HEALTH ASSESSMENT | NCM 101

COLLECTING OBJECTIVE DATA

• Begin the examination with the less intrusive procedures such

INTRODUCTION TO OBJECTIVE DATA
as V/S, height, and weight
OBJECTIVE DATA
• Throughout the examination, continue to explain what
• Data directly observed by the examiner. procedure you are performing and why you are performing it.
• Data include: • Approach the client from the right-hand side of the examination
1. physical characteristics (skin color, posture) table or bed because most examination techniques are
2. body functions (HR, RR) performed with the examiner’s right hand.
3. appearance (dress, hygiene) • You may ask the client to change positions frequently,
4. behavior (mood, affect) depending on the part of the examination being performed.
5. measurement (BP, Temp, Ht, Wt)
VARIOUS POSITIONS USED TO PERFORM PHYSICAL
6. results of laboratory testing (platelet count, CXR)
EXAMINATION
• Requires basic knowledge in:
1. Sitting
1. Types of and operation needed for the particular
2. Supine
examination
3. Dorsal recumbent position
2. Preparation of the setting, oneself, and the client for the
4. SIM’S position
PA
5. Standing position
- Setting
6. Prone position
- Self
7. Knee-chest position
- Client
8. Lithotomy position
3. Performance of the four assessment techniques: IPPA
(Inspection, Palpation, Percussion, Auscultation)
• The examination setting whether it is in any setting should meet
the following conditions:
o Comfortable, warm room temperature
o Private area free of interruptions from others
o Quiet area free of distractions
o Adequate lighting
o First examination table or bed at a height that prevents
stooping
o A bedside table/tray to hold the equipment needed for the
examination
PREPARING ONESELF
• Assess your own feelings and anxieties before examining the
client.
• Observe the standard precaution – handwashing
o Washing of the hands
o Wear gloves
EQUIPMENTS FOR NUTRITIONAL STATUS EXAMINATION
o Wear mask and protective eye googles if performing an
1. Skinfold calipers
examination
2. Flexible tape measure
o Wear a gown to protect the skin and to prevent spoiling of
3. Skin marking pen
clothing during procedures
4. Platform scale with height attachment
o Patient Care Equipment
o Environmental Control EQUIPMENTS FOR NAIL, HAIR, SKIN
o Linen 1. Examination light
o Occupational Health and Bloodborne pathogen 2. Metric ruler (6 in)
o Patient placement 3. Flashlight
APPROACHING AND PREPARING THE CLIENT 4. Magnifying glass
5. Mirror
• Establish the nurse-client relationship during the client
6. Wood’s light
interview before the PE takes place
7. Braden scale
• At the end of the interview, explain to the client that the PA will
follow and describe what the examination will involve.
• Respect the client’s desires and requests related to the PE.
 HEALTH ASSESSMENT | NCM 101
COLLECTING OBJECTIVE DATA

EQUIPMENTS FOR HEAD AND NECK 3. Large swabs

1. Stethoscope 4. Liquid perp medium
2. Small cup of water
FOUR ASSESSMENT TECHNIQUES
EQUIPMENTS FOR EYE
1. Inspection
1. Penlight
2. Palpation
2. Snellen E chart
3. Percussion
3. Newspaper
4. Auscultation
4. Opaque card
1. INSPECTION
5. Ophthalmoscope
• This is usually the first assessment technique used during
EQUIPMENTS FOR EAR the assessment process.
1. Tuning fork • This is an ongoing process used throughout the entire
2. Otoscope physical assessment and patient encounter.
EQUIPMENTS FOR MOUTH, THROAT, NOSE, SINUS • This is with the use of one’s sense of vision and smell to
1. Penlight consciously observe the patient.
2. 4x4 in small gauze pad • Use of one’s vision and smell
3. Tongue depressor • Careful observation
4. Otoscope • Tangential lighting if necessary
EQUIPMENTS FOR THORACIC AND LUNGS 2. PALPATION
1. Stethoscope • Involves using parts of the hand to touch and feel for the
2. Metric ruler following characteristics:
3. Skin marking pen o Texture – rough or smooth
o Temperature – warm or cold
EQUIPMENTS FOR HEART AND NECK VESSEL
o Moisture – dry or wet
1. Stethoscope
o Mobility –fixed, movable, still, vibrating
2. Metric ruler
o Consistency – soft, hard, fluid-filled
EQUIPMENTS FOR ABDOMINAL o Strength of pulses – (strong/weak/thread)
1. Stethoscope o Size – small, medium, large
2. Flexible tape measure o Shape –well defined, irregular
3. Skin marking pen o Degree of tenderness
4. Two small pillows • TIPS:
EQUIPMENTS FOR MUSCULOSKELETAL o Warm hands
1. Flexible tape measure o Short nails
2. Goniometer o Inform patient when, where, and how the touch will
occur
EQUIPMENTS FOR NEUROLOGIC
• PARTS OF HANDS USED:
1. Cotton tipped applicators
o Fingerpads – fine discriminations, pulses, texture,
2. Newspaper
size, consistency, shape, crepitus
3. Ophthalmoscope
o Ulnar/palmar surface – vibrations, thrills, fremitus
4. Flexible tape measure
o Dorsal surface – temperature
5. Objects to feel (reflex hammer, cotton ball, paper clip)
• Crepitus is a symptom characterized by a crackling or
6. Substances to smell and taste
grating feeling or sound under the skin, around the lungs
7. Snellen E chart
or in the joints. In soft tissues, crepitus is often due to gas,
8. Penlight
most often air, that has abnormally penetrated and
9. Tongue depressor
infiltrated an area (for example, in the soft tissues beneath
10. Tuning fork
the skin).
EQUIPMENTS FOR MALE GENITALIA AND RECTUM
o In a joint, crepitus can indicate cartilage wear in the
1. Gloves and water-soluble lubricant joint space. The term "crepitus" is derived from the
2. Penlight Latin, meaning "a crackling sound or rattle." Typically,
3. Specimen card crepitus is a grinding noise coupled with a sensation
EQUIPMENTS FOR FEMALE GENITALIA AND RECTUM in the affected joint. Crepitus can occur with or
1. Vaginal speculum and water-soluble lubricant without pain.
2. Bifid spatula
 HEALTH ASSESSMENT | NCM 101
COLLECTING OBJECTIVE DATA

• TYPES OF PALPATION: 5. Hyper resonance

1. Light palpation - heard over mostly air
- very little or no pressure (less than 1 cm) - lung with emphysema
- feel the structure using a circular motion - very loud, low, long, booming
- use: feel pulses, tenderness, surface skin texture, 4. AUSCULTATION
temperature, moisture • Listening to sounds produced by the body (heart, lungs,
2. Moderate palpation blood vessels, abdomen)
- depress the skin surface 1 to 2 cm • Stethoscope: does not magnify sound but does block out
- size, consistency, mobility extraneous room sounds
3. Deep palpation • CLASSIFICATIONS:
- place dominant hand on the skin surface and 1. Intensity: loud, soft
nondominant hand on top of the dominant hand 2. Pitch: high, low
to apply pressure (2.5-5 cm or 1 to 2 inches) 3. Duration: length
- feel very deep organs or structures that are 4. Quality: musical, crackling, raspy
covered with thick muscles • Diaphragm: for high-pitched sounds
4. Bimanual palpation - normal heart sounds, breath sounds, bowel sounds
- use two hands, placing one on each side of the - hold the diaphragm firmly against the person’s skin
body part (uterus, breasts, spleen) being - firm enough to leave a slight ring afterward
palpated • Bell: for low-pitched sounds
- one hand apply pressure, other hand feel - abnormal heart sounds and bruit (abnormal loud,
structure blowing, or murmuring sounds)
- size, shape, consistency, mobility - FHT
3. PERCUSSION - Hold lightly against the person’s skin just enough that
• Involves tapping the body parts to produce sound waves it forms a perfect seal; any harder causes the skin to
• The sound waves or vibrations enable the examiner to act as a diaphragm, obliterating the low-pitched
assess the underlying structures sounds
• Uses: • These guidelines should be followed as you practice the
o Determining location, size, and shape technique of auscultation:
o Determining density 1. Eliminate distracting or competing noises from the
o Detecting abnormal masses environment (TV, radio, machinery)
o Eliciting pain 2. Expose the body part you are going to auscultate. Do
o Eliciting reflexes not auscultate through the client’s clothing or gown.
• TYPES OF PERCUSSION: 3. Use the diaphragm of the stethoscope to listen for
1. Direct high pitched sounds, such as normal heart sounds,
2. Blunt and bowel sounds, and press the diaphragm firmly on
3. Indirect the body part being auscultated.
• PERCUSSION SOUNDS: 4. Use the bell of the stethoscope to listen for low-
1. Resonance pitched sounds such as abnormal heart sounds and
- heard over part air and part solid bruits (abnormal loud, blowing, or murmuring
- normal lung sounds). Hold the bell lightly on the body part being
- loud intensity, low pitch, long (length), hollow auscultated.
(quality)
2. Dullness
- over more solid organs (diaphragm, liver)
- medium, medium, moderate, thudlike
3. Flatness
- over very dense tissue (muscle, bones, sternum,
thigh)
- soft, high, short, flat
4. Tympany
- heard over air
- puffed out cheek, gastric bubble
- loud, high, moderate, drumlike