Collecting Objective Data

Collecting objective data is essential for a complete nursing assessment. The nurse must have knowledge
of and skill in three basic areas to become proficient in collecting objective data: necessary equipment
and how to use it; preparing the setting, oneself, and the client for the examination; and how to perform
the four basic assessment techniques. Collecting objective data requires a great deal of practice to
become proficient. Proficiency is needed because how the data are collected can affect the accuracy of
the information elicited.

EQUIPMENT

Each part of the physical examination requires specific pieces of equipment. Table 3-1 lists equipment
necessary for each part of the examination and describes the general purpose of each piece of equipment.
More detailed descriptions of each piece of equipment and the procedures for using them are provided
in the chapters on the body systems where each piece is used, e.g., techniques for using an
ophthalmoscope is included in the eye assessment chapter. However, because the stethoscope is used
during the assessment of many body systems

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.

PREPARING FOR THE EXAMINATION

How well you prepare the physical setting, yourself, and the client can affect the quality of the data you
elicit. 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 to achieve proficiency in all
three aspects of preparation.

Preparing the Physical Setting

The physical examination may take place in a variety of physical 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, warm 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.

A portable lamp is helpful for illuminating the skin and for viewing shadows or contours.

• 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

As a beginning examiner, it is helpful to assess your own feelings and anxieties before examining the client.
Anxiety is easily conveyed to the client, who may already feel uneasy and self-conscious about the
examination. Self-confidence in performing a physical assessment can be achieved by practicing the
techniques on a classmate, friend, or relative. Your “pretend client” should be encouraged to simulate the
client role as closely as possible. It is also important to perform some of your practice assessments with
an experienced instructor or practitioner who can give you helpful hints and feedback on your technique.

General principles to keep in mind while performing a physical assessment include the following:

• Wash your hands before beginning the examination, immediately after accidental direct contact with
blood or other body fluids (you should wear gloves if there is a chance that you will come in direct contact
with blood or other body fluids), and after completing the physical examination or after removing gloves.
If possible, wash your hands in the examining room in front of the client. This assures your client that you
are concerned about his or her safety.

• Wear gloves if you have an open cut or skin abrasion, if the client has an open or weeping cut, if you are
collecting body fluids (e.g., blood, sputum, wound drainage, urine, or stools) for a specimen, if you are
handling contaminated surfaces (e.g., linen, tongue blades, vaginal speculum), and when you are
performing an examination of the mouth, an open wound, genitalia, vagina, or rectum. Change gloves if
moving from contaminated to clean body site, and between patients.

• If a pin or other sharp object is used to assess sensory perception, discard the pin and use a new one for
your next client.

• Wear a mask and protective eye goggles if you are performing an examination in which you are likely to
be splashed with blood or other body fluid droplets (e.g., if you are performing an oral examination on a
client who has a chronic productive cough).

Approaching and Preparing the Client

The nurse–client relationship should be established during the client interview before the physical
examination takes place. This is important because it helps to alleviate any tension or anxiety that the
client is experiencing.

Positioning the Client

Sitting Position

The client should sit upright on the side of the examination table. In the home or office setting, the client
can sit on the edge of a chair or bed. This position is good for evaluating the head, neck, lungs, chest, back,
breasts, axillae, heart, vital signs, and upper extremities. This position is also useful because it permits full
expansion of the lungs and it allows the examiner to assess symmetry of upper body parts. Some clients
may be too weak to sit up for the entire examination. They may need to lie down (supine position) and
rest throughout the examination. Other clients may be unable to tolerate the position for any length of
time. An alternative position is for the client to lie down with his or her head elevated.

Supine Position

Ask the client to lie down with the legs together on the examination table (or bed if in a home setting). A
small pillow may be placed under the head to promote comfort. If the client has trouble breathing, the
head of the bed may need to be raised. This position allows the abdominal muscles to relax and provides
easy access to peripheral pulse sites. Areas assessed with the client in this position may include head,
neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities.

Dorsal Recumbent Position

The client lies down on the examination table or bed with the knees bent, the legs separated, and the feet
flat on the table or bed. This position may be more comfortable than the supine position for clients with
pain in the back or abdomen. Areas that may be assessed with the client in this position include head,
neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses. The abdomen should not be
assessed because the abdominal muscles are contracted in this position.
SIMS’ Position

The client lies on his or her right or left side with the lower arm placed behind the body and the upper
arm flexed at the shoulder and elbow. The lower leg is slightly flexed at the knee while the upper leg is
flexed at a sharper angle and pulled forward. This position is useful for assessing the rectal and vaginal
areas. The client may need some assistance getting into this position. Clients with joint problems and
elderly clients may have some difficulty assuming and maintaining this position.

Standing Position

The client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess
posture, balance, and gait. This position is also used for examining the male genitalia.

Prone Position

The client lies down on his or her abdomen with the head to the side. The prone position is used primarily
to assess the hip joint. The back can also be assessed with the client in this position. Clients with cardiac
and respiratory problems cannot tolerate this position.

Knee–Chest Position

The client kneels on the examination table with the weight of the body supported by the chest and knees.
A 90-degree angle should exist between the body and the hips. The arms are placed above the head, with
the head turned to one side. A small pillow may be used to provide comfort. The knee–chest position is
useful for examining the rectum. This position may be embarrassing and uncomfortable for the client,
and, therefore, the client should be kept in the position for as limited a time as possible. Elderly clients
and clients with respiratory and cardiac problems may be unable to tolerate this position.
Lithotomy Position

The client lies on his or her back with the hips at the edge of the examination table and the feet supported
by stirrups. The lithotomy position is used to examine the female genitalia, reproductive tracts, and the
rectum. The client may require assistance getting into this position. It is an exposed position, and clients
may feel embarrassed. In addition, elderly clients may not be able to assume this position for very long or
at all. Therefore, it is best to keep the client well draped during the examination and to perform the
examination as quickly as possible.

PHYSICAL EXAMINATION TECHNIQUES

Four basic techniques must be mastered before you can perform a thorough and complete assessment of
the client. These techniques are inspection, palpation, percussion, and auscultation.

Inspection

Inspection 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).

Palpation

Palpation consists of using parts of the hand to touch and feel for the following characteristics: texture
(rough/smooth), temperature (warm/cold), moisture (dry/wet), mobility (fixed/movable/still/ vibrating),
consistency (soft/hard/fluid filled), strength of pulses (strong/weak/thready/bounding), size
(small/medium/large), shape (well defined/irregular), and degree of tenderness.

Percussion

Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable
the examiner to assess underlying structures. Percussion has several different assessment uses, including

• Eliciting pain: Percussion helps to detect inflamed underlying structures. If an inflamed area is
percussed, the client’s response may indicate or the client will report that the area feels tender, sore, or
painful.
• Determining location, size, and shape: Percussion note changes between borders of an organ and its

neighboring organ can elicit information about location, size, and shape.

• Determining density: Percussion helps to determine whether an underlying structure is filled with air
or fluid or is a solid structure.

• Detecting abnormal masses: Percussion can detect superficial abnormal structures or masses.
Percussion vibrations penetrate approximately 5 cm deep. Deep masses do not produce any change in
the normal percussion vibrations.

• Eliciting reflexes: Deep tendon reflexes are elicited using the percussion hammer.

Auscultation

Auscultation 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. A stethoscope is used because these body sounds are not audible to
the human ear. The sounds detected using auscultation are classified according to the intensity (loud or
soft), pitch (high or low), duration (length), and quality (musical, crackling, raspy) of the sound