Draping and instruments | CCMA Assisting with the general physical exam

Draping and instruments

During the actual physical examination, the medical assistant can be responsible for several different aspects of patient care. Throughout the examination, the patient may need to be placed in a number of different positions. To protect the patient’s modesty, you should use the proper draping technique for each position. To protect yourself and your patient, you should also use proper body mechanics - keep your back straight, bend at the knees rather than your waist, and position the exam table at a comfortable working height before you assist a patient into place. This section covers draping technique and the instruments used during the exam.

Positioning and draping the patient for the physical examination

Various patient positions are used to facilitate a physical examination. The medical assistant instructs the patient and assists the patient into these positions, ensuring as much ease and modesty as possible. The medical assistant may also help the patient maintain the position during the examination with as little discomfort as possible. Do not place a patient into a position that is uncomfortable or that compromises the patient’s privacy until it is necessary to complete that part of the examination. Never leave the patient’s side if the position could result in a fall.

Draping the patient with a sheet protects the individual from embarrassment and keeps the patient warm. However, the sheet must be positioned so that it allows complete visibility for the examiner and does not interfere with the examination. During the general examination, each part of the body is exposed one portion at a time - for example, when examining the abdomen, the medical assistant folds the sheet down to expose only the abdomen, then repositions it to cover that area before the next region is exposed. For gynecologic and rectal examinations, the sheet is positioned on the diagonal across the patient, or in a diamond shape, with the patient in the lithotomy position and only the perineal area exposed, to provide maximum comfort for the patient while allowing the provider to perform the examination.

Common instruments used during a physical examination displayed — Instruments used for physical exam

Instruments needed for the physical examination

Instrument	Use
Ophthalmoscope	To inspect the inner structures of the eye. It consists of a stainless-steel handle containing batteries and an attached head, which has a light, magnifying lenses, and an opening through which the eye is viewed.
Tongue depressor	A flat, wooden blade used to hold down the tongue when the throat is examined.
Otoscope	To examine the external auditory canal and tympanic membrane. It has a stainless-steel handle containing batteries or is part of a wall-mounted electrical unit. The head of the otoscope has a light that is focused through a magnifying lens; it should be covered with a disposable ear speculum. The light also may be used to illuminate the nasal passages and throat.
Tuning fork	Aluminum, fork-shaped instrument that consists of a handle and two prongs. The prongs produce a humming sound when the provider strikes them against his or her hand. Tuning forks are available in different sizes, and each size produces a different pitch level. A tuning fork is used to check the patient’s auditory acuity and to test bone vibration. A tuning fork can also be used to test for diabetic peripheral neuropathy.
Tape measure	A flexible ribbon ruler that is usually printed in inches and feet on one side and in centimeters and meters on the reverse side. Measurements may be used to assess length and head circumference in infants, wound size, etc.
Stethoscope	A listening device used when certain areas of the body are auscultated, particularly the heart and lungs. This instrument is available in many shapes and sizes. All have two earpieces that are connected to flexible rubber or vinyl tubing. At the distal end of the tubing is a diaphragm or bell (many have both); when it is placed securely on the patient’s skin, it enables the provider to hear internal body sounds.
Reflex hammer	Sometimes called a percussion hammer. This stainless-steel instrument has a hard rubber head that is used to strike the tendons of the knee and elbow to test the neurologic reflexes.
Gloves	Gloves protect the healthcare worker and the patient from microorganisms. According to Standard Precautions, gloves must be worn whenever the potential exists for contact with any body fluid, broken skin or wounds, or contaminated items.
Additional supplies	Gauze, cotton balls, cotton-tipped applicators, disposable tissues, specimen containers, fecal occult blood test cards, Pap test supplies for female patients, lubricating jelly for vaginal and rectal examinations, and laboratory request forms should be easily accessible during the examination.

Standard Precautions: these apply to every patient, regardless of diagnosis, and are the baseline for glove use - gloves go on whenever contact with blood, body fluids, non-intact skin, or contaminated items is possible. Transmission-based precautions are added on top of Standard Precautions only for patients with a known or suspected infection.

Assisting with the general physical exam

Medical assistant roles: positioning, draping, patient comfort
Use proper draping for modesty and warmth
Apply correct body mechanics for safety

Positioning and draping the patient

Assist and instruct patient into exam positions
Maintain privacy and comfort; only expose areas as needed
Never leave patient unattended in unstable positions

Instruments needed for the physical examination

Ophthalmoscope: inspects inner eye structures
Tongue depressor: holds down tongue for throat exam
Otoscope: examines ear canal, tympanic membrane, nasal passages, throat
Tuning fork: tests auditory acuity, bone vibration, peripheral neuropathy
Tape measure: measures length, head circumference, wound size
Stethoscope: auscultates heart, lungs, internal sounds
Reflex hammer: tests neurologic reflexes (knee, elbow)
Gloves: protect against microorganisms, required for contact with fluids or wounds
Additional supplies: gauze, cotton balls, tissues, specimen containers, test cards, lubricating jelly, lab forms

Fowler position

Patient seated, head of table at 90°
Used for head, neck, chest exams; patients with breathing difficulty
Drape placement varies for modesty

Semi-fowler position

Head of table at 45°
Used for postoperative, breathing disorders, head trauma/pain
Drape covers from nipple line down

Supine (horizontal recumbent) position

Patient flat, face up
Examines front of body: heart, breasts, abdomen
Gown opens in front; drape covers unexamined areas

Prone position

Patient face down, ventral surface on table
Used for back exams, certain procedures
Drape from mid-back to below knees; gown opens in back

Dorsal recumbent position

Patient face up, knees flexed, feet flat
Relieves abdominal muscle tension
Used for rectal, vaginal, perineal exams (not with speculum)
Drape in diamond shape for privacy

Lithotomy position

Patient on back, knees flexed, feet in stirrups
Used for vaginal exams with speculum, Pap tests
Drape diagonally, covers knees to ankles and sides of thighs
Position only when provider is ready

Left lateral position

Patient on left side, left arm/shoulder back, right leg flexed upward
Used for rectal, perineal, pelvic exams, rectal medication
Drape diagonally under arms to below knees

Knee-chest position

Patient on knees and chest, buttocks elevated, back straight
Used for proctologic, sigmoid, rectal, some vaginal exams
Gown opens in back; drape diagonally over sacral area
Requires assistance; alternative: knee-elbow position for easier maintenance

Draping and instruments

Positioning and draping the patient for the physical examination

Instruments needed for the physical examination

Instrument	Use
Ophthalmoscope	To inspect the inner structures of the eye. It consists of a stainless-steel handle containing batteries and an attached head, which has a light, magnifying lenses, and an opening through which the eye is viewed.
Tongue depressor	A flat, wooden blade used to hold down the tongue when the throat is examined.
Otoscope	To examine the external auditory canal and tympanic membrane. It has a stainless-steel handle containing batteries or is part of a wall-mounted electrical unit. The head of the otoscope has a light that is focused through a magnifying lens; it should be covered with a disposable ear speculum. The light also may be used to illuminate the nasal passages and throat.
Tuning fork	Aluminum, fork-shaped instrument that consists of a handle and two prongs. The prongs produce a humming sound when the provider strikes them against his or her hand. Tuning forks are available in different sizes, and each size produces a different pitch level. A tuning fork is used to check the patient’s auditory acuity and to test bone vibration. A tuning fork can also be used to test for diabetic peripheral neuropathy.
Tape measure	A flexible ribbon ruler that is usually printed in inches and feet on one side and in centimeters and meters on the reverse side. Measurements may be used to assess length and head circumference in infants, wound size, etc.
Stethoscope	A listening device used when certain areas of the body are auscultated, particularly the heart and lungs. This instrument is available in many shapes and sizes. All have two earpieces that are connected to flexible rubber or vinyl tubing. At the distal end of the tubing is a diaphragm or bell (many have both); when it is placed securely on the patient’s skin, it enables the provider to hear internal body sounds.
Reflex hammer	Sometimes called a percussion hammer. This stainless-steel instrument has a hard rubber head that is used to strike the tendons of the knee and elbow to test the neurologic reflexes.
Gloves	Gloves protect the healthcare worker and the patient from microorganisms. According to Standard Precautions, gloves must be worn whenever the potential exists for contact with any body fluid, broken skin or wounds, or contaminated items.
Additional supplies	Gauze, cotton balls, cotton-tipped applicators, disposable tissues, specimen containers, fecal occult blood test cards, Pap test supplies for female patients, lubricating jelly for vaginal and rectal examinations, and laboratory request forms should be easily accessible during the examination.