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Collecting Objective Data

The document outlines the process and importance of physical assessment in nursing, detailing the four examination techniques: inspection, palpation, percussion, and auscultation. It emphasizes the need for proper preparation of the physical setting, oneself, and the client, as well as the necessary equipment for effective assessment. Additionally, it provides guidelines on client positioning during the examination and anatomical directional terminology.

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Llaga Francis
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20 views60 pages

Collecting Objective Data

The document outlines the process and importance of physical assessment in nursing, detailing the four examination techniques: inspection, palpation, percussion, and auscultation. It emphasizes the need for proper preparation of the physical setting, oneself, and the client, as well as the necessary equipment for effective assessment. Additionally, it provides guidelines on client positioning during the examination and anatomical directional terminology.

Uploaded by

Llaga Francis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Collecting Objective Data:

THE PHYSICAL EXAMINATION


Prof. Vinz Acena, MAN, RN, RM
OBJECTIVES

Identify and explain the process of Physical Assessment.

Identify the four physical assessment techniques.

Understand the different guidelines involve during


physical examination.

4. Enumerate the importance of physical assessment


techniques.
PHYSICAL EXAMINATION

A systematic way of
collecting objective data
from a client using the four
examination techniques.

To assess or identify
current health status
PURPOSE OF PHYSICAL ASSESSMENT
1. Obtain physical data about the client’s
functional abilities
2. Supplement, confirm, or refute data
obtained in the client’s health history
3. Obtain data that will help the nurse
establish diagnoses and plan the client’s care
PURPOSE OF PHYSICAL ASSESSMENT
4. Evaluate the physiologic outcomes of health
care and thus the progress of a patient’s health
problem
5. To make clinical judgments about a client’s
health status
6. To identify areas for health promotion and
disease prevention
BASIC KNOWLEDGE
IN 3 AREAS A NURSE MUST HAVE!
BASIC KNOWLEDGE IN
3 AREAS A NURSE MUST HAVE!
To become proficient with physical assessment skills, the nurse
must know these basic things:

A. Types and operation of equipment needed for the particular


examination.

B. Preparation of the setting, oneself, and the client for physical


assessment.

C. Performance of the four assessment techniques: inspection,


palpation, percussion, and auscultation.
A. EQUIPMENT

Each part of the physical examination


requires specific pieces of equipment.

Prior to 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.
B1. PREPARING THE PHYSICAL SETTING

1. Comfortable, warm room temperature.

2. Private area free of interruptions from others.

3. Quiet area free of distractions.

4. Adequate lighting
5. Firm examination table or bed at a height that
prevents stooping.
6. A bedside table/ tray to hold the equipment needed
for the examination
B2. PREPARING ONESELF
1. Assess your own feelings and anxieties before examining
the client.

2. Wash your hands before beginning the examination.

3. Always wear gloves if there is a chance that you will come


in direct contact with blood or other body fluids.

4. 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
5. 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
C. PERFORMANCE OF THE 4 ASSESSMENT
TECHNIQUES

Inspection

Palpation

Percussion

Auscultation
A. PREPARATION GUIDELINES
PREPARATORY PHASE
1. Introduce self to the client. Verify his identity.
Explain the purpose why such procedure is necessary
and how he could cooperate (i.e. positioning).

2. Help him put on a clean gown and offer a bedpan


or a urinal to empty his bladder.

3. Ensure privacy by closing the doors or pulling the


curtains around him.
PREPARATORY PHASE
4. Invite a relative or a significant other to stay with
the client, as necessary

5. Provide adequate lighting.

6. Gather the Materials or Equipment.

7. Ensure the examination table is at a comfortable


working height. Perform hand hygiene.
B. MATERIALS/
EQUIPMENT NEEDED
The examiners hand are
the “primary
equipment” for
assessment
Cotton ball
& Paper clip
• Test the sense
of touch
Cotton tipped-
Applicators

• Obtain Specimens
Dental
Mirror

• Visualize mouth and throat


structures.
4x4
Gauze

• Obtain specimens;
• Collect drainage
Examination Gloves/ Clean gloves

Gloves Sterile gloves

• Protect the nurse and patient


from contamination
Goggles

• Protect the nurse’s eyes from


contamination by body fluids
Goniometer

• Measure degree of flexion


and extension of joints
Lubricant

• Provide lubrication for


vaginal or rectal examination
Nasal
Speculum

• Dilate nares for inspection of


the nose
Opthalmoscope
• Inspect the interior
structures of the eye
Otoscope

• Inspect the tympanic


membrane and
external ear canal.
Penlight

• Provide a direct light


source and test pupillary
reaction.
Reflex Hammer

• Test deep tendon reflexes


Ruler, Marked in cm

• Measure organs, masses,


growths, and lesions
Skin- marking pen

• Outline masses or enlarged


organs
Specimen containers

• Collect specimens of body


fluids, drainage, or tissue.
Sphygmomanometer

• Measure systolic and


diastolic blood pressure.
Stethoscope

• Auscultate body sounds


Stadiometer

• Measure the height of the


patient.
Tape Measure

• Measure the circumference


of the head, abdomen, and
extremities.
Thermometer

• Measure body temperature


Tongue Blade

• Depress the tongue during


assessment of the mouth
and throat.
Tuning Fork

• Test Auditory function and


vibratory sensation.
Vision chart
(Snellen Chart)

• Test near and far vision


Weighing Scale

• Measure the weight of the


patient
Watch with
second hand

• Time heart rate, fetal pulse,


or bowel sounds when
counting
POSITIONING
YOUR CLIENT
1. STANDING
(The client stands still in a normal,
comfortable, resting posture)

FOR: assessment of posture, gait &


balance.

CONTRAINDICATION: Patients who


are weak, disabled, or paralyzed may
need assistance or may not be able to
assume this position.
2. SITTING
FOR: Head, neck, posterior and
anterior thorax, breast, axillae,
heart, vital signs, upper extremities
lower, extremities and reflexes

CONTRAINDICATION: Elderly and


weak clients may require support
Semi- Fowler’s Position
30-45 degrees

High Fowler’s Position


90 degrees
3. DORSAL RECUMBENT
(The client lies down on the examination table
or bed with the knees bent, the legs
separated, and the feet flat on the table or
bed)
FOR: Head and neck, axillae, anterior thorax,
lungs, breasts, heart, extremities, peripheral
pulses, vital signs and vagina
4. SUPINE
FOR: head, neck, axillae, anterior
thorax, lungs, abdomen,
extremities, peripheral pulses
CONTRAINDICATION: Tolerated
poorly by clients with
cardiovascular and respiratory
problems
5. PRONE POSITION
(The client lies down on the abdomen
with the head to the side.)
FOR: Posterior thorax, hip joint
movement
CONTRAINDICATION: Often not tolerated
by the elderly and people with
cardiovascular and respiratory problem
6. SIM’S POSITION
(The client lies on the right or left side with the
lower arm placed behind the body and the
upper arm flexed at the shoulder and elbow.
The lower leg is slightly flexed at the knee while
the upper leg is flexed at a sharper angle and
pulled forward.)
FOR: assessment of rectum and vagina
CONTRAINDICATION: Difficult for elderly and
people with limited joint movement
7. LITHOTOMY POSITION
(The client lies on the back with the hips
at the edge of the examination table and
the feet supported by stirrups)
FOR: assessment of female rectum and
vagina.

CONTRAINDICATION: May be
uncomfortable and tiring for elderly
people. Often embarrassing
8. KNEE CHEST POSITION
(The client kneels on the examination table
with the weight of the body supported by the
chest and knees. A 90-degree angle should
exist between the body and the hips. The arms
are placed above the head, with the head
turned to one side)
FOR: assessment of rectal area (for brief
period only)
ANATOMICAL DIRECTIONAL TERMINOLOGY
Example:- Point A is SUPERIOR to point B
-Point C is INFERIOR to point B
Example: Umbilicus is on ANTERIOR
(ventral) surface of the body
Further away from Closer to where arm
where arm or leg or leg inserts into
inserts into body body

*ONLY use when describing 2 points on the SAME limb (arm or leg).
Example: Wrist is DISTAL to elbow
Knee is PROXIMAL to ankle
SYMMETRICAL ASYMMETRICAL

=
THANK YOU!
Prof. Vinz Acena, MAN, RN, RM
Our Lady of Fatima University
Valenzuela Campus

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