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Chapter 3 Collecting Objective Data notes
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Chapter 3 Collecting Objective Data: The Physical Examination
Learning Objectives
1. Explain how to prepare oneself, the physical environment, and the client for a physical
examination.
a. Preparing self:
i. Assess own feelings & anxieties.
ii. Achieve confidence by performing a physical assessment on a friend/ fam.
iii. Prevent transmission of infections
1. Wash hands before examination, after examination, & when in direct
contact w/ body fluids
2. Wear gloves when there is a possibility of contact w/ body fluids
3. Wear PPE prn
4. Pt care equipment
b. Preparing environment:
i. Comfortable, warm temp.
ii. Private area w/o interruptions; close door & pull curtains
iii. Quiet w/o distractions
iv. Adequate lighting: sunlight works best if available.
v. Firm examination bed/ table w/ bedside table/ tray to hold equipment needed
b. Preparing the client:
i. Establish nurse-client relationship
ii. Explain procedure & describe the step of the Physical examination
iii. Respect client's requests / desires
iv. Explain importance of examination
v. Leave room when client changes
vi. Begin exam w/ less intrusive procedures
vii. Explain the procedures
viii. Explain to client why position change is necessary
2. Survey the various pieces of equipment needed to perform a physical examination.
3. Describe various client positions used for different parts of the physical examination
a. sitting: client is sitting upright on side of exam table.
i. This position is good for evaluating the head, neck, lungs, chest, back,
breast, vital signs, & upper extremities. This position permits full
expansion of lungs & allows examiner to assess symmetry of body parts
b. supine: client lies down w/ legs together on exam table.
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i. Small pillow may be placed for comfort. Raise HOB if pt has difficulty
breathing. In this position the abdominal muscles relax & allows easy
access to peripheral pulse sites. May assess the head, neck, chest,
breasts, axillae, abdomen, heart, lungs & all extremities.
c. dorsal recumbent: pt lies down on exam table w/ knees
bent, legs separated & feet flat on table.
i. Assess head neck, chest, lungs, heart, extremities, breast, & peripheral
pulses. Abdomen should not be assessed bc abdominal muscles are
contracted in this position.
d. sims: pt lies on R/L side w/ lower arm placed behind body
& upper arm flexed at shoulder & elbow. Leg is slightly flexed at the knee while
upper leg is flexed at a sharper angle & pulled forward.
i. Assess the rectal & vaginal areas. Clients w/ joint problems & elderly
clients may have difficulty getting & staying in this position.
e. standing: assess posture, balance, gait, & examination of male
genitalia.
f. prone: pt lies down on Abd w/ head on side.
i. Assesses the hip joint (mainly) & client. Clients w/ cardiac & respiratory
problems cannot tolerate position.
g. knee-chest: client kneels on exam table w/ weigh of body
supported by chest & knees. A 90-degree angle btw body & hips. Arms above
head w/ head turned to one side & small pillow to provide comfort.
i. Used to examine rectum
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h. lithotomy: pt lies on back w/ hips on edge of examination
table & feet supported by stirrups
i. Used to examine female genitalia, reproductive tracts, & rectum
4. Demonstrate correct inspection, palpation, percussion, and auscultation examination
techniques.
a. Inspection: using the sense of vision, smell, & hearing to observe & detect any
normal & abnormal data.
i. Begins the moment that you meet the client & continues throughout the
exam.
ii. Precedes the other techniques bc they can alter the appearance of what
is being inspected.
iii. Make sure the room is at a comfortable temp. w/ good lighting
iv. Look & observe before touching.
v. Only expose the area that is being examined & drape the rest.
b. Palpation: using parts of hand to touch & feel
i. Characteristics to feel:
1. Texture: rough/ smooth; finger pads
2. Temp: warm/ cold; dorsal (back) surface
3. Moisture: wet/ dry; palmar surface
4. Mobility: fixed/ movable/ still/ vibrating; finger pads
5. Consistency: soft/hard/ fluid filled; finger pads
6. Strength of pulses: strong/weak/thready/bounding; finger pads
7. Size: small/medium/ large: finger pads
8. Shape: well defined/ irregular; finger pads
9. Degree of tenderness; finger pads
c. Percussion: tapping of body parts to produce sound waves
i. 3 types of percussion:
1. Direct: direct tapping of body w one/ two fingertips to elicit
tenderness.
2. Blunt: used to detect tenderness over organs
a. Place one hand flat on body & placing fist of other hand to
strike the back of hand flat on body.
3. Indirect: tapping done w/ this percussion produces a sound/ tone
that varies w/ density of the structure. MOST COMMON
a. When density increases, the sound of the tone becomes
quieter
b. Solid tissue = soft tone
c. Fluid = louder tone
d. Air = even louder tone
Sound Intensit Pitch Length Quality Example of Origin
y
Resonance (heard over part air and part Loud Low Long Hollow Normal lung
solid)
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Hyperresonance (heard over mostly air) Very loud Low Long Booming Lung with emphysema
Tympany (heard over air) Loud High Moderat Drumlike Puffed-out cheek, gastric
e bubble
Dullness (heard over more solid tissue) Medium Medium Moderat Thud-like Diaphragm, pleural effusion,
e liver
Flatness (heard over very dense tissue) Soft High Short Flat Muscle, bone, sternum,
thigh
TABLE 3-3 Sounds (Tones) Elicited by Percussion
ii. Percussion is used for:
1. Eliciting pain: detects inflamed underlying structures. When an
inflamed area is percussed the pt may have a physical response /
may state that it painful/ sore.
2. Determining location, size, & shape: percussion note changes
btw borders of an organ & may elicit info about location, size, &
shape.
3. Determining density: percussion helps determine if there is fluid/
air in a structure / if the structure is a solid.
4. Detecting abnormal masses: percussion can detect superficial
abnormal structures/ masses.
a. Percussion vibrations penetrate ≈ 5 cm deep
5. Eliciting reflexes: reflexes are elicited using the percussion
hammer
d. Auscultation: requires the use of a stethoscope to listen for heart sounds,
movement of blood through cardiovascular sys., movement of bowel, &
movement of air through respiratory tract.
i. We use a stethoscope bc these body sounds are not audible to the
human ear.
ii. Sounds are classified according to:
1. Intensity: loud/ soft
2. pitch: high/ low
3. duration: length
4. quality: musical, crackling, raspy
iii. eliminate distracting noises
iv. expose body part that is being auscultated.
5. Differentiate between light, deep, and bimanual palpation.
a. Light palpation: place dominant hand lightly on surface of the structure.
i. Little to no depression < 1cm
ii. Feel surface using circular motion
iii. Use for: Pulses, tenderness, surface skin texture, temp, & moisture.
b. Moderate palpation: depress the skin surface to 1-2 cm w/ dominant hand &
use circular motion to feel
i. Feel for easily palpable body organs/ masses
ii. Note: size, consistency, & mobility.
c. Deep palpation: place dominant hand on skin & nondominant hand on top of
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dominant hand to apply pressure.
i. Depression: 2.5- 5 cm
ii. To feel very deep organs & structures that are covered by thick muscle
d. Bimanual palpation: two hands, one hand on each side of the body part (uterus,
breasts, spleen) to palpate.
i. Use one hand to apply pressure & other hand to feel structure
ii. Note: size, shape, consistency, & mobility of structures
6. Discuss the purpose of the bell and diaphragm of the stethoscope.
a. Diaphragm: high pitched sounds
i. Normal heart sounds, breath sounds, & bowel sounds
ii. Press the diaphragm firmly on body part
b. Bell: low-pitched sounds
i. Abnormal heart sounds & bruits (abnormal loud, blowing, or murmuring
sounds)
ii. Hold the bell lightly on body part.
iii. Things to do:
1. Place earpieces into outer ear canal & angle them toward the
nose
2. Warm diaphragm & bell before using
3. Explain what you are listening to
4. Avoid listening through close
a. If pt has a hairy chest keep shirt on
iv.
