OBJ

• The nurse strives to ensure that the examination setting meets conditions such as comfortable, warm room temperature, private area free of interruption, quiet area free of distraction, adequate lighting, firm examination table or bed, bedside table/tray to hold equipment
• Prior to the examination, collect the necessary equipment and place it in the area where the examination will be performed to promote organization and prevent the nurse from leaving the client to search for a piece of equipment
• Establish a nurse-client relationship during the client interview before the physical examination to alleviate tension or anxiety
• Preparing the physical setting, oneself, and the client can affect the quality of the data elicited
• Collection of Objective Data

  Basic knowledge in three areas:

  1. Types of 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
• Preparing Oneself

  Assess your own feelings and anxieties before examining the client, practice self-confidence
• Explain to the client that the physical assessment will follow the interview and describe what the examination will involve
• Methods of validation

  1. Recheck your own data through a repeat assessment

  2. Clarify data with the client by asking additional questions

  3. Verify the data with another healthcare professional

  4. Compare objective findings with subjective findings
• Client examination

  1. To alleviate any tension or anxiety that the client is experiencing

  2. At the end of the interview, explain to the client that the physical assessment will follow and describe what the examination will involve

  3. Respect the client's desire and requests related to the physical examination

  4. Explain to the client the purpose of the procedure

  5. Begin the examination with less intrusive procedures such as TPR and BP taking
• Information from subjective data

  • Biographic data
  • Present health concern review
  • Past health history data
  • Family history
  • Lifestyle and health practices information
• Throughout the examination

  1. Continue to explain the procedure being performed and why it is being performed

  2. Approach the client from the right-hand side of the examination table or bed

  3. Prepare the client for changes of positions
• Nonthreatening/nonintrusive procedures


  • Feel more comfortable and ease client anxiety
• Documentation (Nurses' notes)

  1. Purpose: Provide the healthcare team with a database for care of the client, help identify health problems, formulate nursing diagnosis, plan immediate and ongoing interventions

  2. Information requiring documentation: Nursing history, physical assessment (subjective and objective data)
• Validating and documenting data

  1. Purpose of validation: Confirming or verifying that the subjective and objective data collected are reliable and accurate

  2. Steps: Deciding whether the data require validation, determining ways to validate the data, identifying areas where data are missing

  3. Conditions that require data to be rechecked and validated: Discrepancies or gaps between subjective and objective data, discrepancies or gaps in client statements, abnormal or inconsistent findings
• Objective data establish baseline data for ongoing assessments, and validate the subjective data obtained during the nursing history interview
• Report


  Oral, written or computer-based communication intended to convey information to others
• The Chart is a legal record of care
• Data included in family history

  • Client’s biologic family(history of the disease)
  • Genogram
• Assessment forms used for documentation

  • Initial assessment form
  • Open-ended forms (traditional form)
• Documentation


  Any written legal record of all pertinent interactions with the patient in the course of nursing process
• Recording


  Process of making an entry on a client record
• Lifestyle and health practices information

  • Risk behaviors such as past or present smoking
• Objective data help to further define the client’s problems
• Purposes of client’s records include communication, recording of diagnostic therapeutic orders, core planning, quality care review, research, education, financial reimbursement, and legal documentation
• Discussion


  An oral informal, oral consideration of a subject by 2 or more healthcare personnel to identify a problem or establish strategies to resolve a problem
• Systematic approaches for examination

  • Head-toe
  • Major body systems
  • Functional health patterns
  • Human response patterns
• Contents of the patient record

  • Admission record
  • Consent for hospitalization
  • Discharge summary
  • Medical history
  • ECG form
  • X-ray
  • Ultrasound and CT Scan results
  • Laboratory results
  • TPR Sheet
  • I and O Sheet
  • IVF Sheet
  • Medication Sheet
  • Doctor’s order and progress Notes
  • Nurses notes and treatment record
  • Charge slips
• Documentation Guidelines

  • The Computerized record

  2. Ensuring Confidentiality: Personal password required, never leave the computer terminal unattended, do not leave client information displayed on the monitor, shred all unneeded computer-generated worksheets, know the facility’s policy and procedure for correcting an entry error, follow agency procedure for correcting or documenting sensitive materials, IT personnel must install a firewall to protect the server from unauthorized access

  3. General Guidelines for Recording: Date and time, Timing, Legibility, Permanence, Accepted Terminology, Correct Spelling and Grammar, Signature, Accuracy, Sequence, Appropriateness, Completeness, Conciseness, Legal Prudence
• Data to be Charted

  • All doctor’s orders: (a) Medicines given, the time at which they are, and when, used to relieve a condition that should respond to treatment within a short time. (b) Inspections, or if venipunctures/injections done, time result, and by whom.

  2. Symptoms: (a) Subjective data, (b) Objective data, (b1) All conditions that call for particularly careful attention to their record e.g. following surgical operation or X-ray or other treatment that may have harmful effects, accidents, chills, convulsions and when patient is very ill.
• Types of Forms in Health Assessment

  • OPEN-ENDED FORMS (TRADITIONAL FORM): Calls for narrative description of problem and listing of topics. Provides total picture including specific complaints and symptoms in the client’s own words.

  2. CUED OR CHECKLIST FORMS: Standardized data collection. Lists (categorizes) information that alerts the nurse to specific problems or symptoms assessed for each client.

  3. INTEGRATED CUED CHECKLIST: Combines assessment data with identified nursing diagnoses. Helps cluster data, focuses on nursing diagnosis, assists in validating nursing diagnosis labels, and combines assessment with problems listing forms.

  4. NURSING MINIMUM DATA SET: Comprises format commonly used in long term care facilities. Has a cued format that prompts nurse for specific criteria; usually computerized.
• Frequent or Ongoing Assessment Forms


  • Flowcharts, progress notes
• • Focused or Specialty Area Assessment Forms

  • Cardiovascular or neurologic assessment documentation forms