Percussion

It is the examination by tapping with the fingers on the body to determine the condition of the
internal organs by Lu the sounds that are produced. It is done by placing a finger of the left hand
firmly against a part to be examined and tapping with the finger tips of the right hand. Produces
sound waves by using the fingers as a hammer. Place the interphalangeal joint of the middle
finger on the skin surface of the nondominant hand. Using the tip of the middle finger of the
dominant hand, strike the placed finger. Vibration is produced by the impact of the fingers
striking against underlying tissue. Sound or tone of the vibration is determined by body area or
organ percussed. Normal lung areas produce a resonance sound; liver sounds are dull and a flat
sound is heard over muscle.

Characteristics of sound produced are:

Resonance: A low pitched and loud sound heard over the normal lung tissues.

Hyperresonance: Very loud, very low pitch sound longer than resonance and is of booming
quality signifies emphysema.

Tympany: A drum-like sound heard over the air-filled tissues, such as gastric air bubble.

Dull: A medium-pitched sound with a medium duration without resonance heard over solid
tissues, such as heart and liver.

Flat: A high-pitched sound with a short duration without resonance heard over complete solid
tissues, such as hand, thigh. In physical diagnosis, percussion is the In method of examination in
which the surface of the body In is struck to emit sounds that vary in quality according th to the
underlying tissues.

Types of Percussion

There are four types of percussion techniques-immediate, mediate, direct fist percussion, and
indirect fist percussion. It is important to keep in mind that the sounds produced from percussion
are generated from body tissue up to 5 cm below the patient should have the opportunity to void
before the the surface of the skin. If the abdomen is to be percussed.

Different parts of the hand are used to measure different factors:

Fingertips: It is used to swelling, vibration, or pulsation underneath.

Grasping of finger and thumb: It easily identifies the position, shape, and mass of the organ.

Dorsum of hand: Used to assess the temperature of the body.

The base of fingers: Base of fingers or ulnar joints used to identify vibrations.
Immediate Percussion

y Immediate or direct percussion is the striking of an area of the body directly. To perform
immediate percussion:

• Spread the index or middle finger of the dominant hand slightly apart from the rest of the
fingers.

• Make a light tapping motion with the finger pad of the index finger against the body part being
percussed.

• Note what sound is produced.

Mediate Percussion

Mediate percussion is also referred to as indirect percussion. This is a skill that takes time and
practice to develop and to use effectively. Most sounds are produced using mediate percussion.
Follow these steps to perform mediate percussion:

1. Place the nondominant hand lightly on the surface to be percussed.

2. Extend the middle finger of this hand, known as the pleximeter, and press its distal phalanx
and distal interphalangeal joint firmly on the location where percussion is to begin. The
pleximeter will remain stationary while percussion is performed in this location.

3. Spread the other fingers of the nondominant hand apart and raise them slightly off the surface.
This prevents interference and, thus, dampening of vibrations during the actual percussion.

4. Flex the middle finger of the dominant hand, called the plexor. The fingernail of the plexor
finger should be very short to prevent undue discomfort and injury to the nurse. The other fingers
on this hand should be fanned.

5. Flex the wrist of the dominant hand and place the hand directly over the pleximeter finger of
the nondominant hand.

6. With a sharp, crisp, rapid movement from the wrist of the dominant hand, strike the pleximeter
with the plexor. At this point, the plexor should be perpendicular to the pleximeter. The blow to
the pleximeter should be between the distal interphalangeal joint and the fingernail. Use the
finger pad rather than the fingertip of the plexor to deliver the blow. Concentrate on the
movement to create the striking action from the dominant wrist only.

7. As soon as the plexor strikes the pleximeter, withdraw the plexor to avoid dampening the
resulting vibrations. Do not move the pleximeter finger.

8. Note the sound produced from the percussion.

9. Repeat the percussion process one or two times in this T location to confirm the sound.

10. Move the pleximeter to a second location, preferably the th contralateral location from where
the previous percussion was performed. Repeat the percussion process in this manner until the
entire body surface area being assessed has been percussed. Figure 6.8 shows characteristics of
percussion notes.

Direct Fist Percussion

Direct fist percussion is used to assess the presence of tenderness and pain in internal organs,
such as the liver or the kidneys. To perform direct fist percussion:

• Explain this technique thoroughly so the patient does not think you are hitting him/her.

• Draw the dominant hand up into a fist.

• With the ulnar aspect of the closed fist, directly hit the area where the organ is located. The
strike should be of moderate force, and it may take some practice to achieve the right intensity.
The presence of pain in conjunction with direct fist percussion indicates inflammation of that
organ or a strike of too high an intensity.

Methods of percussion:

• Direct percussion: Tapping patient's body directly with the distal end of a finger

• Indirect percussion

Using either the index and middle finger or just the middle finger of one hand, which strikes
against the middle finger of the other hand.

Touch patient only with the finger that is being tapped (to avoid dampening the sound)

Another method: Tap middle finger with the rubber head of a reflex hammer

Indirect Fist Percussion

The purpose of indirect fist percussion is the same as direct fist percussion. In fact, the indirect
method is preferred over the direct method. It is performed in the following manner:

• Place the palmar side of the nondominant hand on the skin's surface over the organ to be
examined. Place the fingers adjacent to one another and in straight alignment with the palm.
• With the ulnar aspect of the closed fist, use moderate intensity to hit the outstretched
nondominant hand on

• Draw up the dominant hand into a closed fist.

The nondominant hand absorbs some of the force of the striking hand. The resulting intensity
should be of sufficient force to produce pain in the patient if organ inflammation is present.
Figure 6.9 shows percussion sound.

Methods of Percussion

The percussion can be done by two methods. These are:

1. Direct percussion: Striking the body surface directly with one or two fingers, eg, ascitic thrill.

2. Indirect percussion: Placing the middle finger of the non- dominant hand firmly against the
body surface and striking the distal joint of now-dominant finger with the middle fingers of the
dominant hand.

In the method the left middle finger is laid upon the body surface to serve as a pleximeter; it is
struck sharp blow with the tip of the right middle finger, the plexor immediate or direct. The
body surface is struck directly with one or more fingers of a hand.

Sonorous Percussion

• This term is applied to any method of percussion when its purpose is to ascertain the density of
the tissue by the sound emitted when struck.

• Various densities emit sounds given special meanings. The percussion notes may be arranged
in sequence according to the density that produces them, from least to most dense: tympany
hyperresonance, resonance, impaired resonance, dullness, flatness.

• Certain steps in normal tissues. Tympany is the sound emitted by percussing the air-filled
stomach; resonance is produced by striking the air-filled lungs; flatness results from the thigh.

• In general the pitch or frequency of the sounds progresses through the series from lowest for
tympany to highest for he flatness; the duration of the sound ranges in the series from long to
short.

• Sonorous percussion is employed to ascertain the density of the lungs, the pleural space, the
pleural layers, and the hollow viscera of the abdomen.

Definitive Percussion

• Definitive percussion where two structures in apposition fro have greatly contrasting densities,
as demonstrated by their percussion notes, mapping of area of greater density furnishes a concept
of the size of the structure or the extent of its border.

Definitive percussion is commonly employed to ascertain the location of the lung bases, the
width of the lung apices, the height of fluid in the pleural cavity the width of the mediastimum,
the size of the heart, the outline of dense masses in the lungs the size and shape of the liver and
spleen, the size of a distended gallbladder and urinary bladder, the level of ascitic fluid.

Auscultation

It is the listening to sounds within the body with the aid of a stethoscope, fetoscope or directly
with the ear placed on the body. Place the stethoscope on the client's bare skin to g listen for the
presence and characteristics of sound waves. e: The bell of the stethoscope is used to detect low-
pitched sounds; the diaphragm detects high-pitched sounds. Note variations in intensity, pitch,
duration, and quality.

This is an important physical examination technique used by your healthcare provider, where he
or she will listen to your heart, lungs, neck or abdomen, to identify if any problems are present.
Auscultation is often performed by using a stethoscope. The stethoscope will amplify sounds es
heard in the area that is being listened to. If there is an abnormal finding on your examination,
further testing may be suggested.

Types of Auscultation

Direct Auscultation

Direct or immediate auscultation is the 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 y
patient's skin surface. An example of immediate Indirect Auscultation

Indirect or mediate auscultation describes the 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. This text describes the use of an acoustic stethoscope

• The neck: When your doctor or healthcare provider is listening to your neck, they are often
listening for a "swishing" sound in your arteries. This may suggest that there is a narrowing of
the arteries, which would increase the sound of blood flow.

• The heart: Normally, your heart produces a "lub-dub" sound, when the heart valves are
opening and closing during the flow of blood. Your healthcare provider will listen to see if your
heart is beating regularly, or if there are any murmurs (extra sounds with every heart beat). Heart
murmurs may be "innocent", meaning they are normal, and non-life threatening, or they may
signify a problem may be present. To diagnose this, your healthcare provider may listen with
their stethoscope to many areas around the heart, instead of just one area, and suggest further
testing, if necessary.

• The lungs: The healthcare provider may listen to your lungs with their stethoscope, anywhere
on your back (posterior), or on the front of your chest wall (anterior). He/she may be able to tell
if air is moving to the bottom of your lungs, by listening to the airflow in and out of your lungs
with each breath. These are called normal lung sounds. If there is a blockage, constriction or
narrowing of your lung tubes, or fluid in your lungs, this can be heard by the examiner (Table
6.3).

• The abdomen: The abdomen will be examined using a stethoscope, to listen for any
"swishing" sounds of blood through the arteries near your stomach (such as the aorta), or
abnormal bowel sounds.

• Other locations: Auscultation may be used anywhere your healthcare provider wants to listen.

Characteristics of Sound

• Intensity: Loud, medium, soft

• Pitch: Low, high, medium

• Duration: Short, longer, medium

• Quality: Booming, hollow, dull, drum-like

Techniques

• Stethoscope is used to block extraneous sounds when assessing the condition of heart, blood
vessels, lungs, pleura and intestines.

• Bell/diaphragm after cleaning and warming is placed directly against skin because clothing
may interfere with normal sounds.

• Bell used to hear soft pitched sounds, such as S1, S2 sounds (abnormal vascular sounds,
murmur).
• Diaphragm of stethoscope is used to hear high pinched sounds, such as breath sounds, bowel
sounds, normal hear sounds

• By placing diaphragm firmly, stabilize it between index middle finger, listen the characteristics
of sound

Manipulations

It is the moving of a part of the body to note its flexibility. Limitation of movements is
discovered by this method.

Definition: A consensus definition of manipulation is "the use of the hands applied to the patient
incorporating the use of instructions and maneuvers to achieve maximal painless movement and
posture of the musculoskeletal sys- tem." Most common types of manipulation involve passive
mechanical forces applied to specific vertebral segments, regions, or other joint segments of the
musculoskeletal system, with a primary goal of restoration of diminished ROM.
Reflexes

Reflexes are automatic muscular responses to a stimulus. When reflexes are absent or otherwise
altered, it can indicate a neurological deficit even earlier than other signs and e symptoms of the
neurological deficit appear) Reflexes can s, be described as primitive and long term. Primitive
reflexes are normally present at the time of birth and these reflexes normally disappear as the
baby grows older; neurological 1- deficits are suspected when these primitive reflexes remain
beyond the point in time when they are expected to disappear. Reflexes, other than the primitive
reflexes remain intact and active during the entire life span, under normal conditions

The primitive reflexes are the:

• Rooting reflex: The infant will turn their head in the direction of the side of the face that is
being gently stroked and, then, the infant will begin a sucking action.

• Sucking reflex: The sucking reflex is demonstrated when the infant performs sucking actions
when anything like a nipple or a finger tip comes in contact with the infant's mouth.

• Tonic neck reflex: The tonic neck reflex, also referred to as the fencing reflex, is demonstrated
when the infant's body takes on the appearance of a fencer's position when the infant's head is
turned to the right or to the left.

• Galant or truncal incurvation reflex: This reflex is seen when the infant moves their hips
toward the direction of gentle tap on their back near the spine when the infant is in the prone
position.)

• Grasp reflex: Newborns grasp fingers and other objects that are placed in their palm. They will
also tighten their grasp as the finger or another object is slowly removed.)

• Moro or startle reflex: This reflex normally occurs with a sudden noise, such as clapping of
hands. The infant will jerk when the sound is heard. The infant's head and legs will extend and
the arms will move upward.)

• Step reflex Newborns will perform walking like move- ments when the soles of the infant's
feet touch a surface, such as a floor. The reflex disappears in about six to eight weeks of age.
Figure 6.14 shows examining gag reflexes.• Parachute reflex: The baby extends their arms
forward as if to break a fall when a person holds the infant and rotates their body rapidly) Figure
6.15 shows examining deep tendon reflexes.

The other reflexes are the:

• Pupil reflex: Pupil reflexes include pupil dilation and pupil accommodation) The "PERLA"
mnemonic for pupil reflexes stands for/Pupils Equally Reactive to Light and Accommodation
which is a normal finding) The pupil reflexes for their reactions to light are assessed by using a
flash light in a darkened room. Pupils will normally dilate as the light is withdrawn and they will
normally constrict when the light is brought close to the pupils.) The pupils are assessed not only
for their reaction to light, they are also assessed in terms of their accommodation. Normally, the
pupils will dilate when an object is moved away from the eye and they will constrict as the object
is being brought closer to the eye.

• Plantar reflex: The plantar reflex is elicited when the person performing this assessment
strokes the bottom of the foot and the client's toes curl down.) The Babinski sign occurs when
the foot goes into dorsiflexion and the great toe curls up; this sign is an abnormal response to this
stimulation and it can indicate the presence of deep vein thrombosis.

• Biceps reflex: This reflex is assessed by placing the thumb on the biceps tendon while the
person is in a sitting position and then tapping the thumb with the Taylor hammer.)• Triceps
reflex: This reflex is elicited by tapping the triceps tendon with the Taylor hammer above the
elbow while the client has their hands on their legs when the client is in a sitting position.

• Patellar tendon reflex: This reflex, often referred to as the knee jerk reflex, is elicited by
tapping the patellar area with the Taylor hammer.

• Calcaneal reflex: This reflex, often referred to as the Achilles reflex, is assessed with tapping
on the calcaneal reflex on the ankle with the Taylor hammer.

• Gag reflex: The gag reflex is elicited when the back of the mouth and the posterior tongue is
stimulated with a tongue blade.

Sneeze reflex: Sneezing occurs to rid the nasal passages of irritants.

• Blinking reflex: This reflex is elicited when the eyes are touched or they are stimulated a
sudden bright light or an irritant.

• Cough reflex: Coughing occurs when the airway is stimulated.

• Yawn reflex: Yawning occurs as the result of the body's increased need for oxygen.

Olfaction

Assessment using the sense of smell (olfaction).

A well-developed sense of smell enables a nurse to detect odors that are characteristic of certain
conditions. Some alterations in body function and certain bacteria create characteristic odors, for
example:

• The 'fishy' smell of infected urine

• The ammonia odor associated with concentrated or decomposed urine

The musty or offensive odor of an infected wound

• The offensive rotting odor associated with gangrene (tissue necrosis)

• The smell of ketones on the breath in ketoacidosis (accumulation of ketones in the body)

• The smell of alcohol on the breath-due to ingestion of alcohol

• Halitosis (offensive breath) accompanying mouth infections; for example, gingivitis or certain
disorders of s.) the digestive system; for example, appendicitis

• The foul odor associated with steatorrhea (abnormal amount of fat in the feces)

• The characteristic odor associated with melena (abnormal black tarry stool containing blood)

• The fecal odor of vomitus associated with a bowel obstruction

• Bromhidrosis (offensive smelling perspiration) caused by bacterial decomposition of

perspiration on the skin.