OBJECTIVE DATA COLLECTION Flashcards
1
Q
-include information about the client that the nurse directly observes during interaction with the client and information elicited through physical examination techniques.
A
OBJECTIVE DATA
2
Q
basic knowledge in three areas:
A
- Types and operation of equipment needed for the
particular examination - Preparation of the setting, oneself, and the client for the
physical assessment - Performance of the four examination techniques:
inspection, palpation, percussion, and auscultation
2
Q
- Each part of the physical examination requires specific pieces of equipment.
- Prior to the examination, collect the necessary equipment and place it in the area where the examination will be performed.
*This promotes organization and prevents the nurse from leaving the client to search for a piece of equipment.
A
EQUIPMENT
2
Q
Performance of the four examination techniques:
A
inspection, palpation, percussion, and auscultation
2
Q
Protect examiner in any part of the examination when the examiner may have contact with blood, body fluids, secretions, excretions, and contaminated items, or when disease-causing agents could be transmitted to or from the client
A
Gloves & gown
2
Q
Measure diastolic and systolic blood pressure
A
Sphygmomanometer, Stethoscope:
2
Q
auscultate blood sounds when measuring blood pressure
A
Stethoscope
3
Q
Measure body temperature
A
Thermometer
4
Q
Measures oxygen level
A
Pulse Oximeter
5
Q
Measure skinfold thickness of subcutaneous tissue
A
Skinfold calipers
5
Q
Take heart rate, pulse rate
A
Watch with second hand
6
Q
: Determine perceived pain level
A
Pain Rating Scale
6
Q
: Measure midarm circumference
A
Flexible Tape measure
7
Q
Mark measurements
A
Skin-marking pen
8
Q
Measure height and weight
A
Platform scale with height attachment:
9
Q
Measure size of skin lesions
A
Metric ruler
9
Q
Provide adequate lighting
A
Examination light, penlight
9
Q
Determine the degree of healing of a pressure injury
A
PUSH SCALE
10
Q
Enlarge visibility of lesion
A
Magnifying glass
10
Q
for predicting one’s risk to develop pressure injury
A
Braden Scale
11
Q
Auscultate the thyroid
A
Stethoscope
11
Q
Test distant vision
A
Snellen chart
12
Q
Test Pupillary constriction
A
Penlight
12
Q
help client swallow during examination of the thyroid gland
A
Small cup of water
13
Test near vision
Newspaper
14
Test for strabismus
Opaque card
14
View the red reflex and examine the retina of the eye
Ophthalmoscope
15
Test for bone and air conduction of sound.
Tuning fork:
15
Provide light to view the mouth and the throat and to transilluminate the sinuses
Penlight
16
View the ear canal and tympanic membrane
Otoscope
17
Grasp tongue to examine mouth
4 x 4 small gauze pad
18
Depress tongue to view throat, check looseness of teeth, view cheeks, and check strength of tongue
Tongue depressor
19
Auscultate breath sounds
Stethoscope
19
Measure diaphragmatic excursion.
Metric ruler & skin marking pen
20
Measure jugular venous pressure
Metric ruler
20
Detect bowel sounds
Stethoscope
21
Measure size and mark the area of percussion of organs
Tape measure
21
Place under knees and head to promote relaxation of abdomen
Two small pillows
22
Measure degree of flexion & extension of joints.
Goniometer
22
Measure size of of extremities
Flexible metric measuring tap
23
Test deep tendon reflexes
Reflex hammer
24
Test taste and smell perception
Cotton-tipped applicators and
substances to smell & taste
25
Promote comfort for client
Gloves and water-soluble lubricant
26
Scrotal illumination
Penlight
27
Detect occult blood
Specimen card
28
Inspect cervix through dilatation of the vaginal canal
Vaginal speculum & water soluble
lubricant:
29
Obtain endocervical swab, cervical scrape, & vaginal pool sample
Bifid spatula, endocervical broom
30
Detect occult blood
Specimen card
31
* How well you prepare the physical setting, yourself, and the client can affect the quality of the data you elicit, which will support your clinical judgments.
* As an examiner, you must make sure that you have prepared for all three aspects before beginning an examination.
* Practicing with a friend, relative, or classmate will help you achieve
proficiency in all three aspects of preparation.
PREPARING FOR THE EXAMINATION
(Setting, Patient, & Oneself)
32
* The physical examination may take place in a variety of settings such as a hospital room, outpatient clinic, physician’s office, school health office, employee health office, or a client’s home.
* It is important that the nurse strive to ensure that the examination setting meets the following conditions: Comfortable, room temperature: Provide a warm blanket if the room temperature cannot be adjusted
* Private area free of interruptions from others: Close the door or pull the curtains if possible.
* Quiet area free of distractions: Turn off the radio, television, or other noisy equipment.
* Adequate lighting: It is best to use sunlight (when available). However, good overhead lighting is sufficient.
* Firm examination table or bed at a height that prevents stooping: A roll-up stool may be useful when it is necessary for the examiner to sit for parts of the assessment.
* A bedside table/tray to hold the equipment needed for the examination.
Preparing the Physical Setting
33
* Careful preparation of yourself as an examiner is essential
* assess your own feelings and anxieties before examining the client.
* It is also important to perform these examination techniques with an experienced instructor
* preventing the transmission of infectious agents.
Preparing Oneself
34
* Establish the nurse–client relationship during the client interview before the physical examination takes place
* At the end of the interview, explain to the client that the physical assessment will follow and describe what the examination will involve.
* Respect the client’s desires and requests related to the physical
examination.
* Ask the client to urinate before the examination
* Ask the client to undress and put on an examination gown. Leave the room while the client changes into the gown and knock before reentering the room to ensure the client’s privacy.
* Begin the examination with the less intrusive procedures
* Throughout the examination, continue to explain what procedure you are performing and why you are performing it.
* It is usually helpful to integrate health teaching and health promotion during the examination
* Approach the client from the right-hand side of the examination table or bed
* You may ask the client to change positions frequently, depending on the part of the examination being performed.
Approaching & preparing the client
34
PHYSICAL EXAMINATION TECHNIQUES
inspection, palpation, percussion,
and auscultation.
35
* involves using the senses of vision, smell, and hearing to observe and detect any normal or
abnormal findings.
* This technique is used from the moment that you meet the client and continues throughout the examination.
* Inspection precedes palpation, percussion, and auscultation because the latter techniques can
potentially alter the appearance of what is being inspected.
* Although most of the inspection involves the use of the senses only, a few body systems require the use of special equipment (e.g., ophthalmoscope for the eye inspection, otoscope for the ear inspection).
Inspection
35
GUIDELINES FOR ?????????????????????:
1. Make sure the room is a comfortable temperature.
2. Use good lighting, preferably sunlight
3. Look and observe before touching.
4. Completely expose the body part you are inspecting while draping the rest of the client as appropriate.
5. Note the following characteristics while inspecting the client: color, patterns, size, location, consistency, symmetry, movement, behavior, odors, or sounds. Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or both sides of any individual body part.
INSPECTION
36
PALPATION
In general, the examiner’s fingernails should be short and the hands should be a comfortable temperature
PALPATION
In general, the examiner’s fingernails should be short and the hands should be a comfortable temperature
36
parts of hand that is sensitive to fine discrimination: pulse, texture, size, consistency, shape, crepitus.
finger pads
36
* consists of using parts of the hand to touch and feel for the following characteristics:
1. Texture (rough/smooth)
2. Temperature (warm/cold)
3. Moisture (dry/wet)
4. Mobility (fixed/movable/still/vibrating)
5. Consistency (soft/hard/fluid filled)
6. Strength of pulses (strong/weak/thready/bounding)
7. Size (small/medium/large)
8. Shape (well defined/irregular)
9. Degree of tenderness
Palpation
36
what are the three different parts of the hand used during palpation.
finger pads
ulnar/palmar surface
dorsal surface
37
parts of hand that is sensitive to temperature
dorsal (back) surface
37
parts of hand that is sensitive to vibrations, thrills, fremitus
ulnar or palmar surface
38
Types of Palpation
A.Light palpation:
B. Moderate palpation:
C. Deep palpation:
D. Bimanual palpation:
39
To perform____________ place your dominant hand lightly on the surface of the structure.
NOTE:
1. There should be very little or no depression (<1 cm). 2. Feel the surface structure using a circular motion. Use this technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture.
.Light palpation:
39
Depress the skin surface 1 to 2 cm (0.5–0.75 in.) with your dominant hand, and use a circular motion to feel for easily palpable body organs and masses.
* Note the size, consistency, and mobility of structures you palpate.
Moderate palpation
40
Place your dominant hand on the skin surface and your nondominant hand on top of your dominant hand to apply pressure. This should result in a surface depression between 2.5 and 5 cm (1 and 2 in.).
* This allows you to feel very deep organs or structures that are covered by thick muscle.
Deep palpation
40
Percussion helps detect inflamed underlying structures.
Eliciting pain
40
Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated.
* Use one hand to apply pressure and the other hand to feel the structure.
* Note the size, shape, consistency, and mobility of the
structures you palpate.
Bimanual palpation
40
Percussion helps determine whether an underlying structure is filled with air or fluid or is a solid structure.
Determining density
41
involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying
structures.
different assessment uses, including the following:
A. Eliciting pain:
B. Determining location, size, and shape
C. Determining density
D. Detecting abnormal masses:
E. Eliciting reflexes:
Percussion
42
: Percussion can detect superficial abnormal structures or masses.
Detecting abnormal masses
43
Deep tendon reflexes are elicited using the percussion hammer.
Eliciting reflexes
44
-is the direct tapping of a body part with one or two fingertips to elicit possible tenderness
(e.g., tenderness over the sinuses).
Direct percussion
45
-is used to detect tenderness over
organs (e.g., kidneys) by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.
Blunt percussion
46
is the most commonly used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures.
As density increases, the sound of the tone becomes quieter.
Solid tissue produces a soft tone fluid produces a louder tone
air produces an even louder tone.
*These tones are referred to as percussion notes and are classified according to origin, quality, intensity, and pitch
Indirect or mediate percussion
47
Types of Percussion
Direct percussion
Blunt percussion
Indirect or mediate percussion
48
is a type of assessment technique that requires the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract.
Auscultation
49
to listen for high-pitched
sounds, such as normal heart sounds, breath sounds, and bowel
sounds, and press the diaphragm firmly on the body part being
auscultated.
Use the diaphragm of the stethoscope
50
to listen for low-pitched sounds
such as abnormal heart sounds and bruits (abnormally loud,
blowing, or murmuring sounds). Hold the bell lightly on the body
part being auscultated.
Use the bell of the stethoscope
