Objective Data Flashcards by Enrique Castro

Its a type of data that is reproducible, true for the patient and the nurse, and its a fact.

Objective Data

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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

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Two types of physical assessment

Focused and Complete

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Establish or monitors health status. Assess from head to toe

Complete Physical Assessment

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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

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What to prepare when conducting physical assessment.

yourself
The environment
The patient

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How to prepare yourself before physical assessment

identify yourself
appear calm and organized
avoid interpreting your findings
observe standard and universal precaution

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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

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Preparing the environment before physical assessment

Temp
Lighting
Privacy and noise
Positioning
Draping
Instrumentation
Methods of Examining

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What to consider when positioning the client

clients ability to assume position
Physical condition
energy level
age

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A seated position, unssuported back, leg hanging freely

Sitting Position

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

Supine Position

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

Dorsal Recumbent

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Back lying position with feet supported on stirrups, 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 small pillow

Prone

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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

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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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It provides privacy and warmth. Exposes only the area that is going to be assessed

Draping

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Used to assess internal structure of the eyes. used in a dark room.

Ophthalmososcope

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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

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What equipment is being described?
To view the ear and nose cavities

Otoscope/Nasoscope

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What equipment is being described?
▪ Lengths and circumferences
▪ Abdominal girth
▪ Fundal height

Tape measure/ pocket ruler

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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

1. Direct/immediate Percussion 2. Indirect Percussion 3. 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