as well as considerate and unhurried.

Another important aspect of preparing oneself for the physical examination is preventing the
transmission of infectious agents. Standard precautions are intended for use for all patients
regardless of their risk or presumed infection status. General principles to keep in mind while
performing a physical assessment include the following:

Standard Precautions

Hand Hygiene
o Wash hands before beginning the examination, immediately after accidental direct
contact with blood or other body fluids (gloves should be worn if there is a chance of
direct contact with blood or other body fluids) and after completing the physical
examination.
o It can be done with non-antimicrobial soap and water, antiseptic soap or an antiseptic
hand rub or by performing surgical hand antisepsis.

Gloves
o Wear gloves when touching blood, body fluids, secretions, excretions and contaminated
items.
o Put on clean gloves just before touching mucous membranes and non-intact skin.
o Change gloves between tasks and procedures on the same patient after contact with
material that may contain high concentration of microorganisms.
o Remove gloves promptly after use, before touching non-contaminated items and
environmental surfaces and before going to another patient.
o Wash hands immediately to avoid transfer of microorganisms to other patients or
environments.

Mask, Eye Protection, Face Shield

o Wear a mask and eye protection or a face shield to protect mucous membranes of the
eyes, nose and mouth during procedures and patient care activities that are likely to
generate splashes or sprays of blood, body fluids, secretions and excretions.
Gown
o Wear a gown to protect skin and to prevent soiling of clothing during procedures and
patient care activities that are likely to generate splashes or sprays of blood, body fluids,
secretions and excretions.
o Select a gown that is appropriate for the activity and amount of fluid likely to be
encountered.
o Remove a soiled gown as promptly as possible and wash hands to avoid transfer of
microorganisms to other patients or environments.

Patient Care Equipment

o Handle used patient care equipment soiled with blood, body fluids, secretions and
excretions in a manner that prevents skin and mucous membrane exposure,
contamination of clothing and transfer of microorganisms to other patients or
environments.
o Ensure that reusable equipment is not used for the care of another patient until it has
been cleaned and reprocessed appropriately.
o Ensure that single-use items are discarded properly.

Environmental Control
o Ensure that the hospital has adequate procedures for the routine care, cleaning and
disinfection of environmental surfaces, beds, bedrails, bedside equipment and other
frequently touched surfaces, and ensure that these procedures are being followed.

Linen
o Handle, transport and process used linen soiled with blood, body fluids, secretions and
excretions in a manner that prevents skin and mucous membrane exposure,
contamination of clothing and transfer of microorganisms to other patients or
environments.

Occupational Health and Blood-borne Pathogens

o Take care to prevent injuries when using needles, scalpels and other sharp instruments
or devices, when handling sharp instruments after procedures; when cleaning used
instruments; and when disposing of used needles.
o Never recap used needles or otherwise manipulate them using both hands or use any
other technique that involves directing the point of a needle toward any part of the body;
rather, use either a one-handed scoop technique or a mechanical device designed for
holding the needle sheath.
o Do not remove used needles from disposable syringes by hand; and do not bend break
or otherwise manipulate used needles by hand.

Patient Placement
o Place a patient who contaminates the environment and who does not assist in
maintaining appropriate hygiene or environmental control in a private room.

Approaching and Preparing the Client

The nurse-client relationship must be established during the client interview before the physical
examination takes place. This is important because it alleviate any tension or anxiety that the
client is experiencing. At the end of the interview, explain to the client that the physical
assessment will follow and describe what the examination will involve. For example you might
say to a client, “Mr. Smith base don the information you have given me, I believe that a
complete physical examination should be performed so I can better assess your health status.

Respect the client’s desires and requests related to the physical examination. Some client
requests may be simple such as asking to have a family member or friend present during the
examination. Another request may involve not wanting certain parts of the examination (ex.
breast, genitalia) to be performed. In this situation, you should explain to the client the
importance of examination and the risk of missing important information if any part of the
examination is omitted. Ultimately, however, whether or not to have the examination is the
client’s decision. Some health care providers ask the client to sign a consent form before a
physical examination, especially in situations where a vaginal or rectal examination will be
performed.

Approach the client from the right hand side of the examination table or bed because most
examination techniques are performed with the examiners right hand (even if the examiner is
left-handed. You may ask the client to change positions frequently, depending on the part of
the examination being performed. Prepare the client of these changes at the beginning of the
examination that these position changes are necessary to ensure a thorough examination f
each body part and system. Many clients need assistance getting into require position.

POSITIONING THE CLIENT

Sitting Position
o The client should sit upright on the side of the examination table. In the home or office
setting, the client can sit on the edge of chair or bed.
o For evaluating the skin, head and neck; eyes, ears, nose, mouth and throat; back;
posterior thorax and lungs; anterior thorax and lungs; breast; axillae; heart; peripheral
vasculature; musculoskeletal; neurological.
o Permits full expansion of the lungs and it allows the examiner to assess symmetry of
upper body parts.
o Some clients may be too weak to sit up for the entire examination. They may need to lie
down (supine position) and rest throughout the examination. Other clients may be unable
to tolerate the position for any length of time. An alternative position is for the client to lie
down with his or her head elevated.

Supine Position / Horizontal Recumbent

o Ask the client to lie down with the legs together on the examination table (or bed in a
home setting). A small pillow may be placed under the head to promote comfort.
o If a client has trouble breathing, the head of the bed may need to be raised.
o This position allows abdominal muscles to relax and provides easy access to peripheral
pulse sites.
o For evaluating the head, neck, chest, breasts, axillae, abdomen, heart, lungs and all
extremities.

Dorsal Recumbent Position

o The client lies down on the examination table or bed with the knees bent, the legs
separated and the feet flat on the table or bed.
o May be more comfortable than the supine position for clients with pain on the back or
abdomen.
o For evaluating the head, neck, chest, axillae, lungs, heart, extremities, breasts and
peripheral pulses; female genitalia.
o The abdomen should not be assessed because the abdominal muscles are contracted in
this position.

Sims’ Position
o The client lies on his or her right or left side with the lower arm placed behind the body
and the upper arm flexed at the shoulder and elbow. The lower leg is slightly flexed at the
knee while the upper leg is flexed at a sharper angle and pulled forward.
o For rectal and vaginal area assessment.
o The client may need some assistance getting into this position. Clients with joint problems
and elderly clients may have some difficulty assuming and maintaining this position.

Standing Position
o The client stands still in a normal, comfortable, resting posture.
o For assessment of posture, balance and gait; and male genitalia.

Prone Position
 o The client lies down on his or her abdomen with the head to the side.
o For hip joint and back assessment.
o Clients with cardiac and respiratory problems cannot tolerate this position.
Knee-Chest Position
o The client kneels on the examination table with the weight of the body supported by the
chest and knees. A 90 degree angle should exist between the body and the hips. The
arms are placed above the head, with the head turned to one side.
o A small pillow may be used to provide comfort.
o For examining rectum and prostate.
o This position ay be embarrassing and uncomfortable for the client, and, therefore the
client should be kept in the position for as limited time as possible.
o Elderly clients and clients with respiratory and cardiac problems may be unable to
tolerate this position.

Lithotomy Position
o The client lies on his or her back with the hips on the edge of the examination table and
the feet supported by stirrups.
o For examining female genitalia, reproductive tracts, and the rectum.
o The client may require assistance getting into this position.
o It is an exposed position, the client may feel embarrassed.
o Elderly client may not be able to assume this position for very long or at all.
o It is best to keep the client well draped during the examination and to perform the
examination as quickly as possible.

Fowler’s Position
o Semi-sitting position, a bed position in which the head and the trunk are raised 15-90
degrees. Low or semi-fowler’s: 15-45 degrees, high fowler’s: 90 degrees.
o For evaluating the skin, head and neck; eyes, ears, nose, mouth and throat; thorax and
lungs; heart and peripheral vascular; musculoskeletal; neurological.

Side Lying Position/ Lateral

o The client lies on one side of the body. Flexing the top hip and knee and placing this leg
in front of the body creates a wider, triangular base of support and achieve greater
stability.
o Persons who have sensory or motor deficits on one side of the body usually find that lying
on the uninvolved side is more comfortable
o For evaluating skin, thorax and lungs

B. Physical Examination Guidelines

- Always dress in a clean, professional manner; make sure your name, pin or workplace
identification is visible.

- Remove all bracelet, necklaces, or earrings that can interfere with the physical
assessment.

- Be sure that your fingernails are short and your hands are warm for maximum patient
comfort.

- Be sure your hair will not fall forward and obstruct your vision or touch the patient.

- Arrange for a well-lit, warm and private room.

- Ensure that all the necessary equipment is ready for use and within reach.

- Introduce yourself to the patient: “My name is Marie Jones. I am the nurse who is caring
for you today. I need to assess how your lungs are today.”
 - Clarify with the patient how he or she wishes to be addressed: Miss Jones, Marie, etc.

- Explain what you plan to do and how long it will take; allow the patient to ask questions.

- Instruct the patient to undress; the underpants can be left on until the end of the
assessment or until it is time to perform the genital examination; provide a gown and
drape for the patient and explain how to use them.

- Allow the patient to undress privately; inform the patient when you will return to start the
assessment.

- Have the patient void prior to the assessment.

- Wash your hands in front of the patient to show your concern for cleanliness.

- Observe standard precautions as indicated.

- Ensure that the patient is accessible from both sides of the examination bed or table.

- If a bed is used, raise the height so that you do not have to bend over to perform the
assessment.

- Position the patient as dictated by the body system being assessed.

- Enlist the patient’s cooperation by explaining what you are about to do, where it will be
done, and how it may feel.

- Warm all instruments prior to their use (use your hands or warm water).

- Examine the unaffected body part or side first if a patient’s complain is unilateral.

- Explain to the patient why you may be spending a long time performing one particular
skill: “Listening to the heart requires concentration and time.”

- If a patient complains of fatigue, continue the assessment later (if possible).

- Avoid making crude or negative remarks; be cognizant of your facial expression when
dealing with malodorous and dirty patients or with disturbing findings (infected wounds,
disfigurement, etc).

- Conduct the assessment in a systematic fashion every time. (This decreases the
likelihood of forgetting to perform a particular assessment.)

- Thank the patient when the physical assessment is concluded; inform the patient what
will happen next.

- Document assessment findings in the appropriate section of the patient record.

C. Techniques in Physical Assessment

Physical assessment findings, or objective data, are obtained through the use of four specific
diagnostic techniques: inspection, Palpation, percussion and auscultation. Usually, these
assessment techniques are performed in this order when the body systems are assessed. An
exception is in the assessment of the abdomen, when auscultation is performed prior to
percussion and palpation as the latter two can alter bowel sounds. These four techniques
validate information provided by a patient in the health history, or they can verify suspected
diagnosis.
Usually, the easiest assessment skills to master are inspection and basic auscultation.
Percussion and palpation may take more time and practice to perfect.

INSPECTION

Inspection is concentrated watching. It is close, careful scrutiny, first of the individual as a

whole and then of each body system. It involves using the senses of vision, smell and hearing
to observe and detect any normal or abnormal findings. Inspection is an ongoing process,
used from the moment that you meet the client and all throughout the entire physical
assessment and patient encounter.

Inspection precedes palpation, percussion and auscultation because the latter techniques can
potentially alter the appearance of what is being inspected. Although most of the inspection
involves the use of the senses only, a few body systems require the use of special equipment
(ex. ophthalmoscope for eye assessment).

Inspection using vision:

 Use of sight can reveal many facts about a patient. Visual inspection of a patient’s
respiratory status, for example, might reveal a rate of 38 breaths per minute and a
cyanotic nailbeds. In this case, the patient is tachypneic and possibly hypoic and would
need a more thorough respiratory assessment.

Inspection using smell:

 The examiner’s olfactory sense provides vital information about a patient’s health
status. The patient may have a fruity breath odor characteristic of diabetic
ketoacidosis.

Inspection Guidelines:
- Comfortable temperature room – A too cold or too hot room may alter the
normal behavior of the client and the appearance of the client’s skin.
- Use good lighting (sunlight) – Fluorescent lights can alter the true color of the
skin; abnormalities may be overlooked with dim lights.
- Look and observe before touching – Touch can alter appearance and distract
you from complete, focused observation.
- Completely expose the body part you are inspecting while draping the rest of
the client as appropriate.
- Note the following characteristics while inspecting the client: color, pattern,
size, location, consistency, symmetry, movement, behaviors, odors and sound.
- Compare the appearance of symmetric body parts – ex. eyes, ears, arms,
hands ; or both sides of any individual body part

PALPATION

Palpation is the act of touching a patient in a therapeutic manner to elicit specific information.

Prior to palpating a patient, some basic principles need to be observed:

o You should have short fingernails to avoid hurting the patient as well as yourself.
o Warm hands prior to placing them on the patient; cold hands can make a patient’s
muscle tense, which can distort assessment findings.
o Encourage the patient to continue breathe normally throughout the palpation.
o If pain is experienced during the palpation, discontinue immediately.
o Inform the patient where, when and how the touch will occur, especially when the patient
cannot see what you are doing. In this way, the patient is aware of what to expect in the
assessment process.

Palpation follows and often confirms points you noted during inspection. It applies your sense
of touch to assess these factors: texture, temperature, moisture, mobility, consistency, strength
of pulses, organ location and size, shape, degree of tenderness, as well as any swelling,
vibration, rigidity or spasticity, crepitation, presence of lumps of masses.

Different parts of the hands are best suited for assessing different factors:
o Fingerpads – best for fine tactile discrimination, such as skin texture,
swelling, pulsation and determining presence of lumps.
o The dorsa (backs) of the hands and fingers – best for determining
temperature because the skin here is thinner than on the palms.
o Base of fingers (metacarpophalengeal joints) or ulnar surface of the
hand – best for vibration
*** A grasping action of the fingers and thumb – to detect the position, shape and
consistency of an organ or mass.

Types of Palpation:
1. Light Papation
- Done more frequently than deep palpation and is always performed before
deep palpation.
- Superficial, delicate and gentle palpation.
- The fingerpads are used to gian inforation on the patient’s skin surface to a
depth of approximately 1 cm below the surface.
- Reveal information on skin texture and moisture; overt, large or superficial
masses; fluid, muscle guarding and superficial tenderness; for pulses and temperature.

To perform light palpation:

a. Keeping your fingers of your dominant hand together, place the finger pads
lightly on the skin over the area that is to be palpated. The hand and forearm will be on
a plane parallel to the area being assessed.
b. Depress the skin in 1 cm in light, gentle circular motions.
c. Keeping the finger pads on the skin, let the depressed body surface rebound
to its natural position.
d. If the patient is ticklish, lift the hand off the skin before moving it to another
area.
e. Using a systematic approach, move the fingers to an adjacent area and
continue the process.
f. Continue to move the finger pads until the entire area being examined has
been palpated.
g. If the patient has complained of tenderness in any area, palpate this area last.

2. Moderate Palpation
- Depress the skin surface 1 to 2 cm (0.5 to 0.75 inch) with your dominant hand
and use a circular motion to feel for easily palpable body organs and masses.
- Note the size, consistency and mobility of structures you palpate.

3. Deep Palpation
- Place dominant hand on the skin surface and non-dominant hand on top of
the dominant hand to apply pressure. This should result in a surface depression between
2.5 to 5 cm (1 to 2 inches).
- Allows to feel very deep organs or structures that are covered by thick
muscle.
- Technique most often used for abdominal, male and female reproductive
assessments. Variations in this technique are single-handed and bimanual palpation.

*Bimanual Palpation

Use two hands placing one on each side of the body part (ex. uterus, breast, spleen) being
palpated. Use one hand to apply pressure and the other hand to feel the structure.
Note the size, shape, consistency and mobility of structures you palpate.

PERCUSSION
Percussion is the technique of striking one object against another to cause vibrations that
produce sound. These sound waves or vibrations enable the examiner to asses underlying
structures. Percussion has several assessment uses:
- Eliciting pain – Helps to detect inflamed underlying structures. If an inflamed
area is percussed, the client’s response may indicate or the client will report that the area
feels tender, sore or painful.
- Determining location, size and shape. – Percussion note changes between
borders of an organ and its neighboring organ can elicit information about location, size
and shape.
- Determining density. – Helps to determine whether an underlying structure is
filled with air or fluid or is a solid structure.
- Determining abnormal masses. – Can detect superficial abnormal structures
or masses. Percussion vibrations penetrate approximately 5cm deep. Deep masses do
not produce any change in the normal percussion vibrations.
- Eliciting reflexes – Deep tendon reflexes are elicited using the percussion
hammer.

How to perform percussion:

The Stationary Hand / Pleximeter

- Hyperextend the middle finger of your non-dominant hand and place its distal
portion, the phalanx and interphalengeal joint, firmly against the person’s skin. Avoid the
person’s ribs and scapulae – percussing over a bone yields no data because it always
sounds “dull”.
- Lift the rest of the stationary hand up off the person’s skin. Otherwise the
resting hand will dampen off the produced vibration, just as a drummer uses the hand to
halt a drum roll.

The Striking Hand / Plexor

- Use the middle finger of your dominant hand, hold your forearm close to the
ski surface, with your upper arm and shoulder steady.
- Scan your muscles to make sure they are steady but not rigid. The action is
all in the wrist, and it must be relaxed.
- Spread your fingers, swish your wrist and bounce your middle finger off the
stationary one.
- Aim for just behind the nail bed or at distal interphalengeal joint; the goal is to
hit the portion of the finger that is pushing the hardest into the skin surface.
- Flex the striking finger so that its tip, not the finger pad, makes contact. It hits
directly at right angles to the stationary finger.
- Percuss two ties in this location using even blows. Lift the striking finger off
quickly, arresting finger damps off vibrations. Then move to a new body location and
repeat, keeping your technique even.

***The force of the blow determines the loudness of the note. You do not need a very loud
sound; use just enough force to achieve a clear note. The thickness of the person’s body wall
will be a factor. You will need stronger percussion stroke for persons with obese or very
muscular body walls.

Types of percussion
1. Direct or Immediate – direct tapping of a body part with one or two fingers to elicit
possible tenderness. Ex. tenderness over the sinuses
2. Indirect or Mediate – commonly used method; tapping produces a sound or tone that
varies with the density of underlying structures.
3. Blunt – used to detect tenderness over organ (ex. kidneys) by placing one hand flat
on the body surface and using the fist of the other hand to strike the back of the hand flat
on the body surface.

Production of Sound
Each of the five percussion notes is differentiated by the following components:
1. Amplitude (or intensity)
- a loud or soft sound; the louder the sound, the greater the amplitude
- loudness depends on the force of the blow and the structure’s ability to
vibrate.
2. Pitch (or frequency)
- the number of vibrations per second, written as cps or cycles per second
- more rapid vibrations produce a high-pitched tone, slower vibrations yield a
low-pitched tone.
3. Quality (or timbre)
- a subjective difference due to a sound’s distinctive overtones. A pure tone is a
sound of one frequency
- vibrations within a sound wave produce overtones, overtones allows you to
distinguish a C on a piano from a C on a violin.
4. Duration
- the length of time the note lingers

Sound Intensity Pitch Duration Quality Location

tympany loud high mod. drum-like stomach
resonance mod. to low long hollow normal lung
loud
hyperresonance very loud very low longer than booming emphyse-ma
resonance
dullness soft to mod. high mod. thudlike liver
flatness soft high short flat muscle

AUSCULTATION

Auscultation is the act of active listening to body organs to gather information on a patient’s
clinical status. Auscultation includes listening to sounds that are voluntarily (ex. exasperated
sigh) and involuntarily (ex. heart sound) produced by the body. The sounds detected using
auscultation are classified according to the intensity, pitch, duration and quality of the sound.

Types of Auscultation

1. Direct or Immediate
- process of listening with the unaided ear
- this can include listening to the patient from some distance away or placing the ear
directly on the patient’s skin surface.
- Ex. wheezing that is audible to the unassisted ear in a person having a severe
asthmatic attack

2. Indirect or Mediate
- process of listening with some amplification or mechanical device
- The nurse most often performs mediate auscultation with an acoustic stethoscope,
which does not amplify the body sounds, but instead blocks out environmental
sounds.
- Amplification of body sounds can also be achieved with the use of a Doppler
ultrasonic stethoscope.

The following guidelines should be followed during auscultation:

 Eliminate distracting or competing noises from the environment (radio, TV etc)
 Expose the body part you are going to auscultate. Do not auscultate through the
client’s clothing or gown. Rubbing against the clothing obscures the body sound.
 Use the diaphragm of the stethoscope to listen for high-pitched sound such as
normal heart sounds, breath sounds and bowel sounds, and press the diaphragm firmly
on the body part being auscultated.
 Use the bell of the stethoscope to listen for low-pitched sounds such as abnormal
heart sounds and bruits (abnormal loud, blowing or murmuring sounds heard during
auscultation). Hold the bell tightly on the body part being auscultated.