COLLECTING OBJECTIVE DATA

• The examiner directly observes objective data. These data

include:
• Physical characteristics (e.g., skin color, posture)
• Body functions (e.g., heart rate, respiratory rate)
• Appearance (e.g., dress and hygiene)
• Behavior (e.g., mood, affect)
• Measurements (e.g., blood pressure, temperature, height,
weight)
• Results of laboratory testing (e.g., platelet count, x-ray
findings).

This type of data is obtained by general observation and by using

the four physical examination techniques: inspection,
palpation, percussion, and auscultation. (IPPA)
• Another source of objective data is the client’s
medical/health record, which is the document that contains
information about what other health care professionals (i.e.,
nurses, physicians, physical therapists, dietitians, social
workers) observed about the client.

• Objective data may also be observations noted by the family

or significant others about the client.
• Objective data include information about the client
that the nurse directly observes during interaction
with the client 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 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
 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.
• As an examiner, you must make sure that you have
prepared for all three aspects before beginning an
examination. Practicing with a friend, relative, or
classmate will help you to achieve proficiency in all
three aspects of preparation.
 1. PREPARING THE PHYSICAL SETTING
• The physical examination may take place in a variety of
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. A portable lamp is helpful for illuminating
the skin and for viewing shadows or contours.
• 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.
• Achieve self confidence in performing a physical assessment
by practicing the techniques on a classmate, friend, or
relative. Encourage your “pretend client” to simulate the
client role as closely as possible.
• Wash your hands before beginning the examination,
immediately after accidental direct contact with blood or
other body fluids, and after completing the physical
examination or after removing gloves. If possible, wash your
hands in the examining room in front of the client. This
assures your client that you are concerned about his or her
safety.
• Always wear gloves if there is a chance that you will come in
direct contact with blood or other body fluids. In addition, 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. Change gloves when moving from a contaminated to a
clean body site, and between patients.
• 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).
 2. APPROACHING AND PREPARING THE
CLIENT
• Establish the nurse–client relationship 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. At the end of the
interview, explain to the client that the physical assessment
will follow and describe what the examination will involve.
• For example, you might say to a client, “Mr. Smith, based on
the information you have given me, I believe that a complete
physical examination should be performed so I can better
assess your health status. This will require you to remove
your clothing and to put on this gown. You may leave on your
underwear until it is time to perform the genital
examination.”
• Respect the client’s desires and requests related to the
physical examination. Some client requests may be simple,
such as asking to have a family member or friend present
during the examination. Another request may involve not
wanting certain parts of the examination (e.g., breast,
genitalia) to be performed.
• In this situation, you should explain to the client the
importance of the examination and the risk of missing
important information if any part of the examination is
omitted. Ultimately, however, whether to have the
examination is the client’s decision. Some health care
providers ask the client to sign a consent form before a
physical examination, especially in situations where a vaginal
or rectal examination will be performed.
• 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. If a urine sample is not necessary, ask the
client to urinate before the examination to promote
an easier and more comfortable examination of the
abdomen and genital areas.

• 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. Leave the room while the client
changes into the gown and knock before reentering
the room to ensure the client’s 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. It is usually helpful to
integrate health teaching and health promotion during the
examination (e.g., breast self-examination technique during
the breast examination).
• 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. Prepare the client for
these changes at the beginning of the examination
by explaining that these position changes are
necessary to ensure a thorough examination of each
body part and system.
 POSITIONING THE CLIENT
SITTING POSITION
• The client should sit upright on the side of
the examination table. In the home or office
setting, the client can sit on the edge of a
chair or bed. This position is good for
evaluating the head, neck, lungs, chest,
back, breasts, axillae, 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. Other clients may be unable to tolerate
the position for any length of time. An
alternative position is for the client to lie
down with head elevated.
SUPINE POSITION
• Ask the client to lie down with the legs together on
the examination table (or bed if in a home setting). A
small pillow may be placed under the head to
promote comfort. If the client has trouble breathing,
the head of the bed may need to be raised. This
position allows the abdominal muscles to relax and
provides easy access to peripheral pulse sites. Areas
assessed with the client in this position may include
head, neck, chest, breasts, axillae, abdomen, heart,
lungs, and all extremities.
DORSAL RECUMBENT POSITION
• 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.
This position may be more
comfortable than the supine
position for clients with pain in the
back or abdomen. Areas that may
be assessed with the client in this
position include head, neck, chest,
axillae, lungs, heart, extremities,
breasts, and peripheral pulses. The
abdomen should not be assessed
because the abdominal muscles are
contracted in this position.
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. This position is
useful for assessing the rectal and vaginal areas. The
client may need some assistance getting into this
position. Clients with joint problems and elderly clients
may have some difficulty assuming and maintaining
this position
STANDING POSITION
• The client stands still in a normal,
comfortable, resting posture. This
position allows the examiner to assess
posture, balance, and gait. This
position is also used for examining the
male genitalia.

PRONE POSITION
• The client lies down on the abdomen
with the head to the side. The prone
position is used primarily to assess the
hip joint. The back can also be
assessed with the client in this position.
Clients with cardiac and respiratory
problems cannot tolerate this position.
 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.
• A small pillow may be used to provide
comfort. The knee–chest position is useful
for examining the rectum. This position
may be embarrassing and uncomfortable
for the client; therefore, the client should
be kept in the position for as limited a
time as possible. Elderly clients and clients
with respiratory and cardiac problems
may be unable to tolerate this position.
• The client lies on the back with the
hips at the edge of the examination
table and the feet supported by
stirrups. The lithotomy position is used
to examine the female genitalia,
reproductive tracts, and the rectum.
The client may require assistance
getting into this position. It is an
exposed position, and clients may feel
embarrassed. In addition, elderly
clients may not be able to assume this
position for very long or at all.
Therefore, it is best to keep the client
well draped during the examination
and to perform the examination as
quickly as possible.
 PHYSICAL EXAMINATION TECHNIQUES
• Four basic techniques must be mastered before you can
perform a thorough and complete assessment of the client.
• These techniques are:
I- inspection,
P- palpation
P- percussion
A- auscultation

• After performing each of the four assessment techniques,

examiners should ask themselves questions that will facilitate
analysis of the data and determine areas for which more data
may be needed.
• These questions include:
– Did I inspect, palpate, percuss, or auscultate any deviations from
the normal findings?
– If there is a deviation, is it a normal physical, gerontologic, or
cultural finding; an abnormal adult finding; or an abnormal
physical, gerontologic, or cultural finding?
– Based on my findings, do I need to ask the client more questions to
validate or obtain more information about my inspection,
palpation, percussion, or auscultation findings?
– Based on my observations and data, do I need to focus my physical
assessment on other related body systems?
– Should I validate my inspection, palpation, percussion, or
auscultation findings with my instructor or another practitioner?
– Should I refer the client and data findings to a primary care
provider?

These questions help ensure that data is complete and accurate and
 INSPECTION
• Involves using the senses of vision, smell, and hearing to
observe and detect any normal or abnormal findings.
• Used from the moment that you meet the client and
continues throughout the examination.
• Precedes palpation, percussion, and auscultation because
the latter techniques can potentially alter the appearance
of what is being inspected.
• Although most of the inspection involves the use of the
senses only, a few body systems require the use of special
equipment (e.g., ophthalmoscope for the eye inspection,
otoscope for the ear inspection).
Use the following guidelines as you practice the technique of
inspection:
• Make sure the room is a comfortable temperature.
• Use good lighting, preferably sunlight.
• Look and observe before touching.
• Completely expose the body part you are inspecting while
draping the rest of the client as appropriate.
• Note the following characteristics while inspecting the
client: color, patterns, size, location, consistency,
symmetry, movement, behavior, odors, or sounds.
• Compare the appearance of symmetric body parts (e.g.,
eyes, ears, arms, hands) or both sides of any individual
body part.
 PALPATION
Palpation consists of using parts of the hand to touch and feel for the
following characteristics:
• Texture (rough/smooth)
• Temperature (warm/cold)
• Moisture (dry/wet)
• Mobility (fixed/movable/still/vibrating)
• Consistency (soft/hard/fluid filled)
• Strength of pulses (strong/weak/thready/bounding)
• Size (small/medium/large)
• Shape (well defined/irregular)
• Degree of tenderness

Three different parts of the hand—the fingerpads, ulnar/ palmar

surface, and dorsal surface—are used during palpation. Each part of
the hand is particularly sensitive to certain characteristics.
 PARTS OF HAND TO USE WHEN PALPATING

Hand Part Sensitive To

Fingerpads Fine discriminations: pulses,

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

Dorsal (back) surface Temperature

Specific instructions on how to perform the four types of
palpation follow:

• 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 1 cm).
Feel the surface structure using a circular motion. Use this
technique to feel for pulses, tenderness, surface skin
texture, temperature, and moisture

• Moderate palpation: Depress the skin surface 1 to 2 cm (0.5

to 0.75 inch) 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.
• 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 and 5 cm (1 and 2
inches). This allows you to feel very deep organs or
structures that are covered by thick muscle.

• Bimanual palpation: Use two hands, placing one on

each side of the body part (e.g., uterus, breasts, spleen)
being palpated. 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.
 PERCUSSION
Involves tapping body parts to produce sound waves. These sound
waves or vibrations enable the examiner to assess underlying
structures. Percussion has several different assessment uses,
including:
• Eliciting pain: Percussion helps to detect inflamed underlying
structures. If an inflamed area is percussed, the client’s physical
response may indicate or the client will report that the area feels
tender, sore, or painful.
• 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.
• Determining density: Percussion helps to determine whether an
underlying structure is filled with air or fluid or is a solid
structure.
• Detecting abnormal masses: Percussion can detect
superficial abnormal structures or masses.
Percussion vibrations penetrate approximately 5 cm
deep. Deep masses do not produce any change in the
normal percussion vibrations.

• Eliciting reflexes: Deep tendon reflexes are elicited

using the percussion hammer.
3 TYPES OF PERCUSSION:
1. Direct percussion - direct tapping of a body part with one
or two fingertips to elicit possible tenderness (e.g.,
tenderness over the sinuses)
2. Blunt percussion - used to detect tenderness over organs
(e.g., 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
3. Indirect percussion - is the most commonly used method
of percussion. The tapping done with this type of
percussion produces a sound or tone that varies with the
density of underlying structures. As density increases, the
sound of the tone becomes quieter. Solid tissue produces a
soft tone, fluid produces a louder tone, and air produces an
even louder tone.
These tones are referred to as percussion notes and
are classified according to origin, quality, intensity,
and pitch.
 AUSCULTATION
• A type of assessment technique that requires the use
of stethoscope to listen heart sounds, movement of
blood through the cardiovascular system, movement
of the bowel and movement of air through the
respiratory tract.
• Stethoscope is used because these body sounds are
not audible to the human ear.
Classification of sounds:

• Intensity (loud or soft)

• Pitch (High or low)
• Duration (Length)
• Quality (Musical, crackling, raspy)
Guidelines when practicing auscultation:

• Eliminate distracting or competing noises from the

environment
• Expose body part you are going to auscultate.
• Use diaphragm of the stethoscope for high pitched
sounds (normal heart sounds, breath sounds &
bowel sounds), press diaphragm firmly
• Use bell of the stethoscope for low pitched sounds
(abnormal heart sounds and bruits) hold bell lightly
 VALIDATING ASSESSMENT DATA
• Is a crucial part of assessment that often occurs along with
collection of subjective and objective data.

• It serves to ensure that the assessment process is not ended

before all relevant data have been collected, and helps to
prevent documentation of inaccurate data.

• What types of assessment data should be validated, the

different ways to validate data, and identifying areas where
data are missing are all parts of the process.
 DOCUMENTING DATA
• Documentation of assessment data is an important step of
assessment because it forms the database for the entire
nursing process and provides data for all other members of the
health care team.
• Thorough and accurate documentation is vital to ensure that
valid conclusions are made when the data are analyzed in the
second step of the nursing process. Chapter 4 discusses the
types of documentation, purpose of documentation, what to
document, guidelines for documentation, and different types
of documentation forms (Fig. 1-10).
 ANALYSIS OF ASSESSMENT DATA/ NURSING
DIAGNOSIS: STEP TWO OF THE NURSING PROCESS
• Analysis of the collected data goes hand in hand with the
rationale for performing a nursing assessment. The purpose of
assessment is to arrive at conclusions about the client’s health.
• Nurses often begin to analyze the data in their minds while
performing assessment. To achieve the goal or anticipated
outcome of the assessment, the nurse makes sure that the data
collected are as accurate and thorough as possible.
• During this phase, you analyze and synthesize data to
determine whether the data reveal a nursing concern (nursing
diagnosis), a collaborative concern (collaborative problem), or a
concern that
• to another discipline (referral).
• A nursing diagnosis is defined by the North American Nursing
Diagnosis Association (NANDA, 2012–2014) as “a clinical
judgment about individuals, family or community responses
to actual and potential health problems and life processes.
• A nursing diagnosis provides the basis for selecting nursing
interventions to achieve outcomes for which the nurse is
accountable.
• Collaborative problems are defined as certain “physiological
complications that nurses monitor to detect their onset or
changes in status” (Carpenito, 2012). Nurses manage
collaborative problems by implementing both physician- and
nurse-prescribed interventions to reduce further
complications
 PROCESS OF DATA ANALYSIS

• To arrive at nursing diagnoses, collaborative problems, or

referral, you must go through the steps of data analysis. This
process requires diagnostic reasoning skills, often called
critical thinking.
• The process can be divided into seven major steps:
1. Identify abnormal data and strengths.
2. Cluster the data.
3. Draw inferences and identify problems.
4. Propose possible nursing diagnoses.
5. Check for defining characteristics of those diagnoses.
6. Confirm or rule out nursing diagnoses.
7. Document conclusions.