COLLECTING OBJECTIVE DATA: The Physical Examination Flashcards
include information about the
client that the nurse directly observes during
interaction with the client and information elicited
through physical assessment (examination)
techniques.
OBJECTIVE DATA
- Establish the nurse-client relationship during
the client interaction before physical
examination - Respect the client’s desires & requests related
to the PE - If a urine specimen is necessary, explain to
the client the purpose of a urine sample & the
procedure of giving sample, provide him/her
with a container to use. - Begin the examination with the less intrusive
procedures such as measuring the client’s
temperature, Pulse, Blood pressure, height &
weight. - Approach the client from the right-hand side
of the examination table or bed.
➢Approaching and Preparing the Client
➢Comfortable, warm temperature
➢Private area free of interruptions from other
➢Quiet area free of distractions
➢Adequate lighting
➢Firm examination table or bed at a height that prevents
stooping
➢A bedside table/tray to hold the equipment needed for
the examination
- Characteristics/conditions of the examination
setting
General principles while performing a
Physical Assessment
- Wash you hands
- Standard Precautions
Infection control practices during the delivery of
health care:
➢Hand Hygiene is performed
Standard Precautions
Principles use:
* Wear PPE
* Prevent contamination of clothing
and skin during the process of
removing PPE
* Before leaving the patient’s room or
cubicle, remove & discard PPE
➢Personal Protective Equipment
(PPE)
▪When it can be reasonably
anticipated that contact with
blood, or other potentially
infectious materials, mucous
membranes, non-intact skin,
or potentially contaminated
intact skin.
*Gloves
➢Wear gloves:
That is appropriate to the
task to protect skin and
prevent soiling or
contamination of clothing
and patient care activities.
- Gowns
➢Use PPE to protect the mucous
membrane of the eyes, nose, &
mouth during procedures.
Mouth, Nose, Eye Protection
Educate health personnel on the importance
of source control measures to contain
respiratory secretions to prevent droplet and
fomite transmission of respiratory pathogens,
especially during seasonal outbreak of viral
respiratory tract infections.
RESPIRATORY HYGIENE/COUGH ETIQUETTE
▪ Make sure the room is a comfortable temperature.
▪ Use good lighting
▪ Look and observe before touching
▪ Complete 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 etc.
▪ Compare the appearance of symmetric body parts or
both sides of any individual body part.
Guideline to practice technique of Inspection:
- Palpation consists of using parts of the hand to
touch and feel for the following characteristics:
▪ texture
▪ temperature
▪ moisture
▪ mobility
▪ consistency
▪ strength of pulses
▪ size
▪ shape
▪ degree of tenderness
- Three different parts of the hand & determine
which characteristics you are trying to palpate
Finger pads
▪ Ulnar/palmanarsurface
▪ Dorsal surface
Fine discriminations: pulses, texture, size
consistency, shape, crepitus
Fingerpads
Vibrations, thrills, fremitus
Ulnar or palmar
surface
Temperature
Dorsal (back surface)
comfortable for the client
▪ Use this technique to feel for
pulses, tenderness, surface
skin texture, temperature
and moisture.
*Light palpation
➢Depress the skin surface 1 to 2
cm (0.5 to 0.75 in) with your
dominant hand, and use a
circular motion to feel for easily
palpable body organs & masses.
➢Note the size, consistency and
mobility of structures you
palpate
- Moderate palpation
➢Place you dominant hand on the
skin surface & your non dominant
hand on top of your dominant
hand to apply pressure.
➢Allows you to feel deep organs or
structures that are covered by
thick muscle.
Deep palpation
➢Use two (2) hands, placing one on
each side of the body part
➢Use one hand to apply pressure
and the other hand feel the
structure
➢Note the size, shape, consistency,
and mobility of the structures you
palpate
Bimanual palpation
➢Involves tapping body parts to produce sound
waves
➢These sound waves or vibrations enable the
examiner to assess underlying structures
PERCUSSION
▪Three types of Percussion
Direct percussion
* Blunt percussion
* Indirect or mediate percussion
direct tapping of a body part with
one or two fingertips to elicit possible tenderness.
Direct Percussion
used to detect tenderness over
organs 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.
Blunt Percussion
▪Solid tissues produces a soft tone
▪Fluid produces a louder tone
▪Air produces an even louder tone
Indirect or Mediate Percussion
A stethoscope is used because
these body sounds are not audible to
the human ear.
Auscultation
– loud or soft
Intensity
high or low
Pitch
length
- Duration
musical, crackling, raspy
- Quality
- Eliminate distracting or competing noises from the
environment - Expose the body part you are going to auscultate
- Use the diaphragm of the stethoscope to listen for
high pitched sounds - Use the bell of the stethoscope to listen for low-
pitched sounds, hold the bell lightly on the body part
being auscultated.
Guidelines should be followed as you
practice the technique of auscultation
- Sitting position
- Supine position
- Dorsal recumbent position
- Sim’sposition
- Standing position
- Prone position
- Knee-chest position
- Lithotomy position
Positioning the Client
