Collecting Objective Data Flashcards
1
Q
- Reproducible findings
- True for the patient and for you
- True for you and others
- FACT
A
OBJECTIVE DATA
2
Q
PURPOSE OF PHYSICAL EXAMINATION
A
- Obtain baseline data about the client’s functional abilities
- Supplement, confirm, or refute data obtained in the nursing history
- Obtain data that will establish nursing diagnosis and plan
- Evaluate the physiological outcomes of healthcare
- Make clinical judgments about client’s health status
- Identify areas of health promotion and disease prevention
- Discover you patient’s strengths
3
Q
Types of physical assessment
A
- Complete
- Focused
4
Q
- Body system (cardiovascular system)
- Body area/ Regional (Lungs)
A
Focused Physical Examination
5
Q
Establish or monitor health status
A
Complete Physical Examination
6
Q
Components of Complete Physical Examination
A
- General survey
- Vital signs
- Head
- Neck
- Upper extremities
- Chest and back
- Abdomen
- External genitals
- Anus
- Lower extremities
7
Q
Focused Physical Examination
Used when:
A
- patient is unstable
- Time constraints exist
- Episodic follow-up
8
Q
is used when patient is unstable, time constraints exist and episodic follow-up
A
Focused Physical Examination
9
Q
Focused Physical Examination
Components:
A
- General survey
- Vital signs
- Assessment of the specific area or system
- Quick cephalocaudal scan
10
Q
Situation:
Client complains of abdominal pain
A
inspect, auscultate, percuss and palpate the abdomen; assess vital signs
11
Q
Situation:
The client’s fluid intake is minimal
A
assess tissue turgor, fluid intake and output, and vital signs
12
Q
Preparation
A
- Yourself
- The environment
- The patient
13
Q
Preparing yourself
A
- Identify yourself
- Appear calm and organized
- As a beginner, avoid interpreting your findings
- Observe standard and universal precaution
14
Q
Preparing client
A
- Explain where and when the examination will take place
- Explain what will happen during the examination
- Determine contraindicated positions
- Empty the bladder before the examination
- If examining a child, start with least invasive/ uncomfortable aspect
15
Q
Preparing the Environment
A
- Temperature
- Lighting
- Privacy and noise
- Positioning
- Draping
- Instrumentation
- Methods of Examining
16
Q
Positioning
Consider
A
- Client’s ability to assume a position
- Physical condition
- Energy level
- Age
17
Q
Different Position
A
Sitting
Supine
Dorsal recumbent
Lithotomy
Prone
Sim’s
Knee chest position
18
Q
A seated position, back unsupported and legs hanging freely
A
Sitting
19
Q
Back-lying position with legs extended; with or without pillow under the head
A
Supine
20
Q
Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface
A
Dorsal recumbent
21
Q
Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table
A
Lithotomy
22
Q
Lies on abdomen with head turned to the side, with or without a small pillow
A
Prone
23
Q
Side-lying position with lowermost arm behind the body,
uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
A
Sim’s
24
Q
knees and chest with head is turned to one side, arms extended on the bed, and elbows flexed and resting
A
Knee chest position
25
- Provide privacy and warmth
- Expose only the area to be assessed
Draping
26
Ensure equipment are clean, in good working condition, readily accessible
Instrumentation
27
Designate one area for clean/ unused and another area for dirty/ used
Instrumentation
28
Thermometer
Types:
- Glass mercury thermometer
- Electronic digital thermometer
- Tympanic thermometer
- Temporal artery thermometer
- Disposable paper strips
29
Used in indirect auscultation
Stethoscope
30
Stethoscope tubing should be ________________ long
30 to 35cm
31
Stethoscope internal diameter of
0.3m
32
- Fetal heart sounds
- Locate pulses
Doppler
33
Sphygmomanometer
- Cuff width should be __________ of the arm circumference
40%
34
Sphygmomanometer
Cuff bladder encircle ______________of the arm
80%
35
To assess far and near vision
Visual acuity chart
36
Far vision adult:
20 feet
37
Far vision children:
10 feet
38
vision:
14 inches
39
- Test each eye separately then both eyes together
- Test with and without correction glasses
- No more than 2 mistakes
Visual acuity chart
40
Visual acuity charts (types)
- Snellen eye chart
- E chart
- STYCAR test cards
- Pocket vision screener
41
- Eyes
- Hard-to-see places
Penlight
42
- Assess the internal structures of the eyes
- Always use in dark room
- Right- to- right
- Left- to- lef
Ophthalmoscope
43
Always palpate the _____________________________ for tenderness before inserting an otoscope, if tender proceed carefully
tragus, helix, mastoid process
44
Using Otoscope/Nasoscope on adults:
pull the helix up
45
Using Otoscope/Nasoscope for preschool child
pull the earlobe down
46
- Assess hearing and vibratory sensation
Tuning fork
47
testing vibratory sensation
Low frequency fork (256Hz)
48
assessing hearing
High frequency fork (512Hz)
49
- Lengths and circumferences
- Abdominal girth
- Fundal height
Tape measure/ pocket ruler
50
To assess range of motion exercises
Goniometer
51
Used to measure body fat
Triceps skin fold calipers
52
Used to measure weight
scale
53
- Better visualization of the pharynx
- Assessing gag reflex
Wooden tongue depressor
54
- Used during neurological examination:
- Light touch
- Corneal reflex
Cotton balls
55
Assess hot and cold sensation
Test tubes
56
Assess the sense of smell:
Coffee
57
Assess sense of taste
Sugar and lemon
58
Swallowing ability and thyroid
Cup of water
59
Assess for stereognosis
Paper clip
60
- Assess light touch and pain
- Discard after use
Safety Pin
61
Use when there is risk for exposure to blood or body fluids
Gloves
62
Techniques of Physical Examination
- Inspection
- Palpation
- Percussion
- Auscultation
63
General guidelines
- Be systematic
- Use you patient as a comparative
- Always consider your patient’s growth and developmental stage
64
Inspection
- Visual examination
- Assessing using sense of sight
- Moisture
- Color
- Texture of the body surface
- Shape, size, position, color and symmetry of the body
- Also use sense of hearing and smell
- Use your patient as a comparative
65
- Visual examination
- Assessing using sense of sight
- Moisture
- Color
- Texture of the body surface
- Shape, size, position, color and symmetry of the body
- Also use sense of hearing and smell
- Use your patient as a comparative
Inspection
66
Types of Inspection
- Direct inspection
- Indirect inspection
67
- Use of sense of touch
- Surface characteristics, texture, consistency, temperature
- Masses, organs, pulsation, muscle rigidity, chest excursion
- Able to differentiate areas of tenderness from pain
Palpation
68
Temperature
dorsal aspect of the hand
69
vibration
ball of the hand on palm and ulnar surface
70
fine sensation (pulsations)
finger pads
71
types of palpation
- light palpation
- deep palpation
72
Light palpation
- Temperature, texture, mobility, shape, size
- Pulses
- Areas of edema
- Tenderness
73
Deep palpation
- Organ size, masses
- Rebound tenderness
- Voluntary guarding
- Ballottement
74
Striking a body surface with quick, light blows and eliciting vibrations and sounds
Percussion
75
Percussion
Assess:
- Density of underlying structure
- Areas of tenderness
- Deep tendon reflexes
76
Types of percussion:
- Direct/Immediate Percussion
- Indirect Percussion
- Fist or Blunt Percussion
77
Directly tapping your hand over a body surface
Direct/Immediate Percussion
78
- Plexor, pleximeter technique
- Percussion hammer
Indirect Percussion
79
- Assess organ tenderness
- Can be direct or indirect
Fist or Blunt Percussion
80
▪ Use of sense of hearing
▪ Assess heart sounds, lung sounds, bowel sounds, vascular sounds
▪ Pitch (medium, high or low) oIntensity (soft or loud)
▪ Duration (short or long)
▪ Quality
Auscultation
81
Types of Auscultation:
- Direct Auscultation
- Indirect Auscultation
82
- Without stethoscope
- Respiratory congestion
Direct Auscultation
83
With stethoscope
Indirect Auscultation
84
Patients with special needs
- Children
- Pregnant patients
- Elderly
- Disabled patients
85
Adopt an age appropriate approach:
- Infants
- Children 1 to 2 years old
- Children 2 to 3 years old
- Children 4 to 5 years old
- School- age children
- Adolescent
- Look for normal growth and developmental changes
Children
86
Pregnant Patients
- Assess both mother and fetus
- Include fundal heights and fetal heart tones
- Assess for physiologic changes
- Include nutritional assessment
- Remember that patients may have difficulty changing positions
- Patients may have mood swings
87
Elderly patients
- Do not rush
- Look for developmental changes
- Conserve your patient’s energy
- Allow enough time to respond
88
Disabled patients
- Identify the disability
- Focus on patient’s functional ability and mental capacity
- Modify as necessary
89
is a systematic study of right and wrong conduct in situations that involve issues of values and morals
Ethics
90
consider in a broad, general manner what is good or bad, right or wrong
Morals
91
are set of enforceable principle and rules established to protect society.
Laws
92
is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including benefits and risks of treatment, alternatives to treatment and prognosis if not treated by a health care provider.
Informed Consent
93
2 Types of Consent
- Express Consent
- Implied Consent
94
- Either oral or written agreement
- The more invasive procedure or the greater potential for risk to the client, the greater the need for written permission.
Express Consent
95
Exists when the individual’s nonverbal behavior indicates agreement
Implied Consent
96
reponsible for obtaining informed consent for specific medical and surgical treatment.
Primary care provider, usually the physician
97
may obtain informed consent for procedures that he/she will perform as a dependent nursing intervention (e.g. NGT insertion, drug administration).
Nurse
98
ELEMENTS OF AN INFORMED CONSENT
- Completeness (Disclosure)
- Comprehension
- Voluntariness
- Competence
99
Patients need a great deal of information to make educated decision.
Completeness (Disclosure)
100
The patient (or his surrogate decision maker) must understand the explanation.
Comprehension
101
The patient must be free to accept or reject the treatment.
Voluntariness
102
The person must have the capacity to understand the information and make a choice about his situation.
Competence
103
3 groups of people who cannot provide consent
- Minors
- Unconscious/injured
- Mentally Ill
104
Be sure to make a record of all interaction with clients, as well as the patient’s refusal or noncompliance with treatment.
Charting
105
Charting should always be:
F – Factual
A – Accurate
C – Complete
T – Timely
106
Done if a standard care is breached or an unusual incident occurs (e.g. a visitor or patient falls or is somehow injured)
Incident Report
107
is a law that seeks to protect all forms of information, be it private, personal, or sensitive. It meant to cover both natural and juridical persons involved in the processing of personal information.
RA No. 10173 or Data Privacy Act
108
Any information whether recorded in a material form or not, from which the identity of an individual is apparent or can reasonably and directly ascertained by the entity holding the information, or when put together with other information would directly and certainly identify an individual.
Personal information
109
SENSITIVE PERSONAL INFORMATION
1. race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations;
2. health, education, genetic or sexual life of a person;
3. civil, criminal or administrative proceedings
4. unique identifiers issued by government agencies peculiar to an individual;
5. specifically established by law as classified
110
Any operation or any set of operations performed upon personal information including, but not limited to, the collection, recording, organization, storage, updating or modification, retrieval, consultation, use, consolidation, blocking, erasure or destruction of data.
Processing
111
a person or organization who controls the collection, holding, processing or use of personal information, including a person or organization who instructs another person or organization to collect, hold, process, use, transfer or disclose personal information on his or her behalf.
Personal Information Controller
112
An individual whose personal information is processed
Data subject
113
DATA PRIVACY PRINCIPLES
- Transparency
- Legitimate purpose
- Proportionality
114
A data subject must be aware of the nature, purpose, and extent of the processing of his or her personal data, including the risks and safeguards involved, the identity of
personal information controller, his or her rights as a data subject, and how these can be exercised.
Transparency
115
The processing of information shall be compatible with a declared and specified purpose, which must not be contrary to law, morals, or public policy.
Legitimate purpose
116
The processing of information shall be adequate, relevant, suitable, necessary, and not excessive in relation to a declared and specified purpose.
Proportionality
117
begins with the opening moments of the patient encounter
GENERAL SURVEY/STATUS
118
“First impression” of your patient
- Use your senses and observation skills
GENERAL SURVEY/STATUS
119
- Is the patient acutely or chronically ill?
- Is the patient frail?
- Is the patient fit or robust?
- Is the patient overweight or underweight?
Apparent State of Health
120
- Is the patient awake, alert, and responsive to you and others in the environment?
- Is the patient drowsy, lethargic or stuporous?
- Is the patient unconscious?
LEVEL OF CONSCIOUSNESS
121
- Is there clutching of the chest?
- Is there pallor? Cyanosis? Diaphoresis?
- Is there labored breathing, wheezing, or coughing?
SIGNS OF DISTRESS
122
Is there wincing, diaphoresis, protectiveness of a painful area, grimacing, or unusual posture favoring one limb or region of the body?
Pain
123
Are there any anxious facial expressions, fidgety movements, cold moist palms, inexpressive or flat affect, poor eye contact, or psychomotor slowing?
Anxiety or Depression
124
- Observe facial expression at rest, during conversation and social interactions, and during the physical examination
- Ask yourself what is the patient’s face telling me?
- Do you see pain, fear, or anxiety?
- Does the patient maintain eye contact?
- Is his/her facial expression happy or sad?
- Look at the facial features. Are they symmetrical?
Facial Characteristics
125
Drooping of the eyelid
Ptosis
126
May indicate a transient ischemic attack or stroke.
Drooping on one side of the face
127
- Bulging or protruding eyeballs
- May suggest hyperthyroidism
Exopthalmos
128
Pale complexion or unusual lightness of skin color, may indicate anemia, malnutrition, vitamin deficiency
Pallor
129
Bluish discoloration of the skin or mucous membrane, may indicate poor oxygenation.
Cyanosis
130
Yellowish discoloration of the skin or mucous membranes; may suggest an underlying hepatobiliary tract disease.
Jaundice
131
Medical term for a mole, a common benign skin lesion but some may be malignant.
Nevus
132
may reflect cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences
Excess Clothing
133
suggest gout, bunions, edema, or other painful foot conditions
Holes or slippers
134
can contribute to foot and back pain, calluses, falls, and infection
Run-down shoes
135
suggest joint pain; studies show that wearing copper jewelry may ease arthritic pain
Copper bracelets
136
can be associated with alcohol and drug use
Jewelries, tattooes, and body piercings
137
They may be clues to the patient’s personality, mood,
lifestyle, and self-regard
Hair, finger nails, and use of make up
138
suggest the length of a possible illness
“Grown-out” hair and nail polish
139
may suggest high levels of ketones
fruity odor/acetone breath
140
a complication of Type 1 diabetes
diabetic ketoacidosis
141
A disorder where your body makes too much cortisol
Cushing’s syndrome
142
excessive abdominal fat
Truncal obesity
143
collection of excess fat behind the neck
Buffalo hump
144
May reflect a cardiopulmonary problem
Nail clubbing and edema
145
May reflect arthritic changes
Deformities
146
sitting upright
Left-sided heart failure
147
leaning forward with arms braced
COPD (Chronic obstructive pulmonary disease)
148
is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing
Review of Systems
149
Estimated Due of Confinement or Estimated Due Date Last Menstrual Period
Nagele’s Rule
150
Obstetric / Gynecologic History
GTPAL
Gravida (# of Pregnancy)
Term
Preterm
Abortion
Children Living
151
woman who is or has been pregnant
Gravida
152
woman who has never has been pregnant
Nulligravida
153
first time pregnant
Primigravida
154
pregnant more than once
Multigravida
155
past pregnancies that have reached viability (24 AOG)
Para
156
has never completed to period of viability
Nullipara
157
completed one pregnancy regardless the result
Primipara
158
completed two or more pregnancies
Multipara
159
USE specific RULES, THEORIES, principles, and PERSPECTIVES TO inquire into THE justification of ah individual’s action in a PARTICULAR situation
ETHICS
160
They should be told everything they would
consider important in making a treatment
decision
Completeness (disclosure)
161
Ask the patient to describe in his own words
the procedure to which he is consenting
Comprehension
162
- He must not be pressured or coerced to give consent
- There must be no actual or implied threat
Voluntariness
163
REPORTING AND DOCUMENTING
REMEMBER:
If it isn’t documented, it wasn’t done
164
When you first see a patient…
OBSERVE and ASSESS!!!
165
May suggest an underlying neurological disorder
Ptosis
166
Ptosis may suggest an underlying neurological disorder. Example?
Bell’s Palsy, Myasthenia gravis
167
Manner of walking
Gait
168
are rhythmic oscillatory movements
Tremors
169
Three Groups of Tremors
- Resting (or Static) Tremors
- Postural Tremors
- Intention Tremors
170
may present with changes in voice quality
Cranial nerve IX lesion
171
are most prominent at rest and may decrease or diappear with voluntary movement.
Resting (or Static) Tremors
172
appear when the affected part is actively maintaing a posture
Postural Tremors
173
are rhythmic, repetative, bizzare movements hat chiefly involve the face, mouth, jaw and tongue grimacing, pursinf of the li[s, protrusions of the tongue, opening and closing of the mouth, and deviations of the jaw
Oral-Facial Dyskinesias
174
are brief, repetitive, coordinated movements occuring at irregular intervals
Tics
175
are similar to athetoid movements, but often involve larger parts of the body, including the trunk
Dystonia
176
are slower and more twisting and writhing than choreiform movements,a nd ahve a larger amplitude
Athetosis
177
are brief, rapid, jerky, irregular and unpredictable. they occur at rest or interrupt normal coordinated movements
Chorea
178
Level of Consciousness (Arousal): Techniques
Alertness
Lethargy
Obtundation
Stupor
Coma
179
speak to the patient in a normal tone voice
alertness
180
speak to the patient in a loud voice
lethargy
181
shake the patient gently as if awakening a sleeper
obtundation
182
apply a painful stimulus
stupor
183
apply repeated painful stimuli
coma
184
- Is there clutching of the chest?
* Is there pallor? Cyanosis? Diaphoresis?
* Is there labored breathing, wheezing, or coughing?
Cardiac or Respiratory Distress
185
* How is the patient dressed? * Is the clothing suitable for the temperature and weather? Is it clean and appropriate to the setting?
* Excess clothing may reflect cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences
Clothing
186
- View your patient’s body size and build with respect to his or her age and gender
* Is he/she stocky, slender, or of average build? Obese or
cachectic? Proportional?
* Does you patint have abnormal fat distribution?
* Take a close look at the patient’s hand. Do you see clubbing, edema or deformities?
Body Type
187
may reflect a cardiopulmonary problem
Nail clubbing and edema
188
are rhythmic oscillatory movements
tremors
189
3 groups of tremors
resting (static) tremors
postural tremors
intention tremors
