What physical examination techniques should the nurse use for inspection?

    Four primary techniques are used in the physical examination: inspection, percussion, and auscultation. 

1. Inspection - it is the  visual examination, that is, assessing by using the sense of sight. It should be deliberate, purposeful, and systematic. The nurse inspects with the naked eye and with a lighted instrument such as an otoscope.

2. Palpation - it is the examination of the body by using the sense of   touch. The pads of the fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination. Palpation is used to    determine: texture; temperature; vibration; position, size, consistency, and mobility of organs or masses; distension; pulsation; and the presence of pain upon pressure.

          Light Palpation - it should always percede deep palpation because heavy pressure on the fingertips can dull the sense of touch. For light palpation, the nurse extends the dominant hand's fingers parallel to the skin surface and presses gently while moving the hand in a circle. With the light palpation, the skin is slightly depressed. If it is necessary to determine the details of a mass, the nurse presses lightly several times rather than holding the pressure.

            Deep Palpation - it is done with two hands (bimanually) or one hand. In deep bimanual palpation, the nurse extends the dominant hand as for light palpation, then places the finger pads of the nondominant hand on the dorsal surface of the distal interphalangeal joint of the middle three fingers of the dominant hand. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations. For deep palpation using one hand, the finger pads of the dominant hand press over the area to be palpated. Often the other hand is used to support a mass or organ from below.

        To test skin temperature, it is best to use the dorsum or back of the hand and fingers, where the examiner's skin is thinnest. To test for vibration, the nurse should use the palmar surface of the hand.

3. Percussion - it is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt.

       Direct percussion - the nurse strikes the area to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger. The strikes are rapid, and the movement is from the wrist. This technique is not generally used to percuss the thorax but is useful in percussing an adult's sinuses.

         Indirect percussion - the striking of an object held against the body area to be examined. In this technique, the middle finger of the nondominant hand, referred to as the pleximeter, is placed firmly on the client's skin. Only the distal phalanx and joint of this finger should be in contact with the skin. Using the tip of the flexed middle finger of the other hand called the plexor, the nurse strikes the pleximeter, usually at the distal interphalangeal joint.

        Percussion is used to determine the size and shape of internal organs by establishing their borders. It indicates whether tissue is fluid filled, air filled, or solid. Percussion elicits five types of sound:

                Flatness - an extremely dull sound produced by very dense tissue, such as muscle or bone.

                Dullness - a thudlike sound produced by dense tissue such as the liver, spleen, or heart.

                Resonance - a hollow sound such as that produced by lungs filled with air.

                Hyperresonance - not produced in the normal body. It is described as booming and can be heard over an emphysematous lung.

                Tympany - a musical or drumlike sound produced from an air-filled stomach.

4. Auscultation - the process of listening to sounds produced within the body.

       Direct auscultation - the use of the unaided ear, for example, to listen to a repiratory wheeze or the grating of a moving joint.