Body system (cardiovascular system) Body area/ Regional (Lungs

Collecting Objective Data Flashcards by Japeth Jaco

SUBJECTIVE DATA

▪ Perception
▪ Opinion
▪ True for the patient
▪ May or may not be true to you

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OBJECTIVE DATA

▪ Reproducible findings
▪ True for the patient and for you
▪ True for you and others
▪ FACT

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PURPOSE OF PHYSICAL EXAMINATION

▪ Obtain baseline data about the client’s
functional abilities
▪ Supplement, confirm, or refute data
obtained in the nursing history
▪ Obtain data that will establish nursing
diagnosis and plan
▪ Evaluate the physiological outcomes of
healthcare
▪ Make clinical judgments about client’s
health status
▪ Identify areas of health promotion and
disease prevention
▪ Discover you patient’s strengths

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Types of physical assessment

▪ Complete
▪ Focused

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Types of Focused

Body system (cardiovascular
system)
Body area/ Regional (Lungs

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Establish or monitor health status

Complete Physical Examination

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Components of Complete Physical Examination

✓ General survey
✓ Vital signs
✓ Head
✓ Neck
✓ Upper extremities
✓ Chest and back
✓ Abdomen
✓ External genitals

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Focused Physical Examination
Used when:

▪ patient is unstable
▪ Time constraints exist
▪ Episodic follow-up

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Focused Physical Examination
Components:

▪ General survey
▪ Vital signs
▪ Assessment of the specific area or system
▪ Quick cephalocaudal scan

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PA Preparation

▪ Yourself
▪ The environment
▪ The patient

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PA Preparing Yourself

▪ Identify yourself
▪ Appear calm and organized
▪ As a beginner, avoid interpreting your
findings
▪ Observe standard and universal precaution

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PA Preparing client

▪ Explain where and when the examination will take place
▪ Explain what will happen during the
examination
▪ Determine contraindicated positions
▪ Empty the bladder before the examination
▪ If examining a child, start with least invasive/ uncomfortable aspect

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PA Preparing the Environment

▪ Temperature
▪ Lighting
▪ Privacy and noise
▪ Positioning
▪ Draping
▪ Instrumentation
▪ Methods of Examining

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Positioning Consider

▪ Client’s ability to assume a position
▪ Physical condition
▪ Energy level
▪ Age

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Different Position

Sitting
Supine
Dorsal Recumbent
Lithotomy
Prone
Sim’s
Knee Chest Position

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A seated position, back
unsupported and legs hanging freely.

Sitting

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Back-lying position with legs
extended; with or without pillow under the head

Supine

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Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface.

Dorsal recumbent

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Back-lying position with feet
supported in stirrups; the hips should be in line with the edge of the table

Lithotomy

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Lies on abdomen with head.
turned to the side, with or without a small pillow

Prone

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Side-lying position with
lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow

Sim’s

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knees and chest with head is turned to one side, arms extended on the bed, and elbows flexed and resting.

Knee chest position

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Provide privacy and warmth, expose only the area to be assessed.

Draping

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▪ Ensure equipment are clean, in good
working condition, readily accessible
▪ Designate one area for clean/ unused and
another area for dirty/ used

Instrumentation

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Thermometer Types:

▪ Glass mercury thermometer ▪ Electronic digital thermometer ▪ Tympanic thermometer ▪ Temporal artery thermometer ▪ Disposable paper strips

Used in indirect auscultation.

Stethoscope

Stethoscope parts

▪ Used in indirect auscultation ▪ Tubing should be 30 to 35cm long ▪ Internal diameter of 0.3cm ▪ Has a diaphragm and amplifier (bell) ▪ Have the earpieces pointing forward

▪ Fetal heart sounds ▪ Locate pulses

Doppler

an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff

Sphygmomanometer

Sphygmomanometer ▪ Cuff width should be _____ .

40% of the arm circumference

Sphygmomanometer Cuff bladder encircle ____.

80% of the arm.

To assess far and near vision

Visual acuity chart

▪ Far vision adult: __ feet ▪ Far vision children: __ feet

20 feet 10 feet

Visual acuity charts

▪ Snellen eye chart ▪ E chart ▪ STYCAR test cards ▪ Pocket vision screener

uses for ▪ Eyes ▪ Hard-to-see places

Penlight

Assess the internal structures of the eyes and Always use in dark room

Ophthalmoscope

Always palpate the tragus, helix, mastoid process for tenderness before inserting an otoscope, if tender proceed carefully

Otoscope/Nasoscope

Assess hearing and vibratory sensation

Tuning Fork

Tuning Fork frequencies

▪ Low frequency fork (256Hz): testing vibratory sensation ▪ High frequency fork (512Hz): assessing hearing

Tape measure/ pocket ruler uses.

▪ Lengths and circumferences ▪ Abdominal girth ▪ Fundal height

Goniometer

To assess range of motion exercisers

Used to measure body fat

Triceps skin fold calipers

Scale

▪ Used to measure weight

this is for: ▪ Better visualization of the pharynx ▪ Assessing gag reflex ▪ Break tongue depressors after use

Wooden tongue depressor

▪ Used during neurological examination

Cotton balls

Cotton, used during neurological examination:

▪ Light touch ▪ Corneal reflex

Assess hot and cold sensation.

Test Tubes

Coffee

Assess the sense of smell.

Sugar and lemon

Assess sense of taste

Cup of water

Swallowing ability and thyroid

Paper clip

Assess for stereognosis.

Safety Pin

▪ Assess light touch and pain ▪ Discard after use

Gloves

▪ Use when there is risk for exposure to blood or body fluids

Techniques of Physical Examination

▪ Inspection ▪ Palpation ▪ Percussion ▪ Auscultation

General guidelines

▪ Be systematic ▪ Use you patient as a comparative ▪ Always consider your patient’s growth and developmental stage

Inspection

▪ 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

Types of Inspection

▪ Direct inspection ▪ Indirect inspection

▪ 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

Dorsal aspect of the Hand

for temperature

Ball of the hand on palm and ulnar surface

Vibration

Finger Pads

Fine sensation (pulsations)

Types of Palpation

Light Palpation Deep Palpation

type of palpation with temperature, texture, mobility, shape, size pulses areas of edema tenderness

Light Palpation

Type of palpation with: organ size, masses rebound tenderness. voluntary guarding ballottement

Deep Palpation

Striking a body surface with quick, light blows and eliciting vibrations and sounds

Percussion

Percussion Assess:

Assess: * Density of underlying structure * Areas of tenderness * Deep tendon reflexes

Types of percussion

Direct/ Immediately percussion Indirect Percussion Fist or Blunt Percussion

Direct tapping your hand over a body surface

Direct/ Immediately percussion

Assess organ tenderness can be direct or indirect

Fist or Blunt Percussion

Percussion Sounds

Resonance Tympany Dullness Hyperresonance Flatness

Plexor, pleximeter technique percussion hammer

Indirect Percussion

▪ Use of sense of hearing

Auscultation

Auscultation, Assesses

Assess heart sounds, lung sounds, bowel sounds, vascular sounds ▪ Pitch (medium, high or low) oIntensity (soft or loud) ▪ Duration (short or long) ▪ Quality

Patients with special needs

▪ Children ▪ Pregnant patients ▪ Elderly ▪ Disabled patients

Types of Auscultation:

Direct auscultation Indirect auscultation

is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing.

Review of Systems

Nagele’s Rule →

Estimated Due of Confinement or Estimated Due Date Last Menstrual Period Subtract 3 months Add 7 days Add 1 year

woman who is or has been pregnant

Gravida

woman who has never has been pregnant

Nulligravida

first time pregnant

Primigravida

pregnant more than once

Multigravida

past pregnancies that have reached viability (24 AOG)

Para

has never completed to period of viability

Nullipara

completed one pregnancy regardless the result

Primipara

completed two or more pregnancies

Multipara

Obstetric / Gynecologic History

GTPAL Gravida (# of Pregnancy) Term Preterm Abortion Children Living

This refers to the total number of times a woman has been pregnant, regardless of the outcome

Gravida

This indicates the number of full-term pregnancies a woman has had. A full-term pregnancy is one that lasts at least 37 weeks.

Term

This represents the number of preterm pregnancies a woman has experienced. pregnancy is one that ends before 37 weeks of gestation.

Preterm

In the context of GTPAL, refers to the number of pregnancies that were terminated before 20 weeks of gestation. It includes both spontaneous abortions (miscarriages) and induced abortions.

Abortion

This denotes the number of living children a woman currently has. It does not include the current pregnancy.

Living

Collecting Objective Data Flashcards

(91 cards)