Module 01: Data Analysis and Assessment (Part 01) Flashcards
1
Q
What is the first and the most critical phase of the nursing process, This involves both the collection of objective and subjective data. This is more than just gathering information in pertinent to health status but also analysis and synthesis of accrued datum,
A
Assessment or Health Assessment
2
Q
What is the purpose of health assessment?
A
To collect subjective and objective data to determine a client’s overall level of functioning in order to make a professional and clinical judgement.
3
Q
How should health assessment be executed?
A
The nurse should perform holistic data collection wherein the mind, body, and spirit are considered to interdependent factors that affect the client’s overall well being.
4
Q
What are the different phases of the nursing process?
A
(1) Assessment
(2) Diagnosis
(3) Planning
(4) Implementation
(5) Evaluation
Erring health assessment in precedent of the following factors may adversely affect the phases
5
Q
This is used to collective subjective and objective data.
A
Health Assessment (Information collection or gathering data)
6
Q
This is used to analyze subjective and objective data to make and prioritize professional clinical judgements concerning client concerns, collaborative problems or referral.
A
Diagnosis (information, interpretation as well as stating problems and strengths)
7
Q
This is used to generate solutions, developing a plan and determining which outcomes need to be met first.
A
Planning (Setting nursing goals desired outcomes and planning interventions)
8
Q
This involves taking action, prioritizing and implementing the planned interventions.
A
Implementation (performing the nursing interventions)
8
Q
This is concerned with the assessment of whether outcomes have been met and revising the plan if the interventions did not make a difference or they were ineffective.
A
Evaluation (patient’s status and effectiveness of nursing interventions)
9
Q
According to Doenges and Moorhouse, the nursing process is characterized to be?
A
Dynamic or Cyclic
10
Q
Based on the Nursing Scope of Practice what should the nurse do?
A
the nurse “collects comprehensive data pertinent to the patient’s health or situation”
11
Q
What should the nurse do when she collects comprehensive data for health assessment?
A
(1) Collects data in a systematic and ongoing process
(2) Involves the patient, family, other health care providers, and environment, as appropriate, in holistic data collection
(3) Prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient
or situation
(4) Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data
(5) Uses analytical models and problem-solving tools
(6) Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances
(7) Documents relevant data in a retrievable format
12
Q
What kind of data should the nurse collective in order to attain a holistic subjective and objective data?
A
(1) Physiologic
(2) Psychological
(3) Sociocultural
(4) Developmental
(5) Spiritual Data
13
Q
What should be the nurse’s focus?
A
How the client’s health status affects activities of daily living and how the client interacts with their family and community.
14
Q
This helps to organize information and promotes collection of holistic data
A
Nursing Framework
15
Q
What are the basic sections of the nursing framework?
A
(1) History of the Present Health Concern
(2) Personal Health History
(3) Family History
(4) Lifestyle and Health Practices
(5) Physical Assessment
16
Q
This provides the procedure, normal findings, and abnormal findings for each step of examining particular body part or system
A
Physical Assessment
17
Q
What is the end result of nursing assessment?
A
(1) Identification of client problems
(2) Identification of collaborative problems that require interdisciplinary care
(3) Identification of medical problems that require immediate referrals
18
Q
This theory is based on 3 concepts which is existence
of sufficient motivation, belief that one is susceptible/ vulnerable to a serious problem and the belief to change following a health recommendation
A
Health Belief Model
19
Q
Who proposed the health belief model?
A
Becker and Rosenstock 1987
20
Q
This is a model developed by the US department of health and human services (DHHS) aiming to increase lifespan and improve the quality of health of all Americans.
A
Healthy people 2030
21
Q
Who proposed the health promotion model?
A
Nola J. Pender, 1996
22
Q
What are the steps of health assessment?
A
(1) Collection of Subjective Data
(2) Collection of Objective Data
(3) Validation of Data
(4) Documentation of Data
23
Q
What should the nurse do prior to assessment?
A
(1) The medical record and other members of the health team provides basic biographical data, chronic illness and clues on how present illness affects patient’s ADL.
(2) Keep an open mind and avoid premature judgments
(3) If you are unfamiliar with client’s diagnoses or laboratory findings, educate yourself
(4) Take a minute to reflect on your own feelings regarding your initial encounter with the client
(5) Organize material that you will need for assessment
24
These are sensations or symptoms, perceptions, desires,
preferences, beliefs, ideas, values and personal information that can be elicited and verified only by the client
Subjective Data
25
This provides a focus for the physical exam and identify potential nursing diagnoses.
Health History
26
How should the Health History begin?
It should begin with an explanation to the client of why the information is being requested.
27
What does the Health History include?
(1) Biographic Data
(2) Reasons for seeking health care
(3) History of present health concern
(4) Family Health History
(5) Review of Body Systems
(6) Lifestyle and health practices profile
(7) Developmental Level
28
This is considered as the primary source and all others are secondary sources.
Client
29
What should be considered when collecting biographical information and sharing it in a form of academic discussion?
Identifiable information must be deleted and initials are used to protect the client's privacy
30
What happens when the reliability of the client as a source of information is unreliable?
The immediate family member or caregiver can give detailed data regarding the patient.
31
This question is associated to the assistance given to the client in focusing on the most significant health concern.
What is your major health problem or concerns at this time?
32
The health problem or the reasons for seeking the health care may be called as?
May be termed as chief complaint during initial physician interview?
33
This question is associated in encouraging the client to discuss fears or other feelings about having to see a health care provider.
How do you feel about having to seek health care?
34
What should the nurse do when gathering the information related to the history of the patient's present health concern?
(1) Encourage the client to explain the health problem or symptom in as much detail as possible and what the client perceives as causing the problem
(2) Ask the client to evaluate what makes the problem worse, what makes it better, previous management/treatment done, what effect the problem has had with daily life and ability to provide self-care
35
The information gathered in this section will help the nurse to evaluate the client's insight into the problem and the client's plans for managing it.
History of Present Health Concern
36
This mnemonic approach is used to aid symptom analysis.
COLDSPA
37
This describes the sign or symptom (such as the feeling, appearance, sound, smell, or taste?) "What does the pain feel like?
Character or Characteristics
38
This describes the beginning of the pain. "When did this pain start?"
Onset
39
This describes where the pain is felt, whether it radiates or not or if it occurs anywhere else. "Where does it hurt the most? Does it radiate or go to any other part?"
Location
40
This describes how long the pain lasts as well as if it is recurring or not. "How long does the pain last? Does it come and go or is it constant?"
Duration
40
This describes how bad the pain is and if it is detrimentally bothering the patient. "How intense is the pain? Rate it on a scale of 1 to 10?"
Severity
41
This describes what makes the pain better or worse. "What makes your back pain worse or better? Are there any treatment to the pain?"
Pattern
42
This describes what other symptoms occur with it and how it affects the patient holistically. "What do you think caused it to start? Do you have any other problems that may seem related to your back pain in your life and daily activities?"
Associated Factors/How it Affects the client?
43
What does COLDSPA mean?
(1) Characteristics
(2) Onset
(3) Location
(4) Duration
(5) Severity
(6) Pattern
(7) Associated Factors
44
What does LOCSTAAM mean?
(1) Location
(2) Onset
(3) Character
(4) Severity
(5) Timing
(6) Associated Symptoms
(7) Aggravating and Alleviating Factors
(8) Meaning
45
What does PQRST mean?
(1) Provoking/relieving
(2) Quality
(3) Region and Radiation
(4) Severity
(5) Time
46
In PQRST symptom analysis, it answers the questions, what brings the pain on, what makes it worse? What medications are you using at the moment? How often are you taking them? Do they help you? Do they cause any side effects? Have you taken anything else in the past for this pain and what was the effect of that?
Provoking/ Relieving
47
In PQRST symptom analysis, this describes the pain such as what it feels like (if it's stabbing, burning, sharp or aching?)
Quality
48
In PQRST symptom analysis, this refers to the location of the pain and if it spreads anywhere else?
Region and Radiation
49
In PQRST symptom analysis, this describes how severe the pain is now, at its worst and at its least. It also intends to probe into the effect of the pain to the patient's daily activities.
Severity
50
In PQRST symptom analysis, it intends to answer the question regarding when the pain started? If it is constant or intermittent? How often it occurs and how long it transpires?
Time
51
This portion focuses on questions related to childhood illnesses and immunizations, adult co morbidities, past surgeries or accident and prolonged episodes of pain, allergies and prescription medications.
Personal Health History
52
What is the focus of the patient's Personal Health History?
(1) Childhood illnesses and immunizations
(2) Adult co-morbidities
(3) Past surgeries/ accidents
(4) Prolonged episodes of pain, allergies and prescription medications
53
What should the nurse do when recording the patient's Personal Health History?
Note the client's perception about themselves and use open ended questions
54
This section includes many genetic relatives as the client can recall such as maternal and paternal grandparents, aunts and uncles, parents, siblings and children.
Family History
55
This diagram is used to organize the patient's family history.
Genogram
55
In a genogram, how are females indicated?
Circle
56
In a genogram, how are males indicated?
Square
57
In a genogram, if the relative has no health problems, what should the nurse write?
"A/W = Alive and well"
58
In a genogram, if the relative is deceased , what should the nurse write?
X
59
In a genogram, these show genetic relationships.
Straight lines
60
In a genogram, these indicated the patient's spouse or adopted member (not biologically related)
Dotted lines
61
In terms of caring under the review of systems, how should care be taken?
Care must be taken to include only the patient's subjective information and not the nurse's observation
62
When the nurse is in the process of reviewing bodily systems, what should she do?
(1) Document the client’s descriptions of her health status and note denial of signs, symptoms, diseases or problems
(2) Phrase questions in such a way that elicits answers and provoke verbalization of the client
63
This section deals with human responses, which includes nutritional habits, activity and exercise patterns, sleep and rest patterns, self-concept nd selfcare activities, social and community activities, relationships, values and beliefs system, education and work, stress level and coping style and environment
Lifestyle and Health Practices Profile
64
Under Lifestyle and Health Practices Profile, this is the overview of the client's usual daily activity.
Description of typical day
65
This can serve as the nurse's optimal guide towards a healthful sample meal plan.
Food and Nutrition Research Institute Department of Science and Technology Sample One Day Plan
65
Under Lifestyle and Health Practices Profile, the client recalls 24-hour intake with emphasis of what foods are eaten and in what amounts. This also considers how much fluid intake is consumed (caffeinated/ caffeinated)
Nutrition and Weight Management
66
Under the Lifestyle and Health Practices Profile, the nurse assesses how active the client is during an average week.
Activity Level and Exercise
67
What should the nurse do when assessing Activity Level and Exercise of the client?
Distinguish heavy physical work which is stressful and fatiguing and exercise which is designed to reduce stress and strengthen individual
68
What is the recommended exercise regimen?
Recommended exercise regimen of aerobic exercise for 20-30mins 3x/week
69
Under Lifestyle and Health Practices Profile, the client assesses whether the client is getting enough quality sleep and rest. This focuses on specific sleep patterns (hours of sleep, interruptions, whether the client feels rested problems rituals and concerns).
Sleep and Rest
70
What is the ideal or recommended hours of sleep for an average adult?
Compare with recommended 5-8 hours a night for adults but may vary depending on need
71
This scale is used to asses how alert you are feeling.
Stanford Sleepiness Scale
72
This is a screening survey proposed by the division of sleep medicine, Harvard Medical School in 2007, constituted of ten true or false questions.
The Sleep Disorders Screening Survey (Division of Sleep Medicine, Harvard Medical School, 2007).
73
This is a several-page list of symptoms partitioned to address the following sleep disorders: insomnia; excessive daytime sleepiness; depression; hypothyroidism; obstructive sleep apnea; heartburn or reflux disease (GERD); nocturnal myoclonus (limb and leg symptoms); nasal or sinus issues, allergies, asthma, or lung disease; circadian rhythm disorder; hypersomnia; narcolepsy; and parasomnias.
Sleep Disorder Screening Tests (Getbettersleep.com, 2009)
74
This is a 17 item Likert scale with interpretation of results by the Clinical Practice Guideline, 2007.
The Insomnia Screening Questionnaire
75
Under the Lifestyle and Health Practices Profile, this is known as the assessment of how the client view herself including sexual responsibility, basic hygiene practices, regularity of health care checkups, breast/testicular self-exam, and accident and hazard protection
Self-Concept and Self-Care Responsibilities
76
Under the Lifestyle and Health Practices Profile, this helps the nurse discover outlets the client has for support and relaxation and if the client in involved in the community beyond the family and work
Social Activities
77
Under the Lifestyle and Health Practices Profile, this is where the client describes the composition of the family into which they were born and about past and current relationships with these family members
Relationships
78
Under the Lifestyle and Health Practices Profile, this intends to assess the client’s values, philosophical, religious and spiritual beliefs. Note that note all clients are comfortable discussing their feelings and should be respected
Values and Belief System
79
Under the Lifestyle and Health Practices Profile, this section identifies areas of stress and satisfaction in the client’s life, should bring about kind and amount of education the client has, did the client enjoyed school or what he/she perceives his/her education
Education and Work
80
Under the Lifestyle and Health Practices Profile, this investigates the amount of stress the clients perceive they are under and how they cope, how they address events and how they usually respond
Stress Levels and Coping Styles
81
Under the Lifestyle and Health Practices Profile, this is used to assess health hazards unique to the client’s living situation and lifestyle.
Environment
Sample Questions include
(1) What risks are you aware of in your environment?
(2) What type of precautions do you take, if any, when playing contact sports, using chemicals or operating machinery?
(3) Do you believe you are ever in danger of becoming a victim of violence?
82
This is the information about the client that the nurse directly observes during interaction and elicited through physical examination techniques
Objective Data (Gathered from Physical Examination)
83
What are the Three (3) things a nurse should know to become proficient in physical assessment?
(1) Types and operation of equipment needed for the particular examination
(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
84
These are used to protect the examiner in any part of the examination when the examiner may have contact with blood, body fluids, secretions, excretions, and contaminated items or when disease-causing agents could be transmitted to or from the client.
(1) Gloves
(2) Gowns
85
What are the equipment entailed for all examinations?
(1) Gloves
(2) Gowns
(3) Sphygmomanometer
(4) Thermometer
(5) Watch
(6) Pain Scale
86
This is used to measure diastolic and systolic blood pressure.
Sphygmomanometer
87
This is used to measure body temperature.
Thermometer
88
What are the three (3) different types of thermometer?
(1) Oral
(2) Rectal
(3) Tympanic
89
This is a pain scale used measure and assess physical pain. Therefore, it is unsuitable for assessing comfort, mood, or emotions. This is usually utilized for children.
Wong-Baker Faces Pain Rating scale
90
This pain scale is utilized in two approaches namely for: (1) Intubated patients and (2) Non-intubated patients from 3 (no) to 12 (maximum) pain behavior rate.
Behavioral Pain Scale (BPS) Training
91
How is the Total BPS value calculated?
1 + 2 + 3 = Total BPS Value
92
What are the equipment used for the client's nutritional status examination?
(1) Platform Scale
(2) Skin fold calipers
(3) Flexible Tape
(4) Skin marking pen
93
This is a scale with height attachment to measure height and weight.
Platform Scale
94
This is used to measure to skinfold thickness of subcutaneous tissue.
Skinfold Calipers
95
This is used to measure mid-arm circumference.
Flexible tape
96
This is used to mark measurements for the client's nutritional status examination.
Skin Marking Pen
97
What are the medical equipment utilized for skin, hair and nail examination?
(1) Examination light
(2) Penlight
(3) Mirror for the client's self-examination of the skin
(4) Metric ruler
(5) Magnifying glass
(6) Wood's light
98
Under the medical equipment utilized for skin, hair and nail examination, this is used to measure size of skin lesions.
Metric ruler
99
Under the medical equipment utilized for skin, hair and nail examination, this is used to enlarge visibility of lesions.
Magnifying glass
100
Under the medical equipment utilized for skin, hair and nail examination, this is to test for fungal infection.
Wood's light
101
What are the equipment entailed for the client's eye examination?
(1) Penlight
(2) Snellen E chart or Rosenbaum Chart
(3) Newspaper for near vision
(4) Opaque Card
(5) Ophthalmoscope
102
Under the equipment entailed for the client's eye examination, this is used to probe into the client's pupillary constriction.
Penlight
103
Under the equipment entailed for the client's eye examination, this is used to examine and test the client's distant vision.
Snellen E chart or Rosenbaum Chart
104
Under the equipment entailed for the client's eye examination, this is used to assess and test for strabismus.
Opaque Card
105
Under the equipment entailed for the client's eye examination, this is used to view the red reflex and probe into the retina of the client's eye.
Ophthalmoscope
106
Under the equipment entailed for ear examination, this is used to test for bone and air conduction of sound.
Tuning Fork
106
What are the equipment entailed for ear examination?
(1) Tuning Fork
(2) Otoscope
107
Under the equipment entailed for ear examination, this is used to examine and view the ear canal and tympanic membrane of the client.
Otoscope
108
What are the equipment used for mouth, throat, nose and sinus examination?
(1) Penlight
(2) 4x4 inch small gauze
(3) Tongue Depressor
(4) Otoscope
109
Under the equipment used for mouth, throat, nose and sinus examination, this is used to provide light to view the mouth and throat and to transilluminate the sinuses of the client.
Penlight
110
Under the equipment used for mouth, throat, nose and sinus examination, this is used to grasp the tongue to examine the mouth.
4x4 inch small gauze pad
111
Under the equipment used for mouth, throat, nose and sinus examination, this is used to depress the tongue to view the throat, check the looseness of teeth, view cheeks, and check the strength of client's tongue.
Tongue Depressor
112
What are the equipment used for thoracic and lung examination?
(1) Stethoscope
(2) Metric Rule and skin marking pen
113
Under the equipment used for thoracic and lung examination, this is used to auscultate the breath sounds.
Stethoscope
114
Under the equipment used for thoracic and lung examination, this is used to measure the diaphragmatic excursion.
Metric rule and skin marking pen
115
What are the equipment used for the examination of the heart and neck vessel?
(1) Stethoscope
(2) Two metric rulers
116
Under the equipment used for the examination of the heart and neck vessel, this is used to auscultate the heart sounds.
Stethoscope
117
Under the equipment used for the examination of the heart and neck vessel, this is used to measure jugular venous pressure.
Two metric rulers
118
What are the equipment used for the peripheral vascular examination of the patient?
(1) Sphygmomanometer and Stethoscope
(2) Flexible metric
(3) Tuning Fork
(4) Doppler
119
Under the equipment used for the peripheral vascular examination of the patient, this is used to measure blood pressure and auscultate vascular sounds.
Sphygmomanometer and Stethoscope
120
Under the equipment used for the peripheral vascular examination of the patient, this is used to measure size of extremities for edema.
Flexible metric measuring tape
121
Under the equipment used for the peripheral vascular examination of the patient, this is used to detect vibratory sensation.
Tuning Fork
122
Under the equipment used for the peripheral vascular examination of the patient, this is an ultrasound device that goes along with a conductivity gel used to detect pressure and weak pulses not easily heard with a stethoscope.
Doppler
123
What are the equipment used for abdominal examination?
(1) Stethoscope for bowel sounds
(2) Flexible metric measuring tape and marking pen
(3) Two small pillows
124
Under the equipment used for abdominal examination, this is use to measure size and mark the area of percussion of organs.
Flexible metric measuring tape and marking pen
125
Under the equipment used for abdominal examination, this is placed under the knees and head of the client to promote relaxation of the abdomen.
Two pillows
126
What are the equipment used for the musculoskeletal examination?
(1) Flexible metric measuring tape
(2) Goniometer
126
Under the equipment for the musculoskeletal examination, this is used to measure the size of extremities.
Flexible metric measuring tape
127
Under the equipment for the musculoskeletal examination, this is used to measure and probe into the degree of flexion and extension as well as the abduction and adduction of joints.
Goniometer
127
What are the equipment needed for neurologic examination?
(1) Cotton tipped applicators
(2) Newspaper
(3) Ophthalmoscope
(4) Flexible metric measuring tape
(5) Coin or key
(6) Reflex Hammer
(7) Cotton ball and paper clip
(8) Substances to smell and taste
(9) Snellen E chart
(10) Penlight
(11) Tongue depressor
(12) Tuning fork
128
Under the equipment needed for neurologic examination, this is used to put salt or sugar on the tongue of the client to assess taste.
Cotton tipped applicators
129
Under the equipment needed for neurologic examination, this is used to test near vision.
Newspaper
130
Under the equipment needed for neurologic examination, this is used to test stereognosis, which is the ability to recognize the patient's capability through touch.
Objects to feel (Key or Coin)
131
Under the equipment needed for neurologic examination, this is used to the client's deep tendon reflex.
Reflex (percussion) hammer
132
Under the equipment needed for neurologic examination, these are used to test for light, sharp and dull touch along with two point discrimination.
Cotton Ball and paper clip
133
Under the equipment needed for neurologic examination, these are used to examine or probe into the client's smell and taste perceptions.
Substances to smell or taste
133
Under the equipment needed for neurologic examination, this is used to test the client's uvula or gag reflex.
Tongue depressor
134
What are the equipment entailed for the male genitalia and rectum examination?
(1) Gloves and water soluble lubricant
(2) Penlight
(3) Specimen card for occult blood
135
Under the equipment entailed for the male genitalia and rectum examination, this is used to promote comfort for the patient.
Gloves and water soluble lubricant
136
Under the equipment entailed for the male genitalia and rectum examination, this is used for scrotal illumination.
Penlight
137
What are the equipment needed for female genitalia and rectum examination? "Very Beautiful Ladies Love Pink Lace Fashion!"
(1) Vaginal speculum and water-soluble lubricant
(2) Bifid spatula and endocervical broom
(3) Large swabs for vaginal examination
(4) Liquid Pap medium
(5) Ph paper
(6) Feminine napkins
137
Under the equipment needed for female genitalia and rectum examination, this is used to inspect the client's cervix through dilatation of the vaginal canal
Vaginal speculum and water-soluble lubricant
138
Under the equipment needed for female genitalia and rectum examination, this is used to obtain endocervical swab and cervical scrape along with the vaginal pool sample
Bifid spatula and endocervical broom
139
How does a nurse prepare for the examination?
(1) Preparing the physical setting
(2) Preparing oneself
(3) Approaching and preparing the client
140
What are the different settings that may include during examination?
(1) Hospital Room
(2) Outpatient Clinic
(3) Physician’s Office
(4) School Health Office
(5) Employee Health Office
(6) Client’s home
141
How should the nurse prepare the physical setting?
(1) Comfortable, warm room temperature. Provide blanket if necessary
(2) Private area free of interruptions. Close door/ pull curtains if possible
(3) Quiet area free of distractions: Turn off the radio, television or other noisy equipment
(4) Adequate lighting: best to use sunlight
(5) Firm examination table or bed at a height that prevents stooping: Roll-up stool may be useful
(6) Bedside table/tray to hold equipment needed for examination
142
How should the nurse prepare herself?
(1) Assess your own feelings and anxieties before examining the client
(2) Your thoughts and feelings may be easily conveyed to the client (Cross-Transference)
(3) Achieve self-confidence in performing PE by practicing with a classmate, friend or relative
(4) Prepare Personal Protective Equipment depending on the examination to be done (based on OSHA, CDC & DOH Guidelines)
(5) Wash hands (refer to lecture on Infection Control)
(6) If pin or other sharp object is used to assess, discard the pin and use a new one for your next client
142
What are the five (5) moments of hand hygiene?
(1) Before touching a patient
(2) Before a clean or aseptic procedure
(3) After body fluid exposure or risk
(4) After touching a patient
(5) After touching the patient's surroundings
143
How should the nurse approach and prepare the client?
(1) Explain to the client that the physical assessment will follow and describe what the examination will involve
(2) Respect client’s desires and requests related to the physical exam. Some institutions need a consent form prior to any assessment
(3) If urine specimen is needed, explain and provide a container. Otherwise, ask the client to urinate prior to the exam to promote easier and more comfortable exam of the abdomen and genital area
(4) Continue explaining while the procedure is ease client’s anxiety
(5) It is helpful to integrate health teaching and promotion during examination
(6) Approach on the right-hand side (most procedures utilizes the right hand of examiner)
(7) Prepare client for position changes and inquire if they would need assistance
144
What are the privacy concerns that the nurse should take note of?
(1) Leave the room while the client changes into a gown and knock before reentering
(2) Allow the client to wear underwear until genitalia assessment is needed
(3) Lock doors, close curtains/ drapes
(4) Begin with less intrusive procedures
145
In this 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. Some clients may be too weak to sit up for the entire examination. They may need to lie down, face up (supine position) and rest throughout the examination. 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.
Sitting Position
146
In this 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 breath- ing, 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.
Supine Position
147
In this 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 comfort- able 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.
Dorsal recumbent position
148
In this 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.
Sim's position
149
In this 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.
Standing Position
150
In this 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.
Prone Position
151
In this 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 pro- vide comfort. The knee-chest position is useful for examining the rectum. This position may be embarrassing and uncomfortable for the cli- ent; 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.
Knee - Chest Position
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In 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.
Lithotomy Position
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What are the four (4) physical examination techniques?
(1) Inspection
(2) Palpation
(3) Percussion
(4) Auscultation
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This physical examination involves using the senses of
vision, smell and hearing to observe and detect any normal or abnormal findings. This is usually done first
since latter techniques can alter the appearance of the
body part inspected
Inspection
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What should the nurse do in the matter of inspection?
(1) Make sure room has comfortable temperature
(2) Use good lighting, preferably sunlight
(3) Look and observe before touching
(4) Completely expose the body part you are inspecting while draping the rest as appropriate
(5) Compare symmetry of paired body parts
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What should the nurse note during inspection?
Note 1) color, 2)patterns, 3) size, 4) locations, 5)consistency, 6) symmetry, 7) movement, 8) behavior, 9) odors, 10) sounds
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This approach utilized in physical examination is constituted of using the parts of the hand to touch and feel for the following:
Palpation
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Under the physical examination approach of palpation, what are the possible descriptors of texture?
Rough or Smooth
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Under the physical examination approach of palpation, what are the possible descriptors of moisture
Dry or Wet
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Under the physical examination approach of palpation, what are the possible descriptors of consistency and degree of tenderness?
Soft, Hard or Fluid Filled
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Under the physical examination approach of palpation, what are the possible descriptors of size?
Small, Medium or Large
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Under the physical examination approach of palpation, what are the possible descriptors of Temperature?
Warm or Cold
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Under the physical examination approach of palpation, what are the possible descriptors of mobility?
Fixed, Movable, Still or Vibrating
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Under the physical examination approach of palpation, what are the possible descriptors of strength of pulses?
Strong, Weak, Thready or Bounding
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Under the physical examination approach of palpation, what are the possible descriptors of shape?
Well defined or Irregular
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When palpating, which part of the hand is used for fine discrimination when probing into the client's pulses, texture, size, consistency, shape, and crepitus.
Fingerpads
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When palpating, which part of the hand is used for examining vibrations, thrills, and fremitus.
Ulnar or Palmar surface
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When palpating, which part of the hand is used to probe into the client's temperature?
Dorsal (back) surface
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In this palpation type, the nurse should:
(1) Place dominant hand light on the surface
(2) There should be no depression (less than 1cm)
(3) Feel using circular motion
Light Palpation
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What is the indication of light palpation?
Pulses, tenderness, surface skin texture, temperature and moisture
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In this type of palpation, the nurse should:
(1) Depress the skin surface 1-2cm with dominant hand
(2) Use circular motion to palpate
Moderation Palpation
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What is the indication of moderate palpation?
For body organs and masses (Note consistency, size and mobility)
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In this type of palpation, the nurse should:
(1) Place dominant hand on skin surface
(2) Nondominant hand placed on top of dominant hand to apply pressure
(3) Depression should be 2.5-5cm
Deep Palpation
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What is the indication of deep palpation?
For deep organs and structures covered by muscles
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In this type of palpation, the nurse should:
(1) Use two hands, placing one on each side of the body part
(2) Use one hand to apply pressure and the other to feel the structure
Bi-manual Palpation
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What is the indication of Bi-manual Palpation?
Breast, spleen and uterus (Note: size, shape consistency and mobility)
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What should a nurse note during the process of palpation?
(1) Examiner’s fingernails should be short
(2) Hands should be comfortable temperature
(3) Proceed with light palpation first which is safest and most comfortable
(4) Use finger pads and not tips of fingers to palpate
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This type of physical examination approach involves tapping body parts to produce sound waves.
Percussion
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Under the physical examination approach of percussion, the sound or vibration will allow assessment of underlying structures such as:
(1) Eliciting pain – detects inflamed structures
(2) Determine location, size and shape – changes between borders of an organ
(3) Determining density – if filled with air/ fluid/ solid structure
(4) Detecting abnormal masses - can detect superficial abnormal structures or masses (penetrates around 5cm deep)
(5) Eliciting reflexes – through percussion hammer
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Under the physical examination approach of percussion, this detects inflamed structures?
Eliciting Pain
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Under the physical examination approach of percussion, this examines changes between borders of an organ.
Determine location, size, and shape
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Under the physical examination approach of percussion, this probes into whether the area is filled with air, fluid, or solid structure.
Determining density
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Under the physical examination approach of percussion, this detects superficial abnormal structures or masses (penetrates 5 cm deep)
Detecting abnormal masses
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Under the physical examination approach of percussion, this is executed through the aid of a percussion hammer.
Eliciting reflexes
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This type of percussion involves direct tapping of a body
part with 1 or 2 fingers.
Direct
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In this type of percussion, the nurse shall place on hand on the body surface and using fist of the other hand to strike the back of the hand flat
Blunt
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This type of percussion is the most common approach. This produces a sound or tone that varies with density of the structures.
Indirect
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How is indirect percussion executed?
(1) Place the middle finger of your nondominant hand on the body part you are going to percuss
(2) Keep other fingers off the body part being percussed (dampen the tone elicited)
(3) Use the pad of the middle finger of the other hand to strike the middle finger of the nondominant hand
(4) Withdraw finger immediately to avoid clamping the tone
(5) Deliver two quick taps and listen carefully to the tone
(6) Use quick, sharp taps by flexing your wrist, not forearm
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This sound (tone) elicited by percussion is heard over part air and part solid.
Intensity: Loud
Pitch: Low
Length: Long
Quality: Hollow
Example of Origin: Normal Lung
Resonances
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This sound (tone) elicited by percussion is heard over mostly air
Intensity: Very Loud
Pitch: Low
Length: Long
Quality: Booming
Example of Origin: Lung with emphysema
Hyper-resonances
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This sound (tone) elicited by percussion is heard over air.
Intensity: Loud
Pitch: High
Length: Moderate
Quality: Drum-like
Example of Origin: Puffed out cheek, gastric bubble
Tympany
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This sound (tone) elicited by percussion is heard over more solid tissue
Intensity: Medium
Pitch: Medium
Length: Moderate
Quality: Thud-like
Example of Origin: Diaphragm, pleural effusion, liver
Dullness
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This sound (tone) elicited by percussion is heard over very dense tissue
Intensity: Soft
Pitch: High
Length: Short
Quality: Flat
Example of Origin: Muscle, bone, sternum, thigh
Flatness
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This physical examination approach requires the use of stethoscope to listen for heart sounds, movement of blood through the cardiovascular, movement of bowel and movement of air through respiratory tract
Auscultation
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What are the different types of stethoscope?
(1) Acoustic
(2) Electronic
(3) Digital
(4) ultrasound
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This is delineated as the process of confirming or verifying the subjective and objective data you have collected are reliable and accurate
Validation
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What is the purpose of validation?
Errors during assessment will make the data unreliable which results diagnostic errors
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What requires validation?
(1) Discrepancies/gaps between objective and subjective data
(2) Discrepancies/gaps between what the client stated at one time vs another time
(3) Highly abnormal findings or inconsistent with other findings
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What are the methods of validation?
(1) Recheck own data through a repeat assessment
(2) Clarify with client by asking additional questions
(3) Verify with another health care professional
(4) Compare objective with subjective findings
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What are the guidelines for documentation?
1. Keep confidential all documented information in the client record
2. Document legibly and print neatly in nonerasable ink
3. Use correct grammar and spelling. Use only abbreviations that are acceptable and approved by the institution
4. Avoid wordiness that creates redundancy
5. Use phrases instead of sentences to record data
6. Record data findings, not how they are obtained
7. Write entries objectively without making premature judgments or diagnoses
8. Record the client’s understanding and perception
9. Avoid recording the word “normal” for normal findings
10. Record complete information and details for all client symptoms or experiences
11. Include additional assessment content when applicable
12. Support objective data with specific observations obtained during physical examination
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What are the prohibited abbreviations?
Organizations are required to follow a list of prohibited abbreviations, acronyms, symbols, and dose designations, which at a minimum includes the following:
(1) U, u
(2) IU
(3) Q.D., QD, q.d., qd
(4) Q.O.D., QOD, q.o.d, qod
(5) Trailing zero (X.0 mg)
(6) Lack of leading zero (.X mg)
(7) MS
(8) MSO4
(9) MgSO4
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How should a nurse execute charting?
(1) Start with the date and time
(2) To discourage others from adding information to the nurses' notes, draw a line through any blank spaces and sign your name at the far right of the column
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This is anytime one health care provider is transferring client care responsibilities to another healthcare provider
Handoff or Endorsement
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How does Handoff or Endorsement occur
(1) In between shift changes
(2) Leaves the unit for a break
(3) Transferred to another unit or facility
(4) Client leaves the unit for a test
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How can a nurse execute optimal verbal communication of data.
1. Use standardized method of data communication (SBAR)
2. Communicate with good eye contact and face-to-face
3. Allow time for the receiver to ask questions
4. Provide documentation of the data you are sharing
5. Validate what the receiver has heard by questioning or asking to summarize report
6. Telephone reports: record time, receiver, sender and information shared
