Collecting Objective Data

• Competencies of Health Assessment:

  • Techniques to obtain patient information
  • Components of a health assessment
  • How to prepare the patient for the exam
  • Equipment needed for an examination
  • Demonstrate a brief head to toe physical assessment
• Two components of the health assessment:

  • Health History
  • Physical Assessment
• During a health assessment between a patient and nurse:

  • Establish the nurse-patient relationship
  • Gather data: physiological, psychological, cognitive, sociocultural, developmental, spiritual
  • Identify patient strengths
  • Identify actual and potential health problems
  • Establish a base for the nursing process (Assessment)
• General Guidelines for Physical Assessment:

  • Instrumentation
  • Positioning
  • Draping
  • Preparation of the environment
  • Patient preparation
  • Techniques of physical assessment
• Positioning:

  • Sitting: upright chair or dangling off exam table
  • Supine: lie flat on your back
  • Dorsal recumbent: lie back with knees bent
  • Sims’s: lies on either right or left side with lower arm behind the body and upper arm bent at the shoulder and elbow, and knees bent
  • Prone: Pt. lies on abdomen
  • Lithotomy: patient in a dorsal recumbent position with buttocks at the edge of the examining table and feet supported in stirrups
  • Knee to Chest: using the knees and chest to bear the weight of the body
  • Standing
• Draping, preparing the environment:

  • Draping prevents unnecessary exposure, provides privacy, and keeps the patient warm during the physical exam
  • Prepare examination table: place a gown and drape on the table
  • Set up any supplies needed (e.g., otoscope, tuning fork, ophthalmoscope)
  • Pull curtain around or close door to exam room
• Techniques for examination:

  • Inspection: observing, listening, or smelling to gather data
  • Palpation: assessment that uses the sense of touch
  • Percussion: act of striking one object against another to produce a sound
  • Auscultation: act of listening with a stethoscope to sounds produced within the body
• Principles of Accurate Inspection:

  • Ophthalmoscopic: examine the eyes
  • Otoscope: examine the ears, mouth, and nostrils
  • Tuning fork: hearing
  • Nasal speculum: visualize the turbinates of the nose
  • Stethoscope
  • Snellen chart: used to check eyesight
• Palpation:

  • Hands and fingers are sensitive tools to assess temperature, turgor, texture, moisture, vibrations, shape
  • Use the palmar side of the hand
  • Light to deep palpation
  • Examiner's fingernails should be short
  • Start with light palpation before deep palpation
  • Tender areas are palpated last
• Instrumentation or Equipment used for inspecting
• Instrumentation or Equipment used for vision screening
• Principles for Accurate Palpation:

  • Examine condition of abdominal organs
  • Depressed areas must be approximately "2 cm"
  • Assess the turgor of skin measured by lightly grasping the body part with fingertips
• Percussion:

  • Percussion tones are used to assess location, shape, size, and density of tissue
  • Methods of percussion: direct method and indirect method
  • Different percussion sounds produced in different body regions
• Auscultation:

  • Four characteristics assessed: pitch, loudness, quality, duration
  • Direct or immediate auscultation and mediate auscultation
  • Listening to body sounds, movement of air (lungs), blood flow (heart), fluid & gas movement (bowels)
• Another skill used during assessment is smelling to detect characteristic body odors:

  • Assessment of characteristic odors for various conditions
• How to begin...
• Foul-smelling stools in infants may indicate fecal incontinence
• Olfaction from stool may indicate malabsorption syndrome
• Halitosis from the oral cavity may indicate poor dental and oral hygiene, gum disease
• Sweet, fruity ketones from the oral cavity may be from diabetic acidosis
• Musty odor from a casted body part may indicate infection inside the cast
• Fetid odor from tracheostomy or mucous secretions may indicate infection of bronchial trees (pseudomonas bacteria)
• The most important guideline for adequate physical assessment is conscious, continuous practice of physical assessment skills
• Sequence of physical assessment is dependent upon the developmental level of the client
• Allowing time for interaction with the child prior to beginning the examination helps to reduce fears
• In certain age groups, portions of assessment will require physical restraint of the client with the help of another adult
• Distraction and play should be intermingled throughout the examination to assist in maintaining rapport with the pediatric client
• Involving assistance from the child’s significant caregiver may facilitate a more meaningful examination of the younger client
• The examiner should be prepared to alter the order of the assessment and approach to the child based on the child’s response
• Protest or an uncooperative attitude toward the examiner is a normal finding in children from birth to early adolescence, throughout parts or even all the assessment process
• Dividing the physical assessment into parts in order to avoid fatigue in the older client
• Provide a room with a comfortable temperature and no drafts
• Allow sufficient time for clients to respond to directions
• If possible, assess the elderly clients in a setting where they have an opportunity to perform normal activities of daily living in order to determine the client’s optimum potential
• Inspect for color, vascularity, lesions, and body odors
• Inspect external structures, pupils, iris, internal structures, vision, extraocular movement, and peripheral vision of the eyes
• Inspect external ear for shape, size, location bilaterally, and gently palpate for pain, edema, or presence of lesions
• Inspect the nose for size, shape, location, and check for patency using an otoscope for nares and turbinates
• Inspect the sinuses and gently palpate maxillary bone and frontal sinus, normally the sinuses are not painful
• Composed of many structures like lips, tongue, teeth, gums, hard and soft palate, salivary gland, tonsillar pillars, and tonsils