COLLECTING

OBJECTIVE DATA

Bernadette Wyne Tosoc Lee, RN, MAN

¢ Objective data include information
about the client that the nurse
directly observes during interaction
with him and information elicited
through physical assessment
(examination) techniques
TO BECOME PROFICIENT WITH PHYSICAL
ASSESSMENT SKILLS, THE NURSE MUST HAVE
BASIC KNOWLEDGE IN THREE AREAS:

¢ Types of and operation of equipment needed

for particular examination
¢ Preparation of the setting, oneself and the
client for the physical assessment.
¢ Performance of the four assessment
techniques: inspection, palpation, percussion
and auscultation
EQUIPMENT

¢ 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
PREPARING THE PHYSICAL SETTING
¢ Ensure that the examination setting meets the
following conditions:
— Comfortable, warm room temperature
— Private area free of interruptions from others
— Quiet area free of distractions
— Adequate lighting
— Firm examination table or bed at a height that
prevents stooping
— A bedside table/tray to hold equipment needed
PREPARING ONESELF

¢ Assess own feelings and anxieties before

examining the client.
¢ Prevent the transmission of infectious
agents
GENERAL PRINCIPLES IN PERFORMING
PHYSICAL ASSESSMENT

¢ Wash your hands before beginning the

examination, immediately after accidental direct
contact with blood or other body fluids, and after
completing the physical examination.
¢ Wear gloves if you have open cut or skin
abrasion, if the client has an open or weeping cut,
if you are collecting body fluids for a specimen, if
you are handling contaminated surfaces and
when you are performing an examination of the
mouth, an open wound, genitalia, vagina or
rectum.
¢ 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
STANDARD PRECAUTIONS
A. Hand Hygiene
B. Gloves
C. Mask, Eye Protection, Face Shield
D. Gown
E. Patient Care Equipment
F. Environmental Control
G. Linen
H. Occupational Health and Bloodborne Pathogens
I. Patient Placement
APPROACHING AND PREPARING THE
CLIENT

¢ The nurse-client relationship should be

established 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.
¢ Some examination requires the client to sign a
consent form especially in situations where a
vaginal or rectal examination will be performed.
¢ Begin the examination with the less intrusive
procedure such as measuring the client’s
temperature, pulse, blood pressure, height and
weight.
¢ Throughout the examination, continue to explain
what procedure you are performing and why you
are performing it. Integrate health teaching.
¢ Approach the client from the right hand side of
the examination table or bed because most
examination techniques are performed with the
examiner’s right hand.
POSITIONING THE CLIENT

Sitting Position
¢ This position is good for evaluating
the head, neck, lungs, chest, back,
breasts, axillae, heart, vital signs and
upper extremities
¢ Permits full expansion of the lungs
and it allows the examiner to assess
symmetry of upper body parts
Supine Position
¢ Ask the client to lie down with the legs together
on the examination table. A small pillow may be
placed under the head o promote comfort.
¢ 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
with the knees bent, the legs separated and the
feet flat on the table.
¢ 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 to be assessed because the
abdominal muscles are contracted in this
position.
SIMS’ Position
¢ The client lies on his 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.
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 abdomen with the
head to the side.
¢ Used primarily to assess
the hip joint
¢ The back can also be
assessed in this position.
¢ Client 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.
¢ Useful for examining the rectum.

¢ The client should be kept in the position for a

limited time as possible.
Lithotomy Position
¢ The client lies on his back with the hips at the
edge of the examination table and the feet
supported by stirrups.
¢ Used to examine the female genitalia,
reproductive tracts and the rectum.
¢ It is an exposed position and clients may feel
embarrassed. Therefore, it is best to keep the
client well draped during the examination and to
perform examination as quickly as possible.
PHYSICAL EXAMINATION TECHNIQUES

INSPECTION
¢ Involves using the senses of vision, smell and
hearing to observe and detect any normal or
abnormal findings.
¢ A few body systems require the use of special
equipment like ophthalmoscope for the eye
inspection, otoscope for the ear inspection.
GUIDELINES IN THE PRACTICE OF
INSPECTION TECHNIQUE

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, pattern, size,
location, consistency, symmetry, movement,
behavior, odors or sounds
6. Compare the appearance of symmetric
body parts (eye, ears, arms, hands) or both
sides of any individual body part.
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)
— Degree of tenderness
PARTS OF HAND TO USE WHEN
PALPATING

Hand Part Sensitive To

Fingerpads Fine discriminations:
pulses, texture, size,
consistency, shape,
crepitus

Ulnar or palmar surface Vibrations, thrills,

fremitus

Dorsal surface Temperature

FOUR TYPES OF PALPATION
1. Light Palpation
— Place your dominant hand lightly on the
surface of the structure.
— There should be very little or no depression
(less than 1 cm)
— Feel the surface structure using a circular
motion.
— Use this technique to feel for pulses,
tenderness, surface skin texture, temperature
and moisture.
2. Moderate Palpation
• Depress the skin surface 1 to 2 cm 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.
3. Deep Palpation
— Place your dominant hand on the skin surface
and your non dominant hand on top of your
dominant hand to apply pressure.
— This should result in a surface depression
between 2.5 and 5 cm.
— This allows you to feel very deep organs and
structures that are covered by thick muscle.
4. Bimanual Palpation
— Use two hands, placing one on each side of the
body part 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
PERCUSSION
¢ Involves tapping body parts to produces sound
waves.
¢ These sound waves or vibrations enable the
examiner to assess underlying structures
ASSESSMENT USES OF PERCUSSION

1. Eliciting Pain – Helps detect inflamed

underlying structures
2. Determining location, size and shape –
Percussion note changes between borders of an
organ and its neighboring organ.
3. Determining density – Helps determine
whether an underlying structure is filled with
air or fluid or is a solid structure.
4. Detecting abnormal masses – Detect superficial
abnormal structures or masses
5. Eliciting reflexes – Deep tendon reflexes are
elicited using percussion hammer
THREE TYPES OF PERCUSSION
1. Direct Percussion
— Direct tapping of a body part
with one or two fingertips to
elicit possible tenderness.
2. Blunt Percussion
— Used to detect tenderness over
organs 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.
3. Indirect or mediate 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
become quieter.
— Solid tissue produces soft tone, fluid
produces a louder tone and air produces an
even louder tone
TECHNIQUES IN INDIRECT PERCUSSION

¢ Place the middle finger of your non dominant hand on

the body part you are going to percuss.
¢ Keep your other fingers off the body part being
percussed because they will damp the tone you elicit.
¢ Used the pad of your middle finger of the other hand
to strike the middle finger of your non dominant hand
that is placed on the body part.
¢ Withdraw your finger immediately to avoid damping
the tone.
¢ Deliver two quick taps and listen carefully to the
tone.
¢ Use quick, sharp taps by quickly flexing your wrist
not your forearm.
SOUND ELICITED BY PERCUSSION
Sound Intensit Pitch Length Quality Example of
y Origin

Resonance (heard Loud Low Long Hollow Normal Lung

over part air and
part solid)
Hyper-resonance Very Low Long Booming Lung with
(heard over mostly loud emphysema
air)
Tympany (heard Loud High Moderat Drumlike Puffed-out
over air) e cheek, gastric
bubble
Dullness (heard Medium Mediu Moderat Thudlike Diaphragm,
over more solid m e pleural effusion,
tissue) liver
Flatness (heard Soft High Short Flat Muscle, bone,
over very dense sternum, thigh
tissue
AUSCULTATION
¢ Requires the use of 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.
¢ The sounds detected using auscultation are
classified to the intensity (loud or soft), pitch
(high or low), duration (length) and quality
(musical, crackling, raspy) of the sound
GUIDELINES IN AUSCULTATION
¢ Eliminate distracting or competing noises from
the environment.
¢ Expose the body part you are going to auscultate.
Do not auscultate through the client’s clothing.
¢ Use the diaphragm of the stethoscope 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 bell of the stethoscope to listen for low-
pitched sounds such as abnormal heart sounds
and bruits. Hold the bell lightly on the body part
being auscultated.