Objective Data Flashcards
Its a type of data that is reproducible, true for the patient and the nurse, and its a fact.
Objective Data
Purposes of Physical Examination
- obtain baseline data about clients functional abilities
- supplement, confirm, or refute data obtained from nursing history
- obtains data that will establish nursing diagnosis and plan
- Evaluate physiological outcomes of healthcare
- Make clinical judgements
- Identify areas of health promotion and disease prevention
- dicover patient’s strenghts
Two types of physical assessment
Focused and Complete
Establish or monitors health status. Assess from head to toe
Complete Physical Assessment
This type of assessment focuses on a particular part of the body. This is done when patient is unstable, episodic follow up and time constraint situations
Focused Physical Assessment
What to prepare when conducting physical assessment.
- yourself
- The environment
- The patient
How to prepare yourself before physical assessment
- identify yourself
- appear calm and organized
- avoid interpreting your findings
- observe standard and universal precaution
How to prepare your patient before physical assessment
- explain where and where and when the examination takes place
- explain what will happen during examination
- determine contradicted positions
- empty the bladder of client
- start with least invasive aspect of examination if its with child
Preparing the environment before physical assessment
- Temp
- Lighting
- Privacy and noise
- Positioning
- Draping
- Instrumentation
- Methods of Examining
What to consider when positioning the client
- clients ability to assume position
- Physical condition
- energy level
- age
A seated position, unssuported back, leg hanging freely
Sitting Position
Back lying position with legs extended, with or without pillow under the head
Supine Position
Back lying position, with knees flexed and hips externally rotated, has small pillow under the head, soles of feet on the surface
Dorsal Recumbent
Back lying position with feet supported on stirrups, hips should be in line with the edge of the table
Lithotomy
Lies on abdomen with head turned to the side with or without small pillow
Prone
lower most arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
Sim’s Side lying position
knees and chest with head is turned to one side, arms extended on the bed, and elbows flexed and resting
Knee chest position
It provides privacy and warmth. Exposes only the area that is going to be assessed
Draping
Used to assess internal structure of the eyes. used in a dark room.
Ophthalmososcope
What equipment is being described?
▪ Assess hearing and vibratory sensation
▪ Low frequency fork (256Hz): testing
vibratory sensation
▪ High frequency fork (512Hz): assessing
hearing
Tuning fork
What equipment is being described?
To view the ear and nose cavities
Otoscope/Nasoscope
What equipment is being described?
▪ Lengths and circumferences
▪ Abdominal girth
▪ Fundal height
Tape measure/ pocket ruler
What equipment is being described?
▪ To assess range of motion exercisesr
Goniometer
What equipment is being described?
▪ Used to measure body fat
Triceps skin fold calipers
What equipment is being described?
▪ Used to measure weight
▪ If obtaining daily weights, weigh the patient
at the same time with the same scale
Scale
What equipment is being described?
Used to….
▪ Better visualize the pharynx
▪ Assessing gag reflex
▪ broken after use
Wooden tongue depressor
What equipment is being described?
▪ Used during neurological examination:
▪ Light touch
▪ Corneal reflex
Cotton balls
To Assess hot and cold sensation
Test tubes
To Assess the sense of smell
Coffee
To Assess sense of taste
Sugar and lemon
To Assess Swallowing ability and thyroid
Cup of water
To Assess for stereognosis
Paper clip
What equipment is being described?
▪ Assess light touch and pain
▪ Discard after use
Safety Pin
What equipment is being described?
▪ Use when there is risk for exposure to blood
or body fluids
Gloves
What is being described?
▪ 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
General guidelines for Inseptecting a Patient
▪ Be systematic
▪ Use you patient as a comparative
▪ Always consider your patient’s growth and
developmental stage
Types of Inspection
▪ Direct inspection
▪ Indirect inspection
What is being described?
▪ 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
what are the types of palpation
Light and Deep Palpation
What Type of Palpation to Assess
- Temp, texture, mobility, shape, size
- Pulses
- Areas for edema
- Tenderness
Light Palpation
What Type of Palpation to Assess
- Organ size, masses
- Rebound Tenderness
- Voluntary Guarding
- ballotment
Deep Palpation
Striking a body surface with quick, light
blows and eliciting vibrations and sounds
Percussion
Percussion assesses what?
- Density of underlying structure
- Areas of tenderness
- Deep tendon reflexes
Types of Percussion
- Direct/immediate Percussion
- Indirect Percussion
- Fist or Blunt Percussion
Identify the type of percussion
- Directly tapping your hand over a body surface
Direct/immediate Percussion
Identify the type of percussion
Uses plexor, pleximeter technique. Uses Percussion hammer
Indirect Percussion
Identify the type of percussion
- assess organ tenderness
- can be direct and indirect
Fist or Blunt Percussion
This technique uses
▪ 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
Type of Auscultation
Direct and Indirect Auscultation
This type of Auscultation is
- no stethoscope
- Respiratory congestion
Direct Auscultation
This type of Auscultation is uses a stethascope
Indirect Auscultation
Patients with special needs
- Children
- Adopt an age appropriate approach
- Look for normal growth and developmental
changes
Patients with special needs
- 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
Patients with special needs
- Elderly patients
▪ Do not rush
▪ Look for developmental changes
▪ Conserve your patient’s energy
▪ Allow enough time to respond
Patients with special needs
- Disabled patients
▪ Identify the disability
▪ Focus on patient’s functional ability and
mental capacity
▪ Modify as necessary
