Nursing Health Assessment - Collecting Subjective Data
Collecting Subjective Data
Subjective data is an integral part of nursing health assessment.
Subjective data consist of:
Sensations or symptoms
Feelings
Perceptions
Desires
Preferences
Beliefs
Ideas
Values
Personal information
These data can be elicited and verified only by the client.
Subjective data provide clues to possible physiologic, psychological, and sociologic problems.
It also provides the nurse with information that may reveal a client's risk for a problem as well as areas of strengths for the client.
This information is obtained through interviewing.
Effective interviewing skills are vital to accurate and thorough collection of subjective data.
Interviewing
Obtaining a valid nursing health history requires professional, interpersonal, and interviewing skills.
The nursing interview is a communication process that has two focuses:
Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information.
Gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse-client collaboration.
Phases of the Interview
The nursing interview has three basic phases: introductory, working, and summary and closing phases.
Introductory Phase
After introducing himself to the client, the nurse explains the purpose of the interview.
Discusses the types of questions that will be asked.
Explains the reason for taking notes, and assures the client that confidential information will remain confidential.
The nurse also makes sure that the client is comfortable (physically and emotionally) and has privacy.
Essential for the nurse to develop trust and rapport at this point in the interview.
This can begin by conveying a sense of priority and interest in the client.
Developing rapport depends heavily on verbal and nonverbal communication on the part of the nurse.
Working Phase
During this phase, the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level.
The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client.
The nurse and client collaborate to identify the client's problems and goals.
The facilitating approach may be free-flowing or more structured with specific questions, depending on the time available and the type of data needed.
Summary and Closing Phase
During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client.
She also identifies and discusses possible plans to resolve the problem (nursing diagnoses and collaborative problems) with the client.
Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions.
Communication During the Interview
The client interview involves two types of communication: nonverbal and verbal.
Nonverbal Communication
Nonverbal communication is as important as verbal communication.
Your appearance, demeanor, posture, facial expressions, and attitude strongly influence how the client perceives the questions you ask.
Never overlook this type of communication or take it for granted.
Appearance
First take care to ensure that your appearance is professional.
The client is expecting to see a health professional; therefore, you should look the part.
Wear comfortable, neat clothes and a laboratory coat or a uniform.
Be sure your name tag, including credentials, is clearly visible.
Your hair should be neat and not in any extreme style; some nurses like to wear long hair pulled back.
Fingernails should be short and neat; jewelry should be minimal.
Demeanor
Your demeanor should also be professional.
When you enter a room to interview a client, display poise; focus on the client and the upcoming interview and assessment.
Do not enter the room laughing loudly, yelling to a coworker, or muttering under your breath.
Greet the client calmly and focus your full attention on her.
Do not be overwhelmingly friendly or "touchy;" many clients are uncomfortable with this type of behavior.
It is best to maintain a professional distance.
Facial Expression
Facial expressions are often an overlooked aspect of communication.
Because facial expression often shows what you are truly thinking (regardless of what you are saying), keep a close check on your facial expression.
No matter what you think about a client or what kind of day you are having, keep your expression neutral and friendly.
If your face shows anger or anxiety, the client will sense it and may think it is directed toward him or her.
If you cannot effectively hide your emotions, you may want to explain that you are angry or upset about a personal situation.
Admitting this to the client may also help in developing a trusting relationship and genuine rapport.
Portraying a neutral expression does not mean that your face lacks expression; it means using the right expression at the right time.
If the client looks upset, you should appear and be understanding and concerned.
Conversely, smiling when the client is on the verge of tears will cause the client to believe that you do not care about his or her problem.
Attitude
One of the most important nonverbal skills to develop as a health care professional is a nonjudgmental attitude.
All clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices.
Do not act superior to the client or appear shocked, disgusted, or surprised at what you are told; this will cause the client to feel uncomfortable opening up to you and important data concerning his or her health status could be withheld.
Being nonjudgmental involves not "preaching" to the client or imposing your own sense of ethics or morality on him.
Focus on health care and how you can best help the client to achieve the highest possible level of health.
For example, if you are interviewing a client who smokes, avoid lecturing condescendingly about the dangers of smoking.
Accept the client, be understanding of the habit, and work together to improve the client's health.
Let the client know you understand that it is hard to quit smoking, support efforts to quit, and offer suggestions on the latest methods available to help kick the smoking habit.
Silence
Another nonverbal technique to use during the interview process is silence.
Periods of silence allow you and the client to reflect and organize thoughts, which facilitates more accurate reporting and data collection.
Listening
Listening is the most important skill to learn and develop fully in order to collect complete and valid data from your client.
To listen effectively, you need to maintain good eye contact, smile or display an open, appropriate facial expression, maintain an open body position (open arms and hands and lean forward).
Avoid preconceived ideas or biases about your client.
To listen effectively, you must keep an open mind; avoid crossing your arms, sitting back, tilting your head away from the client, thinking about other things, or looking blank or inattentive.
Becoming an effective listener takes concentration and practice.
Verbal Communication
Effective verbal communication is essential to a client interview.
The goal of the interview process is to elicit as much data about the client's health status as possible.
Open-Ended Questions
Open-ended questions are used to elicit the client's feelings and perceptions.
They typically begin with the words "how" or "what."
An example of this type of question is "How have you been feeling lately?"
These types of questions are important because they require more than a one-word response from the client and, therefore, encourage description.
Asking open-ended questions may help to reveal significant data about the client's health status.
Closed-Ended Questions
Use closed-ended questions to obtain facts and to focus on specific information.
The client can respond with one or two words.
The questions typically begin with the words "when" or "did."
An example of this type of question is "When did your headache start?"
Closed-ended questions are useful in keeping the interview on course.
They can also be used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions.
Laundry List
Another way to ask questions is to provide the client with a choice of words to choose from in describing symptoms, conditions, or feelings.
This laundry list approach helps you to obtain specific answers and reduces the likelihood of the client's perceiving or providing an expected answer.
For example, "Is the pain severe, dull, sharp, mild, cutting, or piercing?", "Does the pain occur once every year, day, month, or hour?"
Repeat choices as necessary.
Rephrasing
Rephrasing information the client has provided is an effective way to communicate during the interview.
This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.
For example, your client, Mr. G., tells you that he has been really tired and nauseated for 2 months and that he is scared because he fears that he has some horrible disease.
You might rephrase the information by saying, "You are thinking that you have a serious illness?"
Well-Placed Phrases
Client verbalization can be encouraged by well-placed phrases from the nurse.
If the client is in the middle of explaining a symptom or feeling and believes that you are not paying attention, you may fail to get all the necessary information.
Listen closely to the client during his or her description and use phrases such as "um-hum," "yes," or "I agree" to encourage the client to continue.
Inferring
Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data.
Be careful not to lead the client to answers that are not true.
For example: Your client, Mrs. J., tells you that she has bad pain. You ask where the pain is, and she says, "My stomach."
You notice the client has a hand on the right side of her lower abdomen and seems to favor her entire right side. You say, "It seems you have more difficulty with the right side of your stomach" (use the word "stomach" because that is the term the client used to describe the abdomen).
This technique, if used properly, helps to elicit the most accurate data possible from the client.
Providing Information
Another important thing to consider throughout the interview is to provide the client with information as questions and concerns arise.
Make sure you answer every question as well as you can.
If you do not know the answer, explain that you will find out for the client.
The more clients know about their own health, the more likely they are to become equal participants in caring for their health.
Special Considerations during the Interview
Three variations in communication must be considered as you interview clients: gerontologic, cultural, and emotional.
These variations affect the nonverbal and verbal techniques you use during the interview.
Gerontologic Variations in Communication
Age affects and commonly slows all body systems to varying degrees.
However, normal aspects of aging do not necessarily equate with a health problem, so it is important not to approach an interview with an elderly client assuming that there is a health problem.
Older clients have the potential to be as healthy as younger clients.
When interviewing an elderly client, you must first assess hearing acuity.
Hearing loss occurs normally with age, and undetected hearing loss is often misinterpreted as mental slowness or confusion.
If you detect hearing loss, speak slowly, face the client at all times during the interview, and position yourself so that you are speaking on the side of the client that has the ear with better acuity.
Do not yell at the client.
Older clients may have more health concerns than younger clients and may seek health care more often.
Many times, older clients with health problems feel vulnerable and scared.
They need to believe that they can trust you before they will open up to you about what is bothering them.
Thus establishing and maintaining trust, privacy, and partnership with the older client is particularly important.
It is not unusual for elderly clients to be taken for granted and their health complaints ignored, causing them to become fearful of complaining.
Assure your elderly clients that you are concerned, that you see them as equal partners in health care, and that what is discussed will be between you, their health care provider, and them.
Speak clearly and use straightforward language during the interview with the elderly client.
Ask questions in simple terms; avoid medical jargon and modern slang, but do not talk down to the client.
Show respect is very important; however, if the older client is mentally confused or forgetful, it is important to have a significant other (e.g., spouse, child, close friend) present during the interview to provide or clarify the data.
Cultural Variations in Communication
Ethnic/cultural variations in communication and self-disclosure styles may significantly affect the information obtained.
Be aware of possible variations in the communication styles of yourself and the client.
If misunderstanding or difficulty in communicating is evident, seek help from an expert, what some professionals call a "culture broker."
This is someone who is thoroughly familiar not only with the client's language, culture, and related health care practices but also with the health care setting and system of the dominant culture.
Frequently noted variations in communication styles include:
Reluctance to reveal personal information to strangers for various culturally-based reasons
Variation in willingness to openly express emotional distress or pain
Variation in ability to receive information (listen)
Variation in meaning conveyed by language.
Variation in use and meaning of nonverbal communication: eye contact, stance, gestures, demeanor.
Variation in disease/illness perception: Culture-specific syndromes or disorders are accepted by some groups
Variation in past, present, or future time orientation
Variation in the family's role in the decision-making process
You may have to interview a client who does not speak your language.
To perform the best interview possible, it is necessary to use an interpreter; possibly the best interpreter would be a culture expert (or culture broker).
Consider the relationship of the interpreter to the client; also keep in mind that communication through use of pictures may be helpful when working with some clients.
Emotional Variations in Communication
Not every client you encounter will be calm, friendly, and eager to participate in the interview process; clients' emotions vary for a number of reasons.
Interacting With an Anxious Client
Provide the client with simple, organized information in a structured format.
Explain who you are and your role and purpose.
Ask simple, concise questions.
Avoid becoming anxious like the client; do not hurry and decrease any external stimuli.
Interacting With an Angry Client
Approach this client in a calm, reassuring, in-control manner.
Allow him to ventilate feelings.
However, if the client is out of control, do not argue with or touch the client.
Obtain help from other health care professionals as needed.
Avoid arguing and facilitate personal space so the client does not feel threatened or cornered.
Interacting With a Depressed Client
Express interest in and understanding of the client and respond in a neutral manner.
Do not try to communicate in an upbeat, encouraging manner; this will not help the depressed client.
Interacting With a Manipulative Client
Provide structure and set limits.
Differentiate between manipulation and a reasonable request.
If you are not sure whether you are being manipulated, obtain an objective opinion from other nursing colleagues.
Interacting With a Seductive Client
Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors.
Encourage client to use more appropriate methods of coping in relating to others.
When Discussing Sensitive Issues
First be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone.
Ask simple questions in a nonjudgmental manner.
Allow time for ventilation of client's feelings as needed.
If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialists as needed.
Complete Health History
The health history is an excellent way to begin the assessment process because it lays the groundwork for identifying nursing problems and provides a focus for the physical examination.
The importance of the health history lies in its ability to provide information that will assist the examiner in identifying areas of strength and limitation in the individual's lifestyle and current health status.
Data from the health history also provide the examiner with specific cues to health problems that are most apparent to the client; then these areas may be more intensely examined during the physical assessment.
When a client is having a complete, head-to-toe physical assessment, collection of subjective data usually requires that the nurse take a complete health history.
The complete health history is modified or shortened when necessary.
Taking a health history should begin with an explanation to the client of why the information is being requested, for example, "so that I will be able to plan individualized nursing care with you."
The health history has eight sections:
Biographic data
Reasons for seeking health care
History of present health concern
Past health history
Family health history
Review of body systems (ROS) for current health problems
Lifestyle and health practices profile
Developmental level
Biographic Data
Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others.
The client's birth date, Social Security number, medical record number, or similar identifying data may be included in the biographic data section.
When students are collecting the information and sharing it with instructors, addresses and phone numbers should be deleted and initials used to protect the client's privacy.
The name of the person providing the information needs to be included, however, to assist in determining its accuracy.
The client is considered the primary source and all others (including the client's medical record) are secondary sources.
The client's culture, ethnicity, and subculture may begin to be determined by collecting data about date and place of birth, nationality or ethnicity, marital status, religious or spiritual practices, and primary and secondary languages spoken, written, and read.
This information helps the nurse to examine special needs and beliefs that may affect the client or family's health care.
Gathering information about the client's educational level, occupation, and working status at this point in the health history assists the examiner to tailor questions to the client's level of understanding.
Finally, asking who lives with the client and identifying significant others indicates the availability of potential caregivers and support people for the client.
Reason(s) for Seeking Health Care
This category includes two questions: "What is your major health problem or concerns at this time?" and "How do you feel about having to seek health care?"
The first question assists the client to focus on his most significant health concern and answers the nurse's question, "Why are you here?" or "How can I help you?"
The second question, "How do you feel about having to seek health care?" encourages the client to discuss fears or other feelings about having to see a health care provider.
History of Present Health Concern
This section of the health history takes into account several aspects of the health problem and asks questions whose answers can provide a detailed description of the concern.
First, encourage the client to explain the health problem or symptom in as much detail as possible by focusing on the onset, progression, and duration of the problem; signs and symptoms and related problems; and what the client perceives as causing the problem.
You may also ask the client to evaluate what makes the problem worse, what makes it better, which treatments have been tried, what effect the problem has had on daily life or lifestyle, what expectations are held about recovery, and what is the client's ability to provide self-care.
Because there are many characteristics to be explored for each symptom, a memory helper known as a mnemonic can help the nurse to complete the assessment of the sign, symptom, or health concern.
The mnemonic used in this text is COLDSPA, which is designed to help the nurse explore symptoms, signs, or health concerns:
Character: Describe the sign or symptom.
Onset: When did it begin?
Location: Where is it?
Duration: How long does it last?
Severity: How bad is it?
Pattern: What makes it better or worse?
Associated factors: What other symptoms occur with it? How does it affect you?
Past Health History
This portion of the health history focuses on questions related to the client's past, from the earliest beginnings to the present.
These questions elicit data related to the client's strengths and weaknesses in her health history.
The client's strengths may be physical, social, emotional, or spiritual; the data may also point to trends of unhealthy behaviors such as smoking or lack of physical activity.
The information gained from these questions assists the nurse to identify risk factors that stem from previous health problems.
Sample questions include:
"Can you tell me how your mother described your birth? Were there any problems?"
"What diseases did you have as a child such as measles or mumps? What immunizations did you get and are you up to date now?"
"Do you have any chronic illnesses? If so, when was it diagnosed? How is it treated? How satisfied have you been with the treatment?"
"What illnesses or allergies have you had? How were the illnesses treated?"
"Have you ever been pregnant and delivered a baby? How many times have you been pregnant/delivered?"
"Have you ever been hospitalized or had surgery? If so, when? What were you hospitalized for or what type of surgery did you have? Were there any complications?"
"Have you experienced any accidents or injuries? Please describe them."
"Have you experienced pain in any part of your body? Please describe the pain."
"Have you ever been diagnosed with/treated for emotional or mental problems? If so, please describe their nature and any treatment received. Describe your level of satisfaction with the treatment."
Family Health History
As researchers discover more and more health problems that seem to run in families and that are genetically based, the family health history assumes greater importance.
The family history should include as many genetic relatives as the client can recall.
Include maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings, and the client's children.
Such thoroughness usually identifies those diseases that may skip a generation such as autosomal recessive disorders.
Drawing a genogram helps to organize and illustrate the client's family history; use a standard format so others can easily understand the information.
Also provide a key to the symbols used.
After the diagrammatic family history, prepare a brief summary of the kinds of health problems present in the family.
Review of Systems (ROS) for Current Health Problems
In the review of systems (or review of body systems), each body system is addressed and the client is asked specific questions to draw out current health problems or problems from the recent past that may still affect the client or that are recurring.
Care must be taken in this section to include only the client's subjective information and not the examiner's observations.
During the review of body systems, document the client's descriptions of her health status for each body system and note the client's denial of signs, symptoms, diseases, or problems that the nurse asks about but are not experienced by the client.
The questions about problems and signs or symptoms of disorders should be asked in terms that the client understands, but findings may be recorded in standard medical terminology.
Lifestyle and Health Practices Profile
This is a very important section of the health history because it deals with the client's human responses, which include nutritional habits, activity and exercise patterns, sleep and rest patterns, use of medications and substances, self-concept and self-care activities, social and community activities, relationships, values and beliefs system, education and work, stress level and coping style, and environment.
Here clients describe how they are managing their lives, their awareness of healthy versus toxic living patterns, and the strengths and supports they have or use.
When assessing this area, use open-ended questions to promote a dialogue with the client.
Description of Typical Day
This information is necessary to elicit an overview of how the client sees his usual pattern of daily activity.
The questions you ask should be vague enough to allow the client to provide the orientation from which the day is viewed, for example, "Please tell me what an average or typical day is for you. Start with awakening in the morning and continue until bedtime."
Nutrition and Weight Management
Ask the client to recall what consists of an average 24-hour intake for her with emphasis on what foods are eaten and in what amounts; also ask about snacks, fluid intake, and other substances consumed.
Depending on the client, you may want to ask who buys and prepares the food and when and where meals are eaten.
These questions uncover food habits that are health promoting as well as those that are less desirable.
The client's answers about food intake should be compared with the guidelines illustrated in the "food pyramid".
The client's fluid intake should be compared with the general recommendation of six to eight glasses of water or noncaffeinated fluids daily.
Activity Level and Exercise
Next, assess how active the client is during an average week either at work or at home; inquire about regular exercise.
Some clients believe that if they do heavy physical work at their job, they do not need additional exercise.
Make it a point to distinguish between activity done when working, which may be stressful and fatiguing, and exercise, which is designed to reduce stress and strengthen the individual.
Sleep and Rest
Inquire whether the client feels he is getting enough sleep and rest.
Questions should focus on specific sleep patterns such as how many hours a night the person sleeps, interruptions, whether the client feels rested, problems sleeping (e.g., insomnia), rituals the client uses to promote sleep, and concerns the client may have regarding sleep habits.
Compare the client's answers with the normal sleep requirement for adults, which is usually between 5 and 8 hours a night.
Medication and Substance Use
The information gathered about medication and substance use provides the nurse with information concerning lifestyle and a client's self-care ability.
Medication and substance use can affect the client's health and cause loss of function or impaired senses.
In addition, certain medications and substances can increase the client's risk for disease.
Because many people use vitamins or a variety of herbal supplements, it is important to ask which and how often.
Self-Concept and Self-Care Responsibilities
This includes assessment of how the client views herself and investigation of all behaviors that a person does to promote her health.
Examples of subjects to be addressed include sexual responsibility; basic hygiene practices; regularity of health care checkups (i.e., dental, visual, medical); breast/testicular self-examination; and accident prevention and hazard protection (e.g., seat belts, smoke alarms, and sunscreen).
Social Activities
Questions about social activities help the nurse to discover what outlets the client has for support and relaxation and if the client is involved in the community beyond family and work.
Relationships
Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members.
In this way, you can assess problems and potential support from the client's family of origin.
In addition, similar information should be sought about the client's current family.
If the client does not have any family by blood or marriage, then information should be gathered about any significant others (including pets) that may constitute the client's "family."
Values and Belief System
Assess the client values; in addition, discuss the clients' philosophical, religious, and spiritual beliefs.
Some clients may not be comfortable discussing values or beliefs; their feelings should be respected.
However, the data can help to identify important problems or strengths.
Education and Work
Questions about education and work help to identify areas of stress and satisfaction in the client's life.
Sometimes discussing this area will help the client feel good about what he has accomplished and promote his sense of life satisfaction.
Stress Levels and Coping Styles
To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond.
In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.
Environment
Ask questions regarding the client's environment to assess health hazards unique to the client's living situation and lifestyle.
Look for physical, chemical, or psychological situations that may put the client at risk.
Collecting Objective Data
Objective data include information about the client that the nurse directly observes during interaction with him and information elicited through physical assessment (examination) techniques.
To become proficient with physical assessment skills, the nurse must have basic knowledge in three areas:
Types of and operation of equipment needed for the particular examination (e.g., penlight, sphygmomanometer, otoscope, tuning fork, stethoscope)
Preparation of the setting, oneself, and the client for the physical assessment
Performance of the four assessment techniques: inspection, palpation, percussion, and auscultation
Equipment
Each part of the physical examination requires specific pieces of equipment.
Prior to the examination, collect the necessary equipment 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.
Preparing for the Examination
How well you prepare the physical setting, yourself, and the client can affect the quality of the data you elicit.
Preparing the Physical Setting
The physical examination may take place in a variety of physical 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, warm room temperature (provide a warm blanket if the room temperature cannot be adjusted).
Private area free of interruptions from others (close the door or pull the curtains if possible).
Quiet area free of distractions (turn off the radio, television, or other noisy equipment).
Adequate lighting (it is best to use sunlight when available; however, good overhead lighting is sufficient).
Firm examination table or bed at a height that prevents stooping; a roll-up stool may be useful when it is necessary for the examiner to sit for parts of the assessment.
A bedside table/tray to hold the equipment needed for the examination.
Preparing Oneself
As a beginning examiner, it is helpful to assess your own feelings and anxieties before examining the client.
Another important aspect of preparing yourself for the physical assessment examination is preventing the transmission of infectious agents.
General principles to keep in mind while performing a physical assessment include the following:
Wash your hands before beginning the examination, immediately after accidental direct contact with blood or other body fluids (you should wear gloves if there is a chance that you will come in direct contact with blood or other body fluids), and after completing the physical examination or after removing gloves.
Wear gloves if you have an open cut or skin abrasion, if the client has an open or weeping cut, if you are collecting body fluids (e.g., blood, sputum, wound drainage, urine, or stools) for a specimen, if you are handling contaminated surfaces (e.g., linen, tongue blades, vaginal speculum), and when you are performing an examination of the mouth, an open wound, genitalia, vagina, or rectum.
If a pin or other sharp object is used to assess sensory perception, discard the pin and use a new one for your next client.
Wear a mask and protective eye goggles if you are performing an examination in which you are likely to be splashed with blood or other body fluid droplets (e.g., if you are performing an oral examination on a client who has a chronic productive cough).
Approaching and Preparing the Client
The nurse-client relationship should be established during the client interview before the physical examination takes place; this is important because it helps to alleviate any tension or anxiety that the client is experiencing.
Respect the client's desires and requests related to the physical examination.
If a urine specimen is necessary, explain to the client the purpose of a urine sample and the procedure for giving a sample; provide him or her with a container to use.
Ask the client to undress and put on an examination gown; allow him or her to keep on underwear until just before the genital examination to promote comfort and privacy.
Begin the examination with the less intrusive procedures such as measuring the client's temperature, pulse, blood pressure, height, and weight.
These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with you and help to ease client anxiety about the examination.
Throughout the examination, continue to explain what procedure you are performing and why you are performing it; this helps to ease your client's anxiety.
Approach the client from the right-hand side of the examination table or bed because most examination techniques are performed with the examiner's right hand (even if the examiner is left-handed).
You may ask the client to change positions frequently, depending on the part of the examination being performed.
Physical Examination Techniques
Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client; these techniques are inspection, palpation, percussion, and auscultation.
After performing each of the four assessment techniques, the examiner should ask herself questions that will facilitate analysis of the data and determine areas in which more data may be needed