COLLECTING OBJECTIVE DATA (PHYSICAL EXAMINATION) (DOCUMENTATION OF DATA)

OBJECTIVE DATA
• An objective data includes information about the client that is directly observed during interaction with the
client.
• Information elicited through physical assessment techniques.
• To be able to properly obtain an accurate physical assessment, a nurse must have knowledge in three basic areas:
o Types and operation of equipment needed for a particular examination
o Preparation of the setting, oneself, and the client for the physical assessment
o Performance of the four assessment techniques
PHYSICAL ASSESSMENT
Indications
• Routine screening
• Eligibility prerequisite for health insurance, military service, job, sports, school
• Admission to a hospital or long-term care facility
Points to Remember
• Reviewing general information • Pain assessment
• Introduction to client • This is key to holistic approach
• Obtaining the health history
Equipment Used
All Examinations Gloves and Gown
• Skin fold calipers
• Tape measure
Nutritional Status Examination
• Skin marking pen
• Weighing scale with height attachment
• Penlight
• Mirror
• Metric ruler
Skin, Hair, and Nail Examination • Magnifying glass
• Wood’s light
• Braden scale
• Pressure ulcer scale for healing
• Stethoscope
Head and Neck Examination
• Small cup of water
• Penlight Snellen E chart
• Newspaper
Eye Examination
• Opaque card
• Ophthalmoscope
• Tuning fork
Ear Examination
• Otoscope
• Penlight
Mouth, Throat, Nose, Sinus Examination • Gauze pad
• Tongue depressor
• Otoscope with wide teeth attachment
• Stethoscope
Thoracic and Lung Examination
• Ruler and Skin marking pen
Heart and Neck Vessels • Stethoscope
• Two metric rulers
Peripheral Vascular Examination • Sphygmomanometer and stethoscope
• Tape measure
• Tuning fork
• Doppler ultrasound device
Abdominal Examination • Stethoscope
• Tape measure and marker
• Two small pillows
Musculoskeletal Examination • Tape measure
• Goniometer
Male Genitalia and Rectal Examination • Gloves and lubricant
• Penlight
• Specimen
Female Genitalia and Rectal Examination • Vaginal speculum
• Bifid spatula, endocervical broom
• Large swabs
• Liquid pap medium
• Specimen card
Neurologic Examination • Cotton tip applicator
• Substances to smell and taste
• Same equipment for eye exam
• Object to feel
• Percussion hammer
• Tongue depressor
• Tuning fork
• Cotton ball and paper clip

PREPARING FOR EXAMINATION

• Comfortable, warm room temperature To provide stability (in vital signs, etc.)
• Private area Always note that privacy was given
• Adequate lighting To check for normal and abnormal colors
• Quiet area
• Firm examination table or bed
• A bedside table or tray
PREPARING ONESELF
• Assess your own feelings and anxieties before examining the client
• Self-confidence in performing physical assessment through practice the techniques
• The transmission of infectious agents should be prevented during physical assessment
o Wash hand before the examination, immediately after direct contact with any body fluids, blood, and
contaminated items, and after the examination.
o Always wear gloves.
o When using pin or other sharp object, always use a new one for the next patients.
o Wear a mask and protective eye googles to avoid being splashed with body fluids or blood.
APPROACHING THE CLIENT
• Establish rapport with the client before the examination
• Respect the client’s desire and requests
• Provide privacy to the client
• Begin the examination with the less intrusive procedures
POSITIONING THE CLIENT

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 • Supine/Prone For head, neck, and spine examination
• Dorsal For testicular exams
• Lithotomy To take necessary measurements for those who are pregnant
• Sim’s To insert suppository
• K-C To take specimens and for rectal examinations
PHYSICAL ASSESSMENT TECHNIQUE
Inspection
• Involves using the senses of vision, smell, and hearing
• Used to observe and detect any norm al and abnormal findings
• Use the following guidelines as you practice the technique of inspection:
o Make sure the room is a comfortable temperature.
o Use good lighting.
o Look and observe before touching.
o Only expose body parts being observed.
o Note the following characteristics: color, patterns, size, location, consistency, symmetry, movement,
behavior, odors, or sounds.
o Compare the appearance of symmetric body parts
Palpation
• Consists of using touch
• Palpation is used to feel the following characteristics
o Texture o Strength of pulses
o Temperature o Size
o Moisture o Shape
o Mobility o Degree of tenderness
o Consistency
• Principles of Accurate Palpation
o Fingernails should be short.
o Use sensitive part of the hand.
o Light to deep palpation.
o Palpate the tender area at the end of the examination.
o Let client take slow deep breaths to promote muscle relaxation.
o Assess skin turgor by lightly grasping body part with fingertips.
• Three Parts of the Hand Used During Palpation
o Fingerpads Fine discrimination, Pulse,s Texture, Size, Consistency, Shape , Crepitus
o Ulnar/Palmar Surface Vibrations, Thrills, Fremitus
o Dorsal Surface Temperature

• Types of Palpation
o Light Palpation Place dominant hand lightly on the surface of the structure
Little to no depression
Use circular motion
o Moderate Palpation Depress skin surface 1to 2 cm (0.5 to 0.75 in)
Feel palpable body organs and masses
o Deep Palpation Place dominant hand on skin surface and nondominant hand on top of
dominant hand to apply pressure
Depress skin surface between 2.5 and 5 cm (1and 2 in)
o Bimanual Palpation Use two hands, place one on each side of the body part being palpated
Use one hand to apply pressure and the other hand to feel the structure
Note the size, shape, consistency, mobility of the structures
Percussion
• Involves tapping body parts to produce sound waves
• Uses of Percussion
o Eliciting pain o Detecting abnormal masses
o Determining location, size, and shape o Eliciting reflexes
o Determining density
• Types of Percussion
o Direct Percussion Direct tapping of body part with one or two fingertips to elicit possible
tenderness
o Blunt Percussion Used to detect tenderness over organs by placing one hand flat on the body
surface and using the fist of the other hand to strike the back of the hand
o Indirect Percussion Most commonly used method of percussion
Produces sound or tone that varies with the density of underlying structures
• The Follow Techniques to Help to Develop Proficiency in the Technique of Indirect Percussion
o Place the middle finger of your nondominant hand on the body part you are going to percuss.
o Keep your other fingers off the body part being percussed because they will damp the tone you elicit.
o Use the pad of your middle finger of the other hand (ensure that this fingernail is short) to strike the
middle finger of your nondominant hand that is placed on the body part.
o Withdraw your finger immediately to avoid damping the tone.
o Deliver two quick taps and listen carefully to the tone.
o Use quick, sharp taps by quickly flexing your wrist, not your forearm.
• Solid tissue produces a soft tone, fluid produces a louder tone, air produces an even louder tone.
SOUND INTENSITY PITCH LENGTH QUALITY EXAMPLE OF ORIGIN
Resonance Loud Low Long Hollow Normal lung
Hyper-Resonance Very Loud Low Long Booming Lung with emphysema
Tympany Loud High Moderate Drum-like Puffed-out cheek, gastric bubble
Dullness Medium Medium Moderate Thud-like Diaphragm, pleural effusion liver
Flatness Soft High Short Flat Muscle, bone, sternum, thigh
• Plexor Taps
• Pleximeter To be tapped

Auscultation
• Direct or Immediate Auscultation Accomplished by unassisted ear without amplifying device.
Involves application of ear directly to a body surface.
• Mediate Auscultation Use of stethoscope in the detection of body sounds.
• Used to listen to:
o Heart sounds
o Movement of blood through cardiovascular system
o Movement of bowel
o Movement of air through the respiratory tract
• These guidelines should be followed as you practice the technique of auscultation:
o Eliminate distracting or competing noises from the environment (e.g., radio, television, machinery).
o Expose the body part you are going to auscultate.
o Do not auscultate through the client’s clothing or gown. Rubbing against the clothing obscures the body
sounds.
• Parts of the Stethoscope

• When to Use the Diaphragm and the Bell

o Diaphragm Best for higher pitch sounds
For the breath sounds and normal heart sounds
o Bell Best for lower pitch sounds
For some bowel sounds, heart murmurs, bruits
Olfaction
• Another skill that used d u ring assessment, certain alteration is body function characteristic smelling body can
create odors, detect abnormalities that unrecognized by other means.
• Assessment of characteristic odors
o Alcohol odor from oral cavity means ingestion of alcohol.
o Ammonia from urine means urinary tract infection.
o Body odor from skin, particularly in areas where body parts rub together means poor hygiene, excess
perspiration (bromidrosis).
o Feces odor from wound site means wound abscess.
o Foul–smelling stools in infant from stool means mal absorption syndrome.
o Halitosis from oral cavity means poor dental and oral hygiene, gum disease.
o Sweet, fruity ketones from oral cavity may be from diabetic acidosis.
o Musty odor from casted body part means infection inside cast.
CLIENT’S CHART
• Any relevant record made by a health care practitioner at the time of, or subsequent to, a consultation and/or
examination or the application of health management.
• A thorough record of a patient’s medical history and clinical data.
• Medical charts contain medically relevant events that have happened to a person.
• A good medical chart will paint a clear picture of the patient.
• Complete medical charts help ensure patients receive the best care possible.
• Medical charts provide healthcare providers a glimpse into a patient’s medical history and provide vital details
to help clinicians make sound care decisions.
Information
• Demographics • Surgical history
• Developmental History • Obstetric history
• Immunization Records • Family History
• Medications • Social History
• Medical allergies • Habits
Can Include
• Hand-written contemporaneous notes taken by the health care practitioner.
• Notes taken by previous practitioners attending health care or other health care practitioners
• Referral letters to and from other health care practitioners.
• Laboratory reports and other laboratory evidence
• Audio visual records such as photographs, videos, and tape-recordings.
• Clinical research forms and clinical trial data.
• Other forms completed during the health interaction such as insurance forms, disability assessments and
documentation of injury on duty.
• Death certificates and autopsy reports.
Those Who Can Access
• Individual medical charts must be treated with extreme care.
• Only the patient and the health care team members involved in their care are allowed to view or add to a medical
chart.
• Medical charts belong to the patient.
• He or she has the right to make sure the chart is accurate and can grant another party access to the chart.
VALIDATION OF DATA
Purpose
• Validation is the process of confirming or verifying that the subjective and objective data collected are reliable
and accurate.
Steps
• Deciding if the data needs validation
• Determine ways to validate data
• Identifying areas where data is missing
Conditions that Require Data to be Rechecked and Validated
• Discrepancies or gap between subjective and objective data
• Discrepancies or gaps between what the client says at one time versus another time
• Finding highly abnormal or inconsistent with other findings
Methods
• Recheck own data through a repeat assessment
• Clarify data with the client by asking additional questions
• Verify the data with another health care professional
• Compare objective findings with subjective findings
NOTE
• Abdominal IAPerPal
• Normal IPalPerA
 ASSESSMENT OF SKIN, HAIR AND NAILS
SKIN
• Largest organ of the body
Functions
• Protects the underlying tissues and organs form microorganism, physical trauma, ultraviolet radiation, and
dehydration
• Temperature maintenance
• Fluid and electrolyte balance
• Absorption, excretion, sensation, immunity, and vitamin D synthesis
• Provides identity
Layers of the Human Skin

HAIR NAILS

ASSESSING THE INTEGUMENT

Subjective Data
• Skin problems: skin infection, rashes, lesions, itching, bruising
• Precipitating factors: stress, weather, drugs
• Changes in skin color, lesions
• Presence of birthmarks/moles
• Amount of sun exposure/extreme temperatures
• Scalp lesions, itching, and infections.
• Changes in texture and amount of hair.
• Changes in nails and cuticles nail breaking
• Presence of tattoos
• Routine skin, hair, and nail care
• Changes in sensation
• Pain, tingling, numbness
• Use of topical medications, herbal or nutritional supplements
• Body odor/ perspiration
• Recent hospitalizations/surgeries
• Allergies
• Lifestyle/activities (risk of pressure ulcers)
• Body piercing
• Food/fluid intake
• Smoking and drinking habits
• Stress
Objective Data
• Preparing the Client
o Have the patient wear an examination gown.
o Remove nail enamel, artificial nails, wigs, toupees, or hairpins as appropriate
o Have the Client Sit comfortably (lie down as necessary)
o Ensure privacy
o At comfortable room temperature
o Wear gloves when palpating any lesions
o Observe cultural sensitivity
• Equipment
o Examination light
o Pen light
o Mirror (self-assessment of skin)
o Magnifying glass
o Centimeter ruler
o Gloves
o Woods light/UV light
o Examination gown or drape
KEY POINTS
• Inspect skin color, temperature, moisture, and texture
• Check skin integrity
• Be alert of skin lesions
• Evaluate hair conditions, loss, or unusual growth
• Note nail bed condition and capillar refill
ASSESSMENT TECHNIQUES (SKIN)
Inspection
• Check for angiomas, keratosis, scars, and skin tags
• Check for skin integrity
o Pay attention to pressure point areas

• Normal Findings Skin is intact and there are no reddened areas

 • Clinic Tip
o In the obese client, carefully inspect the skin on the limbs, under the breasts, and in the groin area
where problems are frequent due to perspiration and friction.
Palpation
• Inspect for lesions
o Note for color, shape, and size of lesion. For very small lesions, use magnifying glass
o Note location, distribution, and configuration
o Measure lesion
• Clinical Tip
o Scarifications may be used by some individual who want a scar of keloid
• Temperature
o Skin is normally a warm temperature.
o Abnormal Findings: cool skin, very warm skin
• Mobility and Turgor
o The skin is mobile, with elasticity and returns to its shape quickly.
o Older Adult Consideration: The older client's skin loses its turgor.
o Abnormal Findings: cool skin, very warm skin
• Edema
o Skin rebounds and does not remain indented when pressure is released.

ASSESSMENT TECHNIQUES (HAIR AND SCALP)

Inspection
• Inspect hair and scalp for general color and condition.
o Natural hair color.
o Abnormal Findings: patchy hair color (nutritional deficiencies)
• Inspect and palpate for cleanliness, dryness or oiliness parasites and lesions
o Scalp is clean and dry. Hair is smooth and firm, somewhat elastic.
o Older Adult Consideration: As people age, hair feels coarser and drier.
• Inspect amount and distribution of scalp, body, axillae and pubic hair.
o Varying amounts of terminal hair cover the scalp. axillary, body, and pubic areas according to normal
gender distribution.
o Abnormal Findings: excessive generalized hair loss, patchy hair loss, hirsutism
• Older Adult Consideration
o Older clients have thinner hair because of thinner hair follicles.
o Pubic, axillary, body hair also decreases with aging.
o Alopecia is seen in men. hair loss occurs form to center.
o Older women may have terminal hair growth on the chin owing to…
• Grooming and Cleanliness
o Nails are clean and manicured.
o Abnormal findings: dirty, broken, jagged (poor hygiene)
• Nail color and markings
o Pink tones should be seen. Some longitudinal ridging is normal.
o Dark skinned may have freckles or pigmentation in their nails.
o Abnormal findings: pale or cyanotic nails, splinter hemorrhages, Beau’s line, yellow discoloration,
nail pitting
• Shape of nails
o There is normally 160-degree angle between the nail base and the skin.
 • Kollonychia spoon nails… the opposite of clubbing
Palpation
• Nail Texture
o Nails are basically hard and immobile .
o Cultural Considerations: Dark-Skinned clients may have thicker nails.
o Older Adult Consideration: Older clients' nails may appear thickened, yellow, and britttle tmause of
decreased circulation in the extremities.
o Abnormal Findings: Thickened nails (especially toenails)may be caused by decreased circulation, and
is also seen in onychomysis.
• Nail Texture and Consistency, noting whether nail plate is attached to nail bed.
o Nails are smooth and firm,and nail plate shoudl be firmly attached to the nail bed.
• Test Capillary Refill Time (CRT)
o Pink tone returns immediately to blanched nails beds when pressure is released..
 HEAD AND NECK ASSESSMENT
HEAD
• Cranium
• Face
• 14 Facial Bones

NECK
• Muscles and cervical vertebrae
• Blood vessels
• Thyroid gland
• Lymph nodes
HEAD AND NECK ASSESSMENT
Subjective Data Reports of patient
• Headache
• Head injury
• Dizziness
• Neck pain
• Limitation of motion
• Lumps or swelling
Objective Nurse’s observations, physical assessment