Physical Assessment Terms

Using the right terms when completing a physical assessment helps everyone understand what you found. Working with the correct terminology also gives other professionals a guideline to follow if there are any changes. For instance, if you heard a normal heartbeat, and the next person heard muffled heart sounds, you can quickly act on the change.

Techniques

• One of the techniques you will often use in a physical assessment is auscultation. This is using your stethoscope to hear the various sounds inside the body. You will also palpate, or gently press your fingertips on, parts of the body such as the abdomen. Percussion is gentle tapping that is typically performed over the lungs. Your patient could be in Fowler's position, on his back with the head of the bed raised about 18 inches. Dorsal recumbant position is laying on the back, with legs bent and separated and flat feet.

What You Hear

• Each area of the body has a unique sound.

  When you auscultate, you will hear a variety of sounds. Each area of the body creates a sound that is typical for that area. Listening to the lungs, you will hear normal breath sounds described as vesicular, or soft and swishy; bronchial, or loud and harsh; or bronchovesicular, which is a combination of the two. You can also hear rales, a crackling sound; wheezes, a high-pitched sound; or rhonchi, which are rattling noises. The bowels create a light tinkling sound. The bowel sounds are hyperactive, hypoactive or absent. As you listen to the heart, you will hear at least two sounds, and they could be clear or muffled.

What You See

• When you visually inspect your patient, you will notice any hematomas, or bruises, as well as any lacerations or cuts. Ecchymosis is a bruised area. You will check skin turgor, or how quickly pinched skin returns to normal. You will look for any pulsating masses, or lumps. You will also notice any edema, or swelling, in any part of the body.

What You Feel

• As you palpate, you will notice any fasciculations, or muscle twitches, that occur. Variations in muscle tone, such as atrophy, decreased muscle size, hyper-tonicity or spasticity, can be felt with the fingers. As you palpate the abdomen, you may feel areas of firmness, muscle resistance or pulsations that were not visible.