Chapter 3 - Collecting Objective Data

Chapter 03: Collecting Objective Data

Page 1: Introduction

• Discusses the collection of objective data in physical examination as part of nursing health assessments.

Page 2: Physical Examination Preparation

• Ensuring comfort:

  • Maintain a warm temperature in the examination room.

  • Provide a private area free from interruptions.

  • Utilize a quiet environment with adequate lighting.

• Equipment setup:

  • Use a firm examination table or bed.

  • Have a beside table or tray available to hold equipment.

Page 3: Equipment Needed for Physical Examinations

• General equipment for all examinations:

  • Gloves: Protects the examiner from blood, body fluids, and contaminated items.

  • Gowns: Added protection when contact is anticipated.

Page 4: Vital Signs Examination Equipment

• Required items:

  • Sphygmomanometer: Measures diastolic and systolic blood pressure.

  • Stethoscope: Used for auscultating blood sounds during blood pressure measurements.

  • Thermometer: For measuring body temperature (oral, rectal, tympanic).

  • Watch with second hand: To time heart and pulse rates.

  • Pain rating scale: To assess perceived pain levels.

Page 5: Nutritional Status Examination Equipment

• Instruments for assessment:

  • Skinfold calipers: Measure skinfold thickness of subcutaneous tissue.

  • Flexible tape measure: Measure mid-arm circumference.

  • Skin marking pen: To mark measurement sites.

  • Platform scale with height attachment: Measure height and weight.

Page 6: Skin, Hair, and Nail Examination Equipment

• Essential tools:

  • Examination light: For enhanced visibility during assessments.

  • Metric ruler: To measure the size of lesions or skin abnormalities.

  • Magnifying glass: Improve visibility of skin lesions or conditions.

Page 7: Braden Scale for Predicting Pressure Sore Risk

• Visual representation of the Braden Scale:

  • Used to assess the risk of developing pressure sores based on factors like mobility, moisture, and nutrition.

Page 8: Head and Neck Examination Equipment

• For thyroid examination:

  • Stethoscope: To auscultate the thyroid gland.

  • Cup of water: Assists the client in swallowing during the examination.

Page 9: Eye Examination Equipment

• Tools needed for eye assessment:

  • Penlight: Tests pupillary constriction.

  • Snellen E chart: Tests distant vision.

  • Newspaper: For assessing near vision.

  • Opaque card: Tests for strabismus.

  • Ophthalmoscope: Views the retina and examines the red reflex.

Page 10: Ear Examination Equipment

• Instruments for ear examination:

  • Tuning fork: Assesses bone and air conduction.

  • Otoscope: Examines the ear canal and tympanic membrane.

Page 11: Mouth, Throat, Nose, and Sinus Examination Equipment

• Tools for oral assessment:

  • Penlight: Illuminates the mouth and throat, transilluminates sinuses.

  • Gauze pad: Grasp the tongue for examination.

  • Tongue depressor: Used for viewing throat and assessing oral cavity.

  • Otoscope with wide-tip: Examines the internal nasal structures.

Page 12: Thoracic and Lung Examination Equipment

• Required tools:

  • Stethoscope (diaphragm): Auscultate breath sounds.

  • Metric ruler and skin marking pen: Measure diaphragmatic excursion.

Page 13: Heart and Neck Vessel Examination Equipment

• Essential instruments:

  • Stethoscope (bell and diaphragm): Auscultate heart sounds.

  • Metric rulers: Measure jugular venous pressure.

Page 14: Peripheral Vascular Examination Equipment

• Instruments for vascular assessment:

  • Sphygmomanometer and stethoscope: Measure blood pressure and assess vascular sounds.

  • Flexible metric tape: Measure extremities for edema.

  • Tuning fork: Detect vibratory sensation.

  • Doppler ultrasound device: Detects weak pulses.

Page 15: Abdominal Examination Equipment

• Tools for abdominal assessment:

  • Stethoscope: Detect bowel sounds.

  • Flexible tape and skin marking pen: Mark measurement areas.

  • Pillows: Used to promote abdominal relaxation.

Page 16: Musculoskeletal Examination Equipment

• Required tools:

  • Flexible metric measuring tape: Measure size of extremities.

  • Goniometer: Measures degree of joint flexion and extension.

Page 17: Neurologic Examination Equipment

• Essential items:

  • Cotton-tipped applicators: Tests taste sensation.

  • Objects: Test stereognosis ability (recognizing objects by touch).

  • Reflex hammer: Test deep tendon reflexes.

Page 18: Neurologic Examination Continued

• Additional equipment:

  • Cotton ball and paperclip: Tests light touch and two-point discrimination.

  • Snellen E chart: Assesses vision.

  • Penlight: Evaluate uvala rise and gag reflex.

Page 19: Male Genitalia and Rectum Examination Equipment

• Tools needed:

  • Gloves and lubricant: Promote comfort.

  • Penlight: For illumination.

  • Specimen card: Collects sample for occult blood.

Page 20: Female Genitalia and Rectum Examination Equipment

• Essential tools:

  • Vaginal speculum: Inspect cervix via vaginal canal.

  • Bifid spatula and broom: Collect cervical swabs and samples.

  • Liquid Pap medium: For Pap smear test.

Page 21: Standard Precautions

• Critical protocols:

  • Hand hygiene, use of gloves.

  • Utilize mask, eye protection, and face shield when necessary.

  • Proper management of patient care equipment and linens.

Page 22: Client Approach and Preparation

• Establish rapport:

  • Build a nurse-client relationship.

  • Explain the procedure of the physical assessment clearly.

  • Respect the client’s wishes.

  • Start with less intrusive examinations to ensure comfort.

Page 23: Client Positioning

• Different positions for examination include:

  • Sitting, Supine, Dorsal Recumbent, Sims, Standing, Prone, Knee-chest, Lithotomy.

Page 24-25: Client Positioning Details

• Visuals outlining:

  • Sitting, Supine, Dorsal Recumbent, Sims, and further positions.

Page 26: Physical Examination: Inspection

• Guidelines:

  • Maintain a comfortable room temperature and adequate lighting.

  • Observe areas before touching, and expose the area fully for examination.

  • Note characteristics and compare appearances.

Page 27: Considerations for Examining Older Adults

• Special attention needed:

  • Some positions may be difficult due to age-related mobility issues.

  • Allow for rest periods if necessary, and communicate clearly and slowly.

Page 28: Physical Examination: Palpation

• Types of palpation:

  • Light, Moderate, Deep, and Bimanual.

Page 29: Parts of Hand for Palpating

• Fingerpads, Ulnar surface, Dorsal surface sensitivity:

  • Fine discriminations, vibrations, and temperature assessments.

Page 30: Palpation Characteristics

• Touch characteristics evaluated during palpation:

  • Texture, Temperature, Moisture, Mobility, Consistency, Pulse strength, Size, Shape, and tenderness.

Page 31: Physical Examination: Percussion

• Purposes:

  • Elicit pain, assess densities, detect abnormal masses, and assess reflexes.

Page 32: Physical Examination: Auscultation

• Techniques for effective auscultation:

  • Eliminating noise, exposing relevant body parts, and using proper stethoscope techniques.

Page 33: Sounds Elicited by Percussion

• Examples of percussion sounds:

  • Resonance: Normal lung

  • Hyper-resonance: Lung with emphysema

  • Tympany, Dullness, Flatness: Different tissues and conditions assessed.

Page 34: Physical Examination: Auscultation Techniques

• Using a stethoscope effectively includes:

  • Warming the diaphragm before use and ensuring direct contact with skin.

Page 35: Stethoscope Do’s and Don’ts

• Important practices:

  • Warm diaphragm and properly position earpieces.

  • Avoid listening through clothing for accurate sounds.

Page 36: Conclusion

• Overview of concepts and techniques for conducting thorough objective assessments in nursing.