Francis Obmerga, PhD, RN Collecting Objective Data 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 (examination) techniques. To become proficient with physical assessment skills, the nurse must have basic knowledge in three areas: 1. Types and operation of equipment needed for the particular examination (e.g., penlight, sphygmomanometer, otoscope, tuning fork, stethoscope) 2. Preparation of the setting, oneself, and the client for the physical assessment 3. Performance of the four assessment techniques: inspection, palpation, percussion, and auscultation Collecting Objective Data • Vital signs • Physical Assessment Vital Signs •Measurable signs of cardiopulmonary and thermoregulatory health status Vital Signs or Cardinal Signs is the person’s ✓Temperature ✓Pulse Rate ✓Respiratory Rate ✓Blood Pressure ✓Pain ✓SP02 Physical Assessment Physical Examination Referring to a critical investigation and evaluation of client status Nursing Process Assessment Diagnosis Evaluation Implementation Planning Physical Assessment How is physical assessment important in the care of my patient? Purposes ▪ Obtain physical data about the client’s functional abilities ▪ Supplement, confirm, or refute data obtained in the client’s health history ▪ Obtain data that will help the nurse establish diagnoses and plan the client’s care ▪ Evaluate the physiologic outcomes of health care and thus the progress of a patient’s health problem ▪ To make clinical judgments about a client’s health status ▪ To identify areas for health promotion and disease prevention It is the FIRST STEP of the Health Care Process. The following are its key components: ▪ Health Interview ▪ Physical Examination ▪ Laboratory or Diagnostic Examination ▪ Records Review A systematic way of collecting objective data from a client using the four examination techniques, to assess or identify current health status. Different Approaches: ▪ Cephalocaudal ▪ Proximodistal ▪ Mediolateral ▪ Outer to Inner ▪ External to Internal The sequence of the assessment differs with children and adults. With children, always proceed from the least invasive or uncomfortable aspect of the exam to the more invasive. Preparing the Patient for Physical Assessment ▪Consider the physiological and psychological needs of the patient. ▪Explain the process to the patient. ▪Explain that physical assessments will not be painful (decrease patient fear and anxiety). ▪Ask the patient to change into a gown and empty bladder. ▪Answer patient questions directly and honestly. Preparing the Environment for Physical Assessment ▪Agree upon a time for the assessment. ➢ The time should not interfere with meals, daily routines, or visiting hours. ▪Patient should be as free of pain as possible. ▪Prepare the examination table. ▪Provide a gown and drape for the patient. ▪Gather the supplies and instruments needed for the assessment. ▪Provide a curtain or screen if the area is open to others. ▪ Introduce self to the client. Verify his identity. Explain the purpose why such procedure is necessary and how he could cooperate (i.e. positioning). ▪ Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder. ▪ Ensure privacy by closing the doors or pulling the curtains around him. ▪ Invite a relative or a significant other to stay with the client, as necessary ▪ Provide adequate lighting. ▪ Gather the equipment: height chart, weighing scale, Snellen’s chart, penlight, card board, sterile gloves, tongue depressor, 4x4 Gauze, tuning fork, stethoscope, wrist watch, tape measure, marker/pencil, record sheet & waste receptacle. ▪ Ensure the examination table is at a comfortable working height. Perform hand hygiene. Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA Equipment needed for PA ▪ Position and drape the client appropriately: o Standing = height / weight measurement; posture (spine), gait & balance o Sitting = vital signs taking; thorax o Supine = posterior thorax; spine o Dorsal recumbent = abdominal palpation o Sim’s / Lateral = rectal area; p. thorax o Prone = posterior thorax o Lithotomy = vaginal examination o Knee-chest =rectal area (for brief periods) SITTING = used to take vital signs STANDING = assessment of posture, gait & balance DORSAL RECUMBENT = used in patient having difficulty maintaining supine position SUPINE = allows relaxation of abdominal muscles SIM’s = assessment of rectum and vagina PRONE = assessment of hip and posterior thorax KNEE-CHEST = assessment of rectal area (for brief period only) LITHOTOMY = assessment of female rectum and vagina. (for a brief period only) Methods of Examination I. P. P. A. Technique INSPECTION Visual examination of the patient done in a methodical, deliberate, purposeful, and systematic manner. Assess moisture, color and texture of the body surfaces, as well as shape, position, size, color, and symmetry of the body. PALPATION Examination of the body using the sense of touch. The use of hand to touch and feel the patient’s skin, organs, mass, and other delineated structures in the body The pads of the fingers are used because of their nerve endings that makes them sensitive to tactile discrimination Assess temperature; turgor; texture; moisture; vibrations; position, size, shape, consistency and mobility of organ or masses; distention; pulsation; and the presence pain upon pressure Palmar surfaces of the examiner's fingertips and finger pads are used for discriminatory sensation, such as texture, vibration, presence of fluid, or size and consistency of a mass The dorsum, or back of the hand, is used to assess surface temperature. Light Palpation Place the hand with fingers together parallel to the skin surface or area being palpated, while moving the hand in circle. Light palpation, light pressure is applied by placing the fingers together and depressing the skin and underlying structures about 1/2 inch (1 cm). Use to check muscle tone and to assess for tenderness Deep palpation is used with caution because pressure can damage internal organs. The skin and underlying structures are depressed about 1 inch (2 cm). To identify abdominal organs and abdominal masses. Two – handed deep palpation place the fingers of one hand on top of those of the other. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensation. Deep Palpation is done with two hands (bimanually) or one hand. Usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed Deep Palpation using lower hand to support the body while the upper hand palpates the organ PERCUSSION Striking of the body surface with short, sharp strokes in order to elicit palpable vibrations and characteristic sound. It is used to determine the location, size, shape, and density of underlying structures; to detect the presence of air or fluid in a body space; and to elicit tenderness. TYPES OF PERCUSSION Direct Percussion - using sharp rapid movements from the wrist, strike the body surface to be percussed with the pads of two, three, or four fingers or with the pad of the middle finger alone. Primarily used to assess sinuses in the adult. Indirect Percussion - percussion in which two hands are used and the plexor strikes the finger of the examiner’s other hand, which is in contact with the body surface being percussed (pleximeter- the middle finger of the nondominant hand). Direct percussion. Using one hand to strike the surface of the body. Indirect percussion. Using the finger of one hand to tap the finger of the other hand. Percussion technique Strike at a right angle to the pleximeter using quick, sharp but relaxed wrist motion. Withdraw the plexor immediately after the strike to avoid damping the vibration. Strike each area twice and then move to a new area. Types of sounds heard when using Percussion ▪ ▪ ▪ ▪ Flat — soft, e.g., thigh area Dull — medium, e.g., liver Resonance — loud, e.g., normal lung Hyperresonance — very loud, e.g., emphysematous lung ▪ Tympany — loud, e.g. puffed-out cheek AUSCULTATION Listening to sounds produced within the body. Characteristics of sound heard when using Auscultation ▪ ▪ ▪ ▪ Pitch Loudness Quality Duration - ranging from high to low - ranging from soft to loud - e.g., gurgling or swishing - short, medium or long Stethoscope bell and diaphragm. Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being auscultated. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell lightly against the body part being auscultated.
