Collecting Objective Data Flashcards
SUBJECTIVE DATA
▪ Perception
▪ Opinion
▪ True for the patient
▪ May or may not be true to you
OBJECTIVE DATA
▪ Reproducible findings
▪ True for the patient and for you
▪ True for you and others
▪ FACT
PURPOSE OF PHYSICAL EXAMINATION
▪ 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
Types of physical assessment
▪ Complete
▪ Focused
Types of Focused
- Body system (cardiovascular
system) - Body area/ Regional (Lungs
Establish or monitor health status
Complete Physical Examination
Components of Complete Physical Examination
✓ General survey
✓ Vital signs
✓ Head
✓ Neck
✓ Upper extremities
✓ Chest and back
✓ Abdomen
✓ External genitals
Focused Physical Examination
Used when:
▪ patient is unstable
▪ Time constraints exist
▪ Episodic follow-up
Focused Physical Examination
Components:
▪ General survey
▪ Vital signs
▪ Assessment of the specific area or system
▪ Quick cephalocaudal scan
PA Preparation
▪ Yourself
▪ The environment
▪ The patient
PA Preparing Yourself
▪ Identify yourself
▪ Appear calm and organized
▪ As a beginner, avoid interpreting your
findings
▪ Observe standard and universal precaution
PA Preparing client
▪ 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
PA Preparing the Environment
▪ Temperature
▪ Lighting
▪ Privacy and noise
▪ Positioning
▪ Draping
▪ Instrumentation
▪ Methods of Examining
Positioning Consider
▪ Client’s ability to assume a position
▪ Physical condition
▪ Energy level
▪ Age
Different Position
Sitting
Supine
Dorsal Recumbent
Lithotomy
Prone
Sim’s
Knee Chest Position
A seated position, back
unsupported and legs hanging freely.
Sitting
Back-lying position with legs
extended; with or without pillow under the head
Supine
Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface.
Dorsal recumbent
Back-lying position with feet
supported in stirrups; the hips should be in line with the edge of the table
Lithotomy
Lies on abdomen with head.
turned to the side, with or without a small pillow
Prone
Side-lying position with
lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
Sim’s
knees and chest with head is turned to one side, arms extended on the bed, and elbows flexed and resting.
Knee chest position
Provide privacy and warmth, expose only the area to be assessed.
Draping
▪ Ensure equipment are clean, in good
working condition, readily accessible
▪ Designate one area for clean/ unused and
another area for dirty/ used
Instrumentation
Thermometer Types:
▪ Glass mercury thermometer
▪ Electronic digital thermometer
▪ Tympanic thermometer
▪ Temporal artery thermometer
▪ Disposable paper strips
Used in indirect auscultation.
Stethoscope
Stethoscope parts
▪ Used in indirect auscultation
▪ Tubing should be 30 to 35cm long
▪ Internal diameter of 0.3cm
▪ Has a diaphragm and amplifier (bell)
▪ Have the earpieces pointing forward
▪ Fetal heart sounds
▪ Locate pulses
Doppler
an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff
Sphygmomanometer
Sphygmomanometer
▪ Cuff width should be _____ .
40% of the arm circumference
Sphygmomanometer Cuff bladder encircle ____.
80% of the arm.
To assess far and near vision
Visual acuity chart
▪ Far vision adult: __ feet
▪ Far vision children: __ feet
20 feet
10 feet
Visual acuity charts
▪ Snellen eye chart
▪ E chart
▪ STYCAR test cards
▪ Pocket vision screener
uses for
▪ Eyes
▪ Hard-to-see places
Penlight
Assess the internal structures of the eyes and Always use in dark room
Ophthalmoscope
Always palpate the tragus, helix, mastoid
process for tenderness before inserting an
otoscope, if tender proceed carefully
Otoscope/Nasoscope
Assess hearing and vibratory sensation
Tuning Fork
Tuning Fork frequencies
▪ Low frequency fork (256Hz): testing
vibratory sensation
▪ High frequency fork (512Hz): assessing hearing
Tape measure/ pocket ruler uses.
▪ Lengths and circumferences
▪ Abdominal girth
▪ Fundal height
Goniometer
To assess range of motion exercisers
Used to measure body fat
Triceps skin fold calipers
Scale
▪ Used to measure weight
this is for:
▪ Better visualization of the pharynx
▪ Assessing gag reflex
▪ Break tongue depressors after use
Wooden tongue depressor
▪ Used during neurological examination
Cotton balls
Cotton, used during neurological examination:
▪ Light touch
▪ Corneal reflex
Assess hot and cold sensation.
Test Tubes
Coffee
Assess the sense of smell.
Sugar and lemon
Assess sense of taste
Cup of water
Swallowing ability and thyroid
Paper clip
Assess for stereognosis.
Safety Pin
▪ Assess light touch and pain
▪ Discard after use
Gloves
▪ Use when there is risk for exposure to blood
or body fluids
Techniques of Physical Examination
▪ Inspection
▪ Palpation
▪ Percussion
▪ Auscultation
General guidelines
▪ Be systematic
▪ Use you patient as a comparative
▪ Always consider your patient’s growth and
developmental stage
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
Types of Inspection
▪ Direct inspection
▪ Indirect inspection
▪ 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
Dorsal aspect of the Hand
for temperature
Ball of the hand on palm and ulnar surface
Vibration
Finger Pads
Fine sensation (pulsations)
Types of Palpation
Light Palpation
Deep Palpation
type of palpation with
temperature, texture, mobility, shape, size
pulses
areas of edema
tenderness
Light Palpation
Type of palpation with:
organ size, masses
rebound tenderness.
voluntary guarding
ballottement
Deep Palpation
Striking a body surface with quick, light blows and eliciting vibrations and sounds
Percussion
Percussion Assess:
Assess:
* Density of underlying structure
* Areas of tenderness
* Deep tendon reflexes
Types of percussion
Direct/ Immediately percussion
Indirect Percussion
Fist or Blunt Percussion
Direct tapping your hand over a body surface
Direct/ Immediately percussion
Assess organ tenderness
can be direct or indirect
Fist or Blunt Percussion
Percussion Sounds
Resonance
Tympany
Dullness
Hyperresonance
Flatness
Plexor, pleximeter technique
percussion hammer
Indirect Percussion
▪ Use of sense of hearing
Auscultation
Auscultation, Assesses
Assess heart sounds, lung sounds, bowel
sounds, vascular sounds
▪ Pitch (medium, high or low) oIntensity (soft
or loud)
▪ Duration (short or long)
▪ Quality
Patients with special needs
▪ Children
▪ Pregnant patients
▪ Elderly
▪ Disabled patients
Types of Auscultation:
Direct auscultation
Indirect auscultation
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
Nagele’s Rule →
Estimated Due of
Confinement or Estimated Due Date
Last Menstrual Period
Subtract 3 months
Add 7 days
Add 1 year
woman who is or has been
pregnant
Gravida
woman who has never has
been pregnant
Nulligravida
first time pregnant
Primigravida
pregnant more than once
Multigravida
past pregnancies that have reached viability (24 AOG)
Para
has never completed to period of
viability
Nullipara
completed one pregnancy
regardless the result
Primipara
completed two or more pregnancies
Multipara
Obstetric / Gynecologic History
GTPAL
Gravida (# of Pregnancy)
Term
Preterm
Abortion
Children Living
This refers to the total number of times a woman has been pregnant, regardless of the outcome
Gravida
This indicates the number of full-term pregnancies a woman has had. A full-term pregnancy is one that lasts at least 37 weeks.
Term
This represents the number of preterm pregnancies a woman has experienced. pregnancy is one that ends before 37 weeks of gestation.
Preterm
In the context of GTPAL, refers to the number of pregnancies that were terminated before 20 weeks of gestation. It includes both spontaneous abortions (miscarriages) and induced abortions.
Abortion
This denotes the number of living children a woman currently has. It does not include the current pregnancy.
Living
