Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves?
A. Breast
B. Integumentary
C. Ophthalmic
D. Oral
Correct Answer: D. Oral
Gloves should be worn anytime there is a risk of exposure to the client’s blood or body fluids. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. Ophthalmic, breast, or integumentary examinations normally do not involve contact with the client’s body fluids and do not require the nurse to wear gloves for protection.
Option A: After completing the visual inspection, the patient should be instructed to lay supine. If a site-specific breast complaint is being evaluated, the examiner should begin his/her exam on the opposite, or “normal” side. As one breast is examined, the other is covered for the patient’s comfort. The patient should place the ipsilateral hand above and/or behind their head to flatten the breast tissue as much as possible. The breast tissue itself is evaluated using a sequence of palpation that allows serial progression from superficial to deeper tissues.
Option B: A general assessment of the skin begins at the initial contact with the patient and continues throughout the examination. Specific areas of the skin are assessed during the examination of other body systems unless the chief complaint is a dermatologic problem. However, if there are areas of skin breakdown or drainage, gloves should be used.
Option C: The Royal College of Ophthalmologists have updated their advice on PPE to ophthalmologists and are now recommending that clinicians should wear standard surgical masks when examining or treating patients at the slit lamp. Gowns and gloves are not recommended. They also recommend that plastic breath shields attached to slit lamps provide some protection, but must be disinfected between patients as studies show that the COVID-19 virus is viable for up to 72 hours on plastic surfaces.