objective data

Objective data

include information about the client that the nurse directly observes during interaction with the client and information elicited through physical examination techniques

Equipment

• Each part of the physical examination requires specific pieces of ____.

• Prior to the examination, collect the necessary ____ and place it in the area where the examination will be performed.

*this promotes organization and prevents the nurse from leaving the client to search for a piece of equipment

Gloves & gown

Protect examiner in any part of the examination when the examiner may have contact with blood, body fluids, secretions, excretions, and contaminated items, or when disease-causing agents could be transmitted to or from the client

Sphygmomanometer, stethoscope

Measure diastolic and systolic blood pressure

Stethoscope

Auscultate blood sounds when measuring blood pressure

Thermometer

Measure body temperature

Pulse Oximeter

Measures oxygen level

Watch with second hand

Take heart rate, pulse rate

Pain Rating Scale

Determine perceived pain level

Skinfold calipers

Measure skin fold thickness of subcutaneous tissue

Nutritional Status Examination

Equipments & Purpose:

• Skinfold calipers

• Flexible Tape measure

• Skin-marking pen

• Platform scale with height attachment

Braden Scale

For predicting one’s risk to develop pressure injury

PUSH

Determine the degree of healing of a pressure injury

Skin, Hair and nail examination

Equipment & Purpose

• Examination light, penlight

• Metric ruler

• Magnifying glass

• Braden Scale

• PUSH

Head & Neck Examination

EQUIPMENT & PURPOSE

Stethoscope: Auscultate the thyroid

Small cup of water: help client swallow during examination of the thyroid gland

Opaque card

Test for strabismus

Ophthalmoscope

View the red reflex and examine the retina of the eye

Tuning fork

Test for bone and air conduction of sound

Otoscope

View the ear canal and tympanic membrane

Reflex hammer

Test deep tendon reflexes

Preparing for the Examination (Setting, Patient, & Oneself)

• How well you prepare the physical setting, yourself, and the client can affect the quality of the data you elicit, which will support your clinical judgments.

• As an examiner, you must make sure that you have prepared for all three aspects before beginning an examination.

• Practicing with a friend, relative, or classmate will help you achieve proficiency in all three aspects of preparation.

Preparing the Physical Setting

The physical examination may take place in a variety of settings such as a hospital room, outpatient clinic, physician’s office, school health office, employee health office, or a client’s home.

• It is important that the nurse strive to ensure that the examination setting meets the following conditions: Comfortable, room temperature: Provide a warm blanket if the room temperature cannot be adjusted.

Preparing Oneself

• Careful preparation of yourself as an examiner is essential to be able to gather objective data to elicit sound clinical judgments.

• As a beginning examiner, it is helpful to assess your own feelings and anxieties before examining the client.

Approaching & preparing the client

Establish the nurse–client relationship during the client interview before the physical examination takes place.

*This is important because it helps alleviate any tension or anxiety that the client is experiencing.

• At the end of the interview, explain to the client that the physical assessment will follow and describe what the examination will involve.

Inspection

• involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings.

• This technique is used from the moment that you meet the client and continues throughout the examination.

• Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.

• Although most of the inspection involves the use of the senses only, a few body systems require the use of special equipment (e.g., ophthalmoscope for the eye inspection, otoscope for the ear inspection).

Palpation

Consists of using parts of the hand to touch and feel for the following characteristics:

1. Texture (rough/smooth)

2. Temperature (warm/cold)

3. Moisture (dry/wet)

4. Mobility (fixed/movable/still/vibrating)

5. Consistency (soft/hard/fluid filled)

6. Strength of pulses (strong/weak/thready/bounding)

7. Size (small/medium/large)TABLE 3-2

8. Shape (well defined/irregular)

9. Degree of tenderness

Fingerpads

Which Hand Part is Sensitive to

Fine discriminations: pulses, texture, size, consistency, shape, crepitus

Ulnar or palmar surface

Which Hand Part is Sensitive to

Vibrations, thrills, fremitus

Dorsal surface

Which Hand Part is Sensitive to

Temperature

Light palpation

To perform ____ place your dominant hand lightly on the surface of the structure.

Moderate palpation

Depress the skin surface 1 to 2 cm (0.5–0.75 in.) with your dominant hand, and use a circular motion to feel for easily palpable body organs and masses.

Deep palpation

Place your dominant hand on the skin surface and your non-dominant hand on top of your dominant hand to apply pressure. This should result in a surface depression between 2.5 and 5 cm (1 and 2 in.).

Bimanual palpation

Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated.

Percussion

involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.

Direct percussion

is the direct tapping of a body part with one or two fingertips to elicit possible tenderness

(e.g., tenderness over the sinuses).

Blunt percussion

is used to detect tenderness over organs (e.g., kidneys) by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.

Indirect or mediate percussion

is the most commonly used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures. As density increases, the sound of the tone becomes quieter.

Solid tissue produces a soft tone

fluid produces a louder tone

air produces an even louder tone

Auscultation

is a type of assessment technique that requires the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract.

Diaphragm of the stethoscope

to listen for high-pitched sounds, such as normal heart sounds, breath sounds, and bowel sounds, and press the diaphragm firmly on the body part being auscultated.

Bell of the stethoscope

to listen for low-pitched sounds such as abnormal heart sounds and bruits (abnormally loud, blowing, or murmuring sounds). Hold the bell lightly on the body part being auscultated.

6. Eliminate distracting or competing noises from the environment

(e.g., radio, television, machinery).