- Yourself - The environment - The patient

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

- 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

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

Collecting Objective Data Flashcards by christine tin

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

OBJECTIVE DATA

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

Focused Physical Examination

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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
Anus
Lower extremities

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Focused Physical Examination
Used when:

patient is unstable
Time constraints exist
Episodic follow-up

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is used when patient is unstable, time constraints exist and episodic follow-up

Focused Physical Examination

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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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Situation:
Client complains of abdominal pain

inspect, auscultate, percuss and palpate the abdomen; assess vital signs

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Situation:
The client’s fluid intake is minimal

assess tissue turgor, fluid intake and output, and vital signs

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Preparation

Yourself
The environment
The patient

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Preparing yourself

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

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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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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

Ensure equipment are clean, in good working condition, readily accessible

Instrumentation

Designate one area for clean/ unused and another area for dirty/ used

Instrumentation

Thermometer Types:

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

Used in indirect auscultation

Stethoscope

Stethoscope tubing should be ________________ long

30 to 35cm

Stethoscope internal diameter of

0.3m

- Fetal heart sounds - Locate pulses

Doppler

Sphygmomanometer - Cuff width should be __________ of the arm circumference

40%

Sphygmomanometer Cuff bladder encircle ______________of the arm

80%

To assess far and near vision

Visual acuity chart

Far vision adult:

20 feet

Far vision children:

10 feet

vision:

14 inches

- Test each eye separately then both eyes together - Test with and without correction glasses - No more than 2 mistakes

Visual acuity chart

Visual acuity charts (types)

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

- Eyes - Hard-to-see places

Penlight

- Assess the internal structures of the eyes - Always use in dark room - Right- to- right - Left- to- lef

Ophthalmoscope

Always palpate the _____________________________ for tenderness before inserting an otoscope, if tender proceed carefully

tragus, helix, mastoid process

Using Otoscope/Nasoscope on adults:

pull the helix up

Using Otoscope/Nasoscope for preschool child

pull the earlobe down

- Assess hearing and vibratory sensation

Tuning fork

testing vibratory sensation

Low frequency fork (256Hz)

assessing hearing

High frequency fork (512Hz)

- Lengths and circumferences - Abdominal girth - Fundal height

Tape measure/ pocket ruler

To assess range of motion exercises

Goniometer

Used to measure body fat

Triceps skin fold calipers

Used to measure weight

scale

- Better visualization of the pharynx - Assessing gag reflex

Wooden tongue depressor

- Used during neurological examination: - Light touch - Corneal reflex

Cotton balls

Assess hot and cold sensation

Test tubes

Assess the sense of smell:

Coffee

Assess sense of taste

Sugar and lemon

Swallowing ability and thyroid

Cup of water

Assess for stereognosis

Paper clip

- Assess light touch and pain - Discard after use

Safety Pin

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

Gloves

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

Inspection

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

Temperature

dorsal aspect of the hand

vibration

ball of the hand on palm and ulnar surface

fine sensation (pulsations)

finger pads

types of palpation

- light palpation - deep palpation

Light palpation

- Temperature, texture, mobility, shape, size - Pulses - Areas of edema - Tenderness

Deep palpation

- Organ size, masses - Rebound tenderness - Voluntary guarding - Ballottement

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

Percussion

Percussion Assess:

- Density of underlying structure - Areas of tenderness - Deep tendon reflexes

Types of percussion:

- Direct/Immediate Percussion - Indirect Percussion - Fist or Blunt Percussion

Directly tapping your hand over a body surface

Direct/Immediate Percussion

- Plexor, pleximeter technique - Percussion hammer

Indirect Percussion

- Assess organ tenderness - Can be direct or indirect

Fist or Blunt Percussion

▪ 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

Types of Auscultation:

- Direct Auscultation - Indirect Auscultation

- Without stethoscope - Respiratory congestion

Direct Auscultation

With stethoscope

Indirect Auscultation

Patients with special needs

- Children - Pregnant patients - Elderly - Disabled patients

Adopt an age appropriate approach: - Infants - Children 1 to 2 years old - Children 2 to 3 years old - Children 4 to 5 years old - School- age children - Adolescent - Look for normal growth and developmental changes

Children

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

Elderly patients

- Do not rush - Look for developmental changes - Conserve your patient’s energy - Allow enough time to respond

Disabled patients

- Identify the disability - Focus on patient’s functional ability and mental capacity - Modify as necessary

is a systematic study of right and wrong conduct in situations that involve issues of values and morals

Ethics

consider in a broad, general manner what is good or bad, right or wrong

Morals

are set of enforceable principle and rules established to protect society.

Laws

is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including benefits and risks of treatment, alternatives to treatment and prognosis if not treated by a health care provider.

Informed Consent

2 Types of Consent

- Express Consent - Implied Consent

- Either oral or written agreement - The more invasive procedure or the greater potential for risk to the client, the greater the need for written permission.

Express Consent

Exists when the individual’s nonverbal behavior indicates agreement

Implied Consent

reponsible for obtaining informed consent for specific medical and surgical treatment.

Primary care provider, usually the physician

may obtain informed consent for procedures that he/she will perform as a dependent nursing intervention (e.g. NGT insertion, drug administration).

Nurse

ELEMENTS OF AN INFORMED CONSENT

- Completeness (Disclosure) - Comprehension - Voluntariness - Competence

Patients need a great deal of information to make educated decision.

Completeness (Disclosure)

The patient (or his surrogate decision maker) must understand the explanation.

Comprehension

The patient must be free to accept or reject the treatment.

Voluntariness

The person must have the capacity to understand the information and make a choice about his situation.

Competence

3 groups of people who cannot provide consent

- Minors - Unconscious/injured - Mentally Ill

Be sure to make a record of all interaction with clients, as well as the patient’s refusal or noncompliance with treatment.

Charting

Charting should always be:

F – Factual A – Accurate C – Complete T – Timely

Done if a standard care is breached or an unusual incident occurs (e.g. a visitor or patient falls or is somehow injured)

Incident Report

is a law that seeks to protect all forms of information, be it private, personal, or sensitive. It meant to cover both natural and juridical persons involved in the processing of personal information.

RA No. 10173 or Data Privacy Act

Any information whether recorded in a material form or not, from which the identity of an individual is apparent or can reasonably and directly ascertained by the entity holding the information, or when put together with other information would directly and certainly identify an individual.

Personal information

SENSITIVE PERSONAL INFORMATION

1. race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations; 2. health, education, genetic or sexual life of a person; 3. civil, criminal or administrative proceedings 4. unique identifiers issued by government agencies peculiar to an individual; 5. specifically established by law as classified

Any operation or any set of operations performed upon personal information including, but not limited to, the collection, recording, organization, storage, updating or modification, retrieval, consultation, use, consolidation, blocking, erasure or destruction of data.

Processing

a person or organization who controls the collection, holding, processing or use of personal information, including a person or organization who instructs another person or organization to collect, hold, process, use, transfer or disclose personal information on his or her behalf.

Personal Information Controller

An individual whose personal information is processed

Data subject

DATA PRIVACY PRINCIPLES

- Transparency - Legitimate purpose - Proportionality

A data subject must be aware of the nature, purpose, and extent of the processing of his or her personal data, including the risks and safeguards involved, the identity of personal information controller, his or her rights as a data subject, and how these can be exercised.

Transparency

The processing of information shall be compatible with a declared and specified purpose, which must not be contrary to law, morals, or public policy.

Legitimate purpose

The processing of information shall be adequate, relevant, suitable, necessary, and not excessive in relation to a declared and specified purpose.

Proportionality

begins with the opening moments of the patient encounter

GENERAL SURVEY/STATUS

“First impression” of your patient - Use your senses and observation skills

GENERAL SURVEY/STATUS

- Is the patient acutely or chronically ill? - Is the patient frail? - Is the patient fit or robust? - Is the patient overweight or underweight?

Apparent State of Health

- Is the patient awake, alert, and responsive to you and others in the environment? - Is the patient drowsy, lethargic or stuporous? - Is the patient unconscious?

LEVEL OF CONSCIOUSNESS

- Is there clutching of the chest? - Is there pallor? Cyanosis? Diaphoresis? - Is there labored breathing, wheezing, or coughing?

SIGNS OF DISTRESS

Is there wincing, diaphoresis, protectiveness of a painful area, grimacing, or unusual posture favoring one limb or region of the body?

Pain

Are there any anxious facial expressions, fidgety movements, cold moist palms, inexpressive or flat affect, poor eye contact, or psychomotor slowing?

Anxiety or Depression

- Observe facial expression at rest, during conversation and social interactions, and during the physical examination - Ask yourself what is the patient’s face telling me? - Do you see pain, fear, or anxiety? - Does the patient maintain eye contact? - Is his/her facial expression happy or sad? - Look at the facial features. Are they symmetrical?

Facial Characteristics

Drooping of the eyelid

Ptosis

May indicate a transient ischemic attack or stroke.

Drooping on one side of the face

- Bulging or protruding eyeballs - May suggest hyperthyroidism

Exopthalmos

Pale complexion or unusual lightness of skin color, may indicate anemia, malnutrition, vitamin deficiency

Pallor

Bluish discoloration of the skin or mucous membrane, may indicate poor oxygenation.

Cyanosis

Yellowish discoloration of the skin or mucous membranes; may suggest an underlying hepatobiliary tract disease.

Jaundice

Medical term for a mole, a common benign skin lesion but some may be malignant.

Nevus

may reflect cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences

Excess Clothing

suggest gout, bunions, edema, or other painful foot conditions

Holes or slippers

can contribute to foot and back pain, calluses, falls, and infection

Run-down shoes

suggest joint pain; studies show that wearing copper jewelry may ease arthritic pain

Copper bracelets

can be associated with alcohol and drug use

Jewelries, tattooes, and body piercings

They may be clues to the patient’s personality, mood, lifestyle, and self-regard

Hair, finger nails, and use of make up

suggest the length of a possible illness

“Grown-out” hair and nail polish

may suggest high levels of ketones

fruity odor/acetone breath

a complication of Type 1 diabetes

diabetic ketoacidosis

A disorder where your body makes too much cortisol

Cushing’s syndrome

excessive abdominal fat

Truncal obesity

collection of excess fat behind the neck

Buffalo hump

May reflect a cardiopulmonary problem

Nail clubbing and edema

May reflect arthritic changes

Deformities

sitting upright

Left-sided heart failure

leaning forward with arms braced

COPD (Chronic obstructive pulmonary disease)

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

Estimated Due of Confinement or Estimated Due Date Last Menstrual Period

Nagele’s Rule

Obstetric / Gynecologic History

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

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

USE specific RULES, THEORIES, principles, and PERSPECTIVES TO inquire into THE justification of ah individual’s action in a PARTICULAR situation

ETHICS

They should be told everything they would consider important in making a treatment decision

Completeness (disclosure)

Ask the patient to describe in his own words the procedure to which he is consenting

Comprehension

- He must not be pressured or coerced to give consent - There must be no actual or implied threat

Voluntariness

REPORTING AND DOCUMENTING REMEMBER:

If it isn’t documented, it wasn’t done

When you first see a patient…

OBSERVE and ASSESS!!!

May suggest an underlying neurological disorder

Ptosis

Ptosis may suggest an underlying neurological disorder. Example?

Bell’s Palsy, Myasthenia gravis

Manner of walking

Gait

are rhythmic oscillatory movements

Tremors

Three Groups of Tremors

- Resting (or Static) Tremors - Postural Tremors - Intention Tremors

may present with changes in voice quality

Cranial nerve IX lesion

are most prominent at rest and may decrease or diappear with voluntary movement.

Resting (or Static) Tremors

appear when the affected part is actively maintaing a posture

Postural Tremors

are rhythmic, repetative, bizzare movements hat chiefly involve the face, mouth, jaw and tongue grimacing, pursinf of the li[s, protrusions of the tongue, opening and closing of the mouth, and deviations of the jaw

Oral-Facial Dyskinesias

are brief, repetitive, coordinated movements occuring at irregular intervals

Tics

are similar to athetoid movements, but often involve larger parts of the body, including the trunk

Dystonia

are slower and more twisting and writhing than choreiform movements,a nd ahve a larger amplitude

Athetosis

are brief, rapid, jerky, irregular and unpredictable. they occur at rest or interrupt normal coordinated movements

Chorea

Level of Consciousness (Arousal): Techniques

Alertness Lethargy Obtundation Stupor Coma

speak to the patient in a normal tone voice

alertness

speak to the patient in a loud voice

lethargy

shake the patient gently as if awakening a sleeper

obtundation

apply a painful stimulus

stupor

apply repeated painful stimuli

coma

- Is there clutching of the chest? * Is there pallor? Cyanosis? Diaphoresis? * Is there labored breathing, wheezing, or coughing?

Cardiac or Respiratory Distress

* How is the patient dressed? * Is the clothing suitable for the temperature and weather? Is it clean and appropriate to the setting? * Excess clothing may reflect cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences

Clothing

- View your patient’s body size and build with respect to his or her age and gender * Is he/she stocky, slender, or of average build? Obese or cachectic? Proportional? * Does you patint have abnormal fat distribution? * Take a close look at the patient’s hand. Do you see clubbing, edema or deformities?

Body Type

may reflect a cardiopulmonary problem

Nail clubbing and edema

are rhythmic oscillatory movements

tremors

3 groups of tremors

resting (static) tremors postural tremors intention tremors

Collecting Objective Data Flashcards

(189 cards)