Objective Data

II. Collection of Objective Data

Objective data include information about the client
that the nurse directly observes during interaction
with the client and information elicited through
physical assessment techniques.
• To become proficient with physical assessment
skills, the nurse must have basic knowledge in
three areas:
 II. Collection of Objective Data
a. Types and operation of equipment needed for the
particular examination
b. Preparation of the setting, oneself, and the client
for the physical assessment
c. Performance of the four assessment techniques:
inspection, palpation, percussion and auscultation
 Physical Examination
• Each part of the physical examination requires
specific pieces of equipment.
• Prior to the examination, collect the necessary
equipment and place it in area where the
examination will be performed.
• This promotes organization and prevents the
nurse from leaving the client to search for a
pieces of equipment.
 All examinations
1. Gloves and gowns
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
agent could be transmitted to or from the client
 Vital Signs
1. Sphygmomanometer
•Measures diastolic and
systolic blood pressure

2. Thermometer
•Measure body temperature
 Vital Signs
3. Watch with second hand
• Take heart rate, pulse rate

4. Pain rating scale

• Determine perceived pain
level
 Nutritional Status Examination
1. Skinfold calipers
• Measure skinfold thickness
of subcutaneous tissue

2. Flexible tape measure

• Measure midarm
circumference
 Nutritional Status Examination
3. Skin-marking pen
• Mark measurements

4. Platform scale with height

attachment
• Measure height and weight
Skin, Hair and Nail Examination
1. Penlight
• Provide adequate lighting

2. Mirror
• Client’s self-examination of
the skin
Skin, Hair and Nail Examination
3. Metric ruler
•Measure size of skin
lesions

4. Magnifying glass
•Enlarge visibility of
lesion
Skin, Hair and Nail Examination
5. Wood’s light
• Test for fungus

6.Braden’s scale
• Predict one’s risk for
pressure ulcer
Skin, Hair and Nail Examination
7. Pressure ulcer scale
for healing (PUSH)
• Determine the
degree of healing of
a pressure ulcer
 Head and Neck Examination
1. Stethoscope
• Auscultate the thyroid

2. Small cup of water

• Help client to swallow
during examination of the
thyroid gland
 Eye Examination
1. Penlight
• Test papillary constriction

2. Snellen chart
• Test distant vision
 Eye Examination
3. Newspaper
•Test near vision
4. Opaque card
•Test for strabismus
5. Ophthalmoscope
•Test the red reflex and to
examine the retina of the eye
 Ear Examination
1. Tuning fork
•Test for bone and air
conduction of sound

2. Otoscope
•View the ear canal and
tympanic membrane
 Mouth, Throat, Nose and
Sinusitis Examination
1. Penlight
• Provide light to view the mouth and the throat
and to trans illuminate the sinuses
2. 4x4 small gauze
• Grasp tongue to examine mouth
3. Tongue depressor
•Depress tongue to view throat, check looseness of
teeth, view cheeks, and check strength of tongue
Thoracic and Lung Examination
1. Otoscope
• View the internal nose
2. Stethoscope
• Auscultate breath sounds
3. Metric ruler and marking pen
• Measure diaphragmatic excursion
 Heart and Neck Vessel
Examination
1. Stethoscope
• Auscultate heart sounds

2. Metric ruler
•Measure jugular venous pressure
Peripheral Vascular Examination
1. Sphygmomanometer and stethoscope
• Measure blood pressure and auscultate vascular
sounds
2. Measuring tape
• Measure size of extremities for edema
3. Tuning fork
• Detect vibratory sensation
4. Doppler ultrasound device
•Detect pressure and weak pulses
not easily heard with stethoscope
 Abdominal Examination
1. Stethoscope
• Detect bowel sounds
2. Measuring tape and marking pen
• Measure size and mark the area of percussion of
organ
3. Pillows
• Place under knees and head to promote relaxation
of abdomen
 Musculoskeletal Examination
1. Measuring tape
• Measure size of extremities

2. Goniometer
•Measure degree of flexion
and extension of joints
 Neurologic Examination
1. Cotton-tipped applicator and substances to smell
and taste
• Test taste smell perception
2. Penlight
3. Snellen chart
4. Newspaper
5. Opaque card
6. Ophthalmoscope
• Test vision and extraocular movements and
papillary response
 Neurologic Examination
7. Objects to feel, such as coin or key
•Test for stereognosis (ability to recognize
objects by touch)

8. Reflex hammer
•Test deep tendon reflexes
 Neurologic Examination
9. Cotton ball and paper clip
• Test for light, sharp, and dull touch and two-point
discrimination
10. Tongue depressor
•Test for rise of uvula and gag reflex
11. Tuning fork
•Test for vibratory sensation
 Male Genitals and Rectum
Examination
1. Gloves and lubricant
• Promote comfort for client
2. Penlight
• Scrotal illumination
3. Specimen card
• Detect occult blood
 Female Genitals and Rectum
Examination
1.Vaginal speculum and lubricant
•Inspect cervix through dilation of the
vaginal canal
 Female Genitals and Rectum
Examination
2. Bifid spatula,
endocervical broom
•Obtain endocervical swab
and cervical scrape and
vaginal pool sample
 Female Genitals and Rectum
Examination
3.Large swabs
•Vaginal examination
4. Liquid Pap medium
•Pap smear
5. Specimen card
•Detect occult blood
 Preparation for Assessment
• As an examiner, you must make sure that you
have prepared or all three aspects before
beginning an examination.
1. Preparing the physical setting – it is important
that the nurse strive to ensure that the
examination setting meets the following
conditions
a. comfortable room temperature
b. private room free of interruptions from others,
close the door
 Preparation for Assessment
c. quiet area free of distractions, turn off tv, radio
and other noisy equipment
d. adequate lighting, it is best to use sunlight (when
available), good overhead lighting is sufficient
e. firm examination table or bed at height that
prevents stooping
f. a bedside table or tray to hold the equipment
needed for the examination
 Preparation for Assessment
2. Preparing oneself – it is helpful to assess your
own feelings and anxieties before examining the
client. Anxiety is easily conveyed to the client, who
may already feel uneasy and self-conscious about
the examination. Achieve self-confidence in
performing a physical assessment by practicing the
techniques.
a. wash your hands before the examination,
immediately after the examination, immediately
after accidental direct contact with blood or other
body fluids
 Preparation for Assessment
b. always wear gloves 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
c. wear a mask and protective eye goggles if needed
 Preparation for Assessment
3. Approaching and preparing the client – establish
the nurse-patient 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 examination will follow and
describe what examination will involve.
 Preparation for Assessment
• Respect the client’s desires and requests related
to the physical examination. Some client request
may be simple; some may involve not wanting
certain parts of the examination to be performed.
• Begin the physical examination (PE) with the less
intrusive procedures such as measuring the
client’s temperature, pulse, blood pressure.
• These nonthreatening procedures allow the client
to feel more comfortable with you and help ease
the client’s anxiety about the examination.
 Preparation for Assessment
• Throughout the PE, continue to explain what
procedure you are performing and why you are
performing it.
• This help eases your client’s anxiety. It is usually
helpful to integrate health teaching and health
promotion during the examination.
 POSITIONING
1. Sitting position – this position is good for
evaluating the head, neck, lung, chest, back, breast,
axilla, heart, vital signs, and upper extremities.
•This position is also useful because it permits full
expansion of the lungs and it allows the examiner to
assess symmetry of upper body parts.
POSITIONING

Semi-fowler's position - 15
to 45˚

Fowler's position - 60 to 90˚

 POSITIONING
2. Supine position- this position allows the
abdominal muscles to relax and provides easy
access to peripheral pulse sites. Areas assesses with
the client in this position may include head, neck,
chest, breast, axilla, abdomen, heart, lungs and all
extremities
 POSITIONING
3. Dorsal recumbent – this position may be more
comfortable than the supine position for clients with
pain in the back or the abdomen. The abdomen
should not be assessing because the abdominal
muscles are contracted in this position. Areas
assesses with the client in this position may include
head, neck, chest, breast, axilla, heart, lungs and
peripheral pulses
 POSITIONING
4. Sim’s position – this position is useful for
assessing the rectal and vaginal areas, hips and
joints.
•may be used for unconscious clients because it
facilitates drainage from the mouth and prevent
aspiration of fluids
•used for paralyzed clients because it reduces
pressure over the sacrum a
•Clients with joint problems and elderly clients may
have some difficulty maintaining the position
POSITIONING
 POSITIONING
5. Standing position –
this position allows the
examiner to assess posture,
balance, and gait. This
position is also used for
examining the male
genitalia
 POSITIONING
6. Prone position – it is used primarily to assess the
hip joint and back.
•the only bed position that allows ful extension of
the hip and knee joints
•promote drainage from the mouth and is especially
used for unconcious client or those clients
recovering from surgery
• Clients with cardiac and
respiratory problems
cannot tolerate this
position
 POSITIONING
7. Knee-chest – it is useful for examining the
rectum.
•This position may be embarrassing and
uncomfortable for the client; therefore, the client
should be kept the position as limited time as
possible.
 POSITIONING
8. Lithotomy position – it is used to examine the
female genitalia, reproductive tract, and the rectum.
•It is best to keep the client well draped during the
examination and to perform the examination as
quickly as possible
 POSITIONING
9. Orthopneic position –the client sits either in bed
or on the side of the bed with an overbed table
across the lap
•this position facilitates respiration by allowing
maximum chest expansion
•it is helpful to clients who have problems exhaling,
because they can press the
lower part of the chest against
the edge of the overbed table
 POSITIONING
10. Lateral Position -
also called side-lying
position, the client lies
on one side of the body.
•this position helps to
relieve pressure on the
sacrum and heels
 Techniques in Physical
Assessment
1. Inspection – involves using the senses of vision,
smell, and hearing to observe and detect any
normal or abnormal findings.
• Although most of the inspection involves the
use of senses only, a few body systems require
the use of special equipment.
• Note the following characteristics while
inspecting the client; color, patterns, size,
location, consistency, symmetry, movement,
behavior, odors or sounds
Inspection
 Palpation
2. Palpation – it consists of using body parts of the
hands to touch and feel for the following
characteristic;
•texture (rough/smooth),
•temperature (warm/cold),
•moisture (dry/wet),
•mobility (fixed/movable/still/vibrating),
•consistency (soft/hard/fluid-filled),
 Palpation
• strength of pulses (strong/weak/thread/bounding),
• size (small/medium/large),
• shape (well defined/irregular),
• degree of tenderness.
 Types of Palpation
a. light palpation – to perform light palpation, place
your dominant hand lightly on the surface of the
structure.
• There should be very little or no depression (less
than 1cm). feel the surface structure using a
circular motion.
• Use this technique
to feel for pulses,
tenderness, skin
texture, temperature, and moisture
 Types of Palpation
b. moderate palpation – depress the skin surface 1
to 2 cm with your dominant hand, and use a circular
motion to feel for easily palpable body organs and
masses.
•Note the size, consistency, and mobility of
structures you palpate.
 Types of Palpation
c. deep palpation – place your dominant hand on the
skin surface and your nondominant hand on top of
your dominant hand to apply pressure.
•This should result in a surface depression between
2.5 to 5 cm. This allows you to feel very deep organs
or structure
covered with thick
muscle
 Types of Palpation
d. bimanual palpation – use two hands , placing one
on each side of the body part being palpated
(uterus, breast, spleen).
•Use one hand to apply pressure and the other hand
to feel the structure.
•Note the size, shape,
consistency, and mobility of
the structures you palpate.
Types of Palpation
Parts of Hand to use when Palpating

Hand Part Sensitive to

Fingerpads Fine discriminations: pulses,

texture, size, consistency, shape,
crepitus
Ulnar or palmar Vibrations, thrills, fremitus
surface

Dorsal (back) Temperature

surface
 Percussion
Percussion – involves tapping body parts to produce
sound waves. These sound waves or vibrations
enables the examiner to assess underlying
structures.
Uses of percussion includes:
1. eliciting pain – helps detect inflamed underlying
structures
2. determining location, size and shape – percussion
note changes between borders of an organ and its
neighboring organ can elicit information about
location, size, and shape
 Percussion
3. determining density – it helps determine whether
an underlying structure is filled with air or fluid or
is a solid structure
4. detecting abnormal masses – it can detect
superficial abnormal structures or masses
5. eliciting reflexes – deep tendon reflexes are
elicited using the percussion hammer
 Types of Percussion
a. Direct percussion – is the direct tapping of
a body with one or two fingertips to elicit
possible tenderness
 Types of Percussion
b. Blunt percussion – used to detect tenderness over
organs (eg 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.
 Types of Percussion
c. Indirect or mediate percussion – commonly used
method. It produces sound or tone that varies with
the density of underlying structures.
•As density increases, the sound of tone becomes
quieter. Solid tissue produces a soft tone, fluid
produces a louder tone, and air produces an even
louder tone
 Techniques of indirect
percussion
a. Place the middle finger of your nondominant
hand on the body part you are going to percuss
b. Keep your other fingers off the body part being
percussed because they will damp the tone you
elicit
c. Use the pad of your middle finger of the other
hand to strike the middle finger of your
nondominant hand that is placed on the body part
 Techniques of indirect
percussion
d. Withdraw your finger immediately to avoid
damping the tone
e. Deliver two quick taps and listen carefully to the
tone
f. Use quick, sharp taps by quickly flexing your
wrist, not your forearm
Sounds (Tones) Elicited by Percussion

Sounds Intensity Pitch Length Quality Example of

Origin
Resonance Loud Low Long Hollow Normal lung

Hyperresona Very loud Low Long Booming Lung with

nce emphysema
Tympany Loud High Moderate Drumlike Puffed-out
cheek, gastric
bubble

Dullness Medium Medium Moderate Thud-like Diaphragm,

pleural
effusion, liver

Flatness Soft High Short Flat Muscle, bone,

sternum, thigh
 Auscultation
4. Auscultation – type of assessment technique that
requires
•the use of stethoscope to listen for heart sounds,
•movement of blood through the cardiovascular
system,
•movement of the vowel, and
•movement of air through the
respiratory tract.
 Auscultation
• A stethoscope is used because these body sounds
are not audible to the human ear. The sounds
detected are classified according to the
– intensity (loud or soft),
– pitch (high or low),
– duration (length), and
– quality (musical, crackling
or raspy) of the sounds
Guidelines to be followed when
practicing auscultation
1. Eliminate distracting or competing
noises from the environment
2. Expose the body part you are going
to auscultate. Do not auscultate through
the client’s clothing or gown
3. Use the 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
Guidelines to be followed when
practicing auscultation
4. Use the bell of the stethoscope to listen for
low-pitched sounds such as abnormal heart
sounds and bruits (abnormal loud, blowing,
or murmuring sounds).
•Hold the bell lightly on the
body part being auscultated.
 General Considerations for
Examining Older Adults
1. Some positions may be very
difficult or impossible for the older
client to assume or maintain because
of decreased joint mobility and flexibility.
Therefore, try to perform the examination in a
manner that minimizes position changes
2. It is a good idea to allow rest periods for the
older adult, if needed
3. Some older clients may process information at a
slower rate. Therefore, explain the procedure and
integrate teaching in a clear and slow manner.
 Validation of Data
• Validation of data is the process of
confirming or verifying that the
subjective and objective data you
have collected are reliable and
accurate. The steps of validation
include:
1. Deciding whether the data require validation
2. Determining ways to validate the data
3. Identifying areas for which data are missing
 Validation of Data
• Failure to validate data may result in premature
closure of the assessment or collection of
inaccurate data.
• Errors during assessment cause the nurse’s
judgments to be made on unreliable data, which
results in diagnostic error during the analysis of
data (nursing process).
• Thus validation of data collected during
assessment of the client is crucial.
 Conditions that require data to be
rechecked and validated include:
1. Discrepancies or gaps between the
subjective and objective data
2. Discrepancies or gaps between what the
client says at one time versus another time
3. Findings that are highly abnormal and/or
inconsistent with other findings
 Methods of Validation
1. Recheck your own data through a repeat
assessment
2. Clarify data with the client by asking additional
questions
3. Verify the data with another health care
professional
4. Compare your objective findings to uncover
discrepancies
 Documentation of Data
1. The primary reason for documentation of
assessment data is to promote effective
communication among multidisciplinary health
team members to facilitate safe and efficient client
care.
2. Documented assessment data provide the health
care team with a database that becomes the
foundation for care for the client.
 Documentation of Data
3. It helps identify health problems, formulate
nursing diagnoses, and plan immediate and ongoing
interventions
4. If the nursing diagnosis is made without
supporting assessment data, incorrect conclusions
and interventions may result. The initial and
ongoing assessment documentation
database also establishes a way to
communicate with the multidisciplinary
team members.
 Documentation of Data
Guidelines for Documentation – the way that
nursing assessment are recorded varies among
practice settings. However, several general
guidelines apply to all settings with both written
notes and electronic documentation methods. They
include:
1. Keep confidential all documented
information in the client record.
2. Document legibly or print neatly in
nonerasable ink
 Documentation of Data
3. Use correct grammar and spelling. Use only
abbreviations that are acceptable and approved by
the institution
4. Avoid wordiness that creates redundancy
5. Use phrases instead of sentences to record data
6. Record data findings, not how they were
obtained
7. Write entries objectively, without
making premature judgments or diagnoses
 Documentation of Data
8. Record the client’s understanding and perception
of problems
9. Avoid recording the word “normal” for normal
findings. Also the terms good, fair, poor,
sometimes, occasional, frequently, recently, or
some.
10. Record complete information and
details for all client symptoms or
experiences
 Documentation of Data
11. Include additional assessment content when
applicable
12. Support objective data with specific
observations obtained during the physical
examination
 Sample of Documentation of
PE/PA
Name: Patient M Room No. 143
Diagnosis: t/c CNS Infection
General Condition: patient M was still unconscious
and incoherent, with alteration in mental status,
weak in apperance
Vital Signs
BP 140/90 T - 38.2C P - 88 bpm R - 32 bpm
Skin - warm to touch, with rashes on the right upper
extremities,
 Sample of Documentation of
PE/PA
HEENT:
Head - with fairly distributed black hair, no
dandruff, slightly oily
Eyes - with whitish sclera and pinkish conjunctiva,
no other discharges except tears
Ears - both ears are inclined with outer canthus of
both eyes, no cerumen noted
Nose - no nasal discharges, nasal bridge is intact
Throat - no neck defromities, no palpable mass, no
pain or tenderness upon palpation
 Sample of Documentation of
PE/PA
Chest and Thorax - in respiratory distress, use
accessory muscle when breathing, with audible
wheeze upon auscultation
(OB) BUBBLEHEB
B - Breast - engorged, unengorged
U - Uterus - contracted or boggy
B - bladder - (urine) amount? scanty, moderate;
color? yellow, dark yellow
B - bowel - (stool, flatus), soft, hard
 Sample of Documentation of
PE/PA
L - Lochia - rubra 1-3 days red, serosa 4-7
days pinkish, alba 7-14 days brown
E - episiotomy - where? pain
H - Homan's sign - positive or negative
E - emotional status
B - bonding
 Sample of Documentation of
PE/PA
Abdomen - no tenderness, free of masses or
swelling
GUT - voids freely
Extremities - cannot perform of activities of
daily living, and visible weakness
(generalized)
 Verbal Communication of
Data
• Nurses are often in situations in which they are
required to verbally share their subjective and
objective assessment findings.
• They must be able to report assessment findings
verbally in an effective manner to other health
care workers.
• This occurs anytime one health care provider is
transferring client care responsibilities for the
client’s care to another health care provider.
 Verbal Communication of
Data
• This is referred to as ‘handoff.” This handoff may
occur when the agency shifts changes, nurse
leave the unit for a brake or meal, a client is
transferred to another unit or facility, and when a
client leaves his or her unit for a test or
procedure.
The more people that are involved in a
handoff of information the greater the risk of
a communication error.

In order to prevent data communication

errors it is important to:
• Use a standardized method of data
communication such as SBAR.
• Communicate face to face with good eye
contact
• Allow time for the receiver to ask
questions
• Provide documentation of the data you are
sharing
• Validate when the receiver has heard by
questioning or asking him/her to
summarize your report
• When reporting over a telephone, ask the
receiver to read back what he or she heard
your report and document the phone call
with time, receiver, sender and information
shared.
Thank you