NCM 101

• Objective Data Includes information about the client that is observed by the nurse through interaction, and uses examination techniques
• Otoscope is for the ear
• Tuning fork is for hearing
• Gloves and gowns protect an examiner from direct contact with contaminants
• Physical setting should be Comfortable, private, Quiet, Adequate lighting, Firm bed and table, A bedside tray to hold materials
• Subjective Data includes information about the client's feelings or perceptions
• Approaching the client. 1. Nurse-client relationship should be established during interview but before physical examination. 2. Explain to the client that physical examination will follow, and describe what the examination will involve. 3. Respect the client's desires. 4. Client holds the decision whether to do or not do
• In the process of approaching the client. We begin the examination with the less intrusive procedures such as temperature, weight, pulse, height, and blood pressure
• Always approach the client in the right hand side
• Inspection involves using the senses, vision, smell, and hearing to observe and detect normal and abnormal findings
• During Inspection procedure, Fluorescent lights can alter the color of skin
• Palpation is a process of using the parts of the hand to touch and feel texture, temperature, moisture, mobility, consistency, strength of pulses, size, shape, and degree of tenderness
• Parts of hand during palpation are finger pad, ulnar surface, palmar, and dorsal surface
• Four types of palpation is Light, moderate, deep, and bimanual
• Light palpation uses the dominant hand lightly with little to no depression and moved in a circular motion. It is less than one minute deep, this is used to feel pulses, temperature, texture, tenderness, and moisture
• Moderate palpation depresses the skin using dominant hand in a circular motion. It is 1-2 cm deep or 0.50-0.75 inches. This is used to measure size, mobility, and consistency
• Deep palpation involved placing your dominant hand on skin surface and placing your non dominant hand on top of the dominant hand. It is 2.5- 5cm deep or 1-2 inches deep. Used for parts that are greatly covered with muscle
• Bimanual palpation is using two hands on each side of a body part. Use one hand to apply pressure, and use the other hand to feel structure. Applicable in uterus, breast, and spleen
• Percussion involves tapping body parts to produce sound waves or vibrations
• Percussion is used in eliciting pain, determine location, size and shape, determine density, determine abnormal masses, eliciting reflexes
• Three Types of percussion methods are direct, blunt and indirect
• Auscultation is the procedure that uses a stethoscope
• The diaphragm is used to listen to high pitched sounds, and the bell is used for low pitched sounds
• Standing position is used to speculate balance and gait. And used to observe the male genitalia
• Prone position is when client lies down on her abdomen with her head to the side. This is used to assess the back. Clients with cardiac and respiratory conditions cannot tolerate this position
• Knee chest position is when the client kneel and the weight of the body is supported by the knee and chest and forming a 90 degree angle. Used to examine the rectum
• Lithotomy position is when the client lies on her back with her hips near the edge of the table and the feet is supported by stirrups. This is used to examine female genitalia
• Vital signs consist of

  Temperature, Pulse rate, respiration, blood pressure
• Vital signs As indicators of health status, these measures indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions
• Measurement of vital signs provide data to determine a patient's usual state of health or what we call as baseline data
• Assessment of vital signs provide data to identify the nursing diagnoses, implement plan intervention, and evaluate outcomes of care
• An alteration in vital signs signals a change in physiological function and the need for medical or nursing intervention
• Vital signs are quick and efficient way of monitoring a patient's condition or identifying problems and evaluating his or her response in the intervention
• Vital signs and other physiological measurements are the basis for the clinical decision making and problem solving
• PURPOSES OF VITAL SIGNS TAKING1. To determine the course of illness, which serves as a guide in meeting the need of the patient.2. To afford an opportunity to observe thegeneral condition of the patient.3. To aid the physician in making his diagnosisand planning patient’s care.
• SPECIAL CONSIDERATIONS1. Before Vital Signs are taken, be sure that the patient has rested2. Remember that the frequency of taking the Temperature, Pulse, Respiratory, and BP depends upon the condition of the patient and the policy of the agency3. Inform the Physician or Head Nurse, and Clinical Instructor promptly for ansignificant change in the Vital Signs4. Explain the procedure to the patient so that he/she will feel at ease
• THINGS YOU NEED TO REMEMBER ABOUT VITAL SIGNS TAKING• Objective data• Accuracy• Thoughtful, scientific assessment• Monitoring• Can vary or change• Nursing judgment
• GUIDELINES FOR MEASURING VITAL SIGNS• Vital signs are a part of the assessment database
• 1. Measuring vital signs is a your (nurse) responsibility.
• 2. Assess equipment to ensure that it is working correctly and provides accurate findings.3. Select equipment on the basis of the patient’s condition and characteristics